An alternative gallbladder extraction technique in laparoscopic cholecystectomy

In this era of minimally invasive surgery, the challenge remains in finding techniques to reduce access trauma in terms of fewer and smaller size trocar ports. Our new described technique will allow a smaller subxiphoid port to be used to achieve extraction of the gallbladder without the need to change to a 5 mm laparoscope. We believe this method is easy to learn, safe and with no observable complications from our experience.     

Trocar-site metastasis following laparoscopic cholecystectomy for unsuspected carcinoma of the gallbladder

Fifteen cases of trocar-size metastasis from unsuspected gallbladder carcinoma following laparoscopic cholecystectomy have been reported in the literature. We present the case of a 66-year-old woman who developed this complication 2 1/2 months postoperatively. We feel that carcinoma of the gallbladder is a contraindication to laparoscopic cholecystectomy. When unsuspected lesions are discovered, intraoperative frozen-section lesions will facilitate the surgical management.     

Hyperplastic polyp of the gallbladder in a child

We report a case of hyperplastic polyp of the gallbladder in a 6-year-old girl, successfully treated by laparoscopic cholecyctectomy after a 2-year follow-up from the original diagnosis. On her first admission, serum amylase level was very high, so that congenital pancreaticobiliary maljunction (PBM) was suspected. Although it became clear afterwards that the high serum amylase level was derived from a mumps infection, the diagnosis of PBM was not excluded until intraoperative cholangiography was conducted. The tumor in the gallbladder had doubled in size in 2 years. It was not possible to obtain biopsy specimens for histological diagnosis, so the risk of the tumor being malignant could not be completely excluded until surgical resection had been carried out. In spite of the rapid tumor growth, no neoplastic features were seen in the tumor by histopathological examination of the resected specimen; thus, a diagnosis of a hyperplastic polyp of the gallbladder was made. Received: February 17, 2000 / Accepted: May 22, 2000     

The impact of gallbladder aspiration during elective laparoscopic cholecystectomy: a prospective randomized study

BACKGROUND: The aim of this prospective randomized study was to investigate the effect of gallbladder aspiration during elective laparoscopic cholecystectomy on the operative and postoperative course of patients. METHODS: Between August 2005 and February 2007, 160 consecutive patients with symptomatic cholelithiasis were randomized into 2 clinically comparable groups. Gallbladders were aspirated before dissection in group A (aspiration, n = 80), and they were not aspirated in group C (control, n = 80). Patients' characteristics and general operative outcomes were compared and analyzed. RESULTS: The mean dissection time (P = .45), amount of gas used (P = .49), and liver bed bleeding (P = .30) were not significantly different between group A and group C. Similarly, there were no differences between the groups regarding gallbladder perforation (P = .12), spillage of gallstones into the abdominal cavity (P = 1.00), or wound infection (P = 1.00). CONCLUSIONS: The findings suggest that routine gallbladder aspiration is unnecessary in elective laparoscopic cholecystectomy.     

腹腔镜胆囊切除术中胆囊床胆管损伤的处理

目的探讨预防及处理腹腔镜胆囊切除术（laparoscopic cholecystectomy，LC）时胆囊床胆管（包括右肝管分支及迷走胆管）损伤的对策。方法回顾性分析1997年1月～2004年12月2032例LC中15例胆囊床胆管损伤的临床特征、处理方法及效果。结果5例为慢性结石性胆囊炎急性发作，10例为慢性结石性萎缩性胆囊炎。8例右肝管分支损伤，7例迷走胆管损伤。8例用钛夹夹闭损伤胆管，5例缝合损伤胆管，另2例由于裂口较大且靠近右肝管主干而行开腹胆管修补术。术后胆漏1例，引流5d后痊愈。随访半年～3年，平均23个月，症状消失，无黄疸及胆管炎等并发症发生。结论预防胆囊床处胆管损伤的关键是紧贴胆囊壁剥离胆囊，术中及时发现并采用恰当的处理方法可获得较好的结果。     

胆囊壶腹部结石嵌顿伴胆囊积液的腹腔镜胆囊切除术

目的探讨胆囊壶腹结石嵌顿伴胆囊积脓的腹腔镜胆囊切除术(laparoscop ic cholecystectomy,LC)的可行性及手术方法。方法76例急性胆囊炎伴胆囊壶腹结石嵌顿胆囊积脓行LC。术中见胆囊管增粗37例,阶梯施夹法11例,大号钛夹法9例,套扎线法3例,Hem-o-lok结扎14例;术中取出胆囊管结石9例,处理胆囊床出血6例;6例行胆囊前壁切除手术。结果76例LC全部成功。手术时间50~125 m in,(65.0±32.8)m in。均放置引流,引流量40~90 m l/d,(50.0±10.4)m l/d,术后18~36 h拔除引流管。术后2例出现胆漏,经腹腔引流管引流治愈。76例无术后出血、内脏损伤和胆道损伤等并发症发生。结论急性胆囊炎伴胆囊壶腹结石嵌顿和胆囊积脓患者行LC可行。     

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目的 探讨胆囊癌早期诊治经验。方法 回顾性分析1993－2000年腹腔镜术中发现的41例胆囊癌临床资料。结果 术中探查结合活检明确诊断36例（87．8％）,术后病理诊断5例。I期胆囊癌行腹腔镜胆囊切除术（LC）者,3年生存率100％;Ⅱ期胆囊癌行LC者,3年生存率77．7％,行根治术者,3年生存率100％;Ⅲ期胆囊癌行根治术者,2年生存率75％,3年生存率50％;Ⅳ期胆囊癌行根治术者,2年生存率33％,3年生存率为0;Ⅲ期胆囊癌1例,仅行LC,术后5个月死于肝转移。15例中转剖腹行根治术者,5例未切除套管孔,其中1例切口种植。结论 现代腹腔镜技术可弥补影像学的不足。早期发现胆囊癌并对Ⅱ期以上胆囊癌行根治术,能提高术后生存率,效果优于仅行LC者,对LC中转剖腹手术者,应切除套管孔以防切口种植。     

Laparoscopic excision of a triple gallbladder

Triplication of the gallbladder is a rare congenital anomaly of the biliary tract; there are only nine reported cases to date. We report a case in which laparoscopic cholecystectomy was performed in a patient with biliary colic and choledocholithiasis. Preoperative assessment with ultrasound and endoscopic retrograde cholangiopancreatography (ERCP) failed to reveal the eventual findings of a triple gallbladder. Successful excision of the triple gallbladder was carried out laparoscopically, and the final diagnosis was confirmed by the pathologist. The patient made an uneventful postoperative recovery and was free of gastrointestinal symptoms at follow-up. This case report describes the first laparoscopic excision of a triple gallbladder and highlights the importance of pre-/perioperative imaging to allow for the safe dissection of rare anomalies of the biliary tract via the laparoscopic approach.     

Port-sites excision for gallbladder cancer incidentally found after laparoscopic cholecystectomy

Port-site recurrence represents a severe complication in the case of incidental gallbladder cancer (ICG) discovered after laparoscopic cholecystectomy, and is reported to occur in 17% of cases. For this reason port-sites excision is an essential surgical step during the second operation, which includes liver resection (segments 4b and 5) and lymph node dissection (hepatic pedicle and retroduodeno-pancreatic region). In this article we describe a simple technique to obtain a radical port-site excision with the aim to standardize this surgical step and to perform it in a radical way. Port-sites excision is the accurate and complete excision of the parietal channel created by the trocar during the previous cholecystectomy. This channel is often Z-shaped. In the second operation, the presence of peritoneal adhesions helps to identify exactly the previous site of entry of the trocar in the peritoneal cavity. Trocar reinsertion through the abdominal wall along the correctly identified original path allows the excision of a perfect cylinder of abdominal wall including all of the layers from the skin to the peritoneum.     

Laparoscopic cholecystectomy only could be an appropriate treatment for selected clinical R0 gallbladder carcinoma

Background Laparoscopic cholecystectomy (LC) for gallbladder carcinoma still is controversial except for the early stages of gallbladder carcinoma (Tis). This study was designed to evaluate and revisit the role of LC in treating gallbladder carcinoma. Methods Available medical records of patients with surgeries for gallbladder carcinoma were retrospectively investigated from August 1992 to February 2005. Results Among 219 patients treated for gallbladder carcinoma, 57 (26%) underwent LC. A total of 16 patients (28.1%) underwent subsequent radical cholecystectomy (LC–RC), and 41 (71.9%) were only followed up without radical surgery (LC). Tis was found in 11 patients (19.3%), T1a in 3 patients (5.3%), T1b in 8 patients (14%), T2 in 19 patients (33.3%), and T3 in 16 patients (28.1%). The findings showed R0 in 14 cases of the radical cholecystectomy group, and clinical R0 was noted in 30 cases of the LC-only group. No survival differences were noted between LC and LC–RC (p = 0.2575), especially in the case of T2 lesions (p = 0.6274), nor between the R0 and clinical R0 (p = 0.5839). However, significant survival differences were noted between the R2 and R0 groups, and between R2 and clinical R0, respectively (p < 0.001). Conclusions The findings show that LC could be appropriate treatment for gallbladder carcinoma only in selected cases of clinical R0 lesions.     

腹腔镜胆囊切除术与意外胆囊癌

目的:探讨腹腔镜胆囊切除术后意外发现胆囊癌的处理方法。方法:对1997～2001年14例腹腔镜胆囊切除术中或术后意外发现的胆囊癌进行临床病理分析。结果:14例意外胆囊癌中男2例,女12例。平均年龄66.1岁。术前诊断1例为胆囊息肉,余13例为胆囊炎胆囊结石(92.8%)。有7例中转开腹手术,1例因发现转移仅在腹腔镜下行腹壁肿块活检术,6例完成腹腔镜胆囊切除术。术后病理TNM分期:0期1例,Ⅰ期4例,Ⅱ期3例,Ⅲ期3例,Ⅳb期3例。至随访截止时,已有9人死亡,5人仍存活,存活期超过36个月者有4人,最长者已存活68月。结论:腹腔镜胆囊切除术不适用于胆囊癌病人。提倡腹腔镜术中对可疑病灶进行冰冻切片病理检查。对胆囊癌侵犯深度超过肌层者应中转开腹或术后再次开腹行根治性手术。     

Unexpected gallbladder cancer and laparoscopic surgery

Case histories of three patients who underwent laparoscopic cholecystectomy for unexpected gallbladder cancer are reviewed. Port-site recurrence was observed in two of them. In one patient whose abdominal wall recurrent tumor was excised, a new recurrence developed, but after the reexcision she is symptom-free 10 months after the last procedure. The surgeon has to be aware of the fact that the survival rate can be doubled in stage pT2 if cholecystectomy is followed by extended radical operation. Only gallbladder cancer in stage pT1 does not need further procedure, except for excision of port sites. In case of uncertain diagnosis preoperative frozen section is recommended. Port-site recurrence does not mean an incurable stage of the disease or a sign of diffuse metastases. Even after reexcision of abdominal wall metastasis patients might be free from other detectable recurrences.     

腹腔镜胆囊切除术2 800例术中胆囊床的处理

目的探讨腹腔镜胆囊切除术（1aparoscopic cholecystectomy，LC）中胆囊床的处理方法。方法回顾分析我院1997年9月一2005年8月2800例LC的临床资料。结果在胆囊床的处理过程中，有2570例采用常规方法处理，46例采用非常规方法，余184例采用常规与非常规相结合的方法处理。12例胆漏，经充分引流治愈。26例胆囊床出血，1例术后2h行剖腹探查，余25例为术中出血。结论LC术中胆囊床的处理应根据术中所见胆囊床的具体类型来决定，一旦发生胆漏或出血等并发症，不应盲目处理，需视具体情况采取相应措施。     

Routine intraoperative aspiration of gallbladder during laparoscopic cholecystectomy

Background Technical modifications and methods for gallbladder dissection to minimize the risk of gallbladder perforation during laparoscopic cholecystectomy (LC) are described. The authors aimed to investigate the effects of gallbladder aspiration during LC on the operative and postoperative course of patients. Methods For this study, 200 patients undergoing LC for symptomatic cholelithiasis were randomly divided into two groups. Gallbladders were aspirated before dissection in group A (n = 100), and they were not aspirated in group B (n = 100). Operative and postoperative data on the patients were collected. Results The rate of gallbladder perforation was significantly lower in group A than in group B (p = 0.0003). The operative time was significantly shorter in group A (46.70 ± 15.93 min) than in group B (60.75 ± 22.09 min) (p = 0.047). Postoperative complications were more numerous in group B. The hospital stay was significantly longer in group B (1.55 ± 0.81 days) than in group A (1.3 ± 0.5 days; p = 0.004). Conclusion The findings demonstrate the advantages of gallbladder aspiration in elective cases.     

Successful laparoscopic management of duplicate gallbladder: A case report and review of literature

IntroductionGallbladder duplication is a rare congenital anomaly. Recognition of this anomaly and its various types is important since it can complicate a simple hepatobiliary surgical procedure.Presentation of caseWe report a case of a 42 year old female who presented a 6 year history of intermittent right upper quadrant abdominal pain. Her basic blood investigations including liver function tests were normal. Pre-operative imaging revealed a cystic lesion communicating with biliary tree representing duplicated gallbladder. She subsequently underwent successful laparoscopic cholecystectomy. The operative challenges were more than those anticipated at the usual laparoscopic gallbladder procedures. After six months follow up the patient remained asymptomatic.DiscussionPreoperative diagnosis plays a crucial role in planning surgery, and preventing possible biliary injuries or re-operation if accessory gallbladder has been overlooked during initial surgery. Magnetic resonance cholangiopancreatography (MRCP) is the imaging modality of choice for suspected duplicate gallbladder. Laparoscopic cholecystectomy for duplicate gallbladder is a challenging operation and should be performed with meticulous dissection of the cysto-hepatic triangle.ConclusionGallbladder anomalies should be anticipated in the presence of a cystic lesion reported around the gallbladder. The laparoscopic cholecystectomy remains feasible for intervention and should be done by an experienced laparoscopic surgeon.     

Laparoscopic cholecystectomy and incidental carcinoma of the extrahepatic bilary tree.

BACKGROUND AND OBJECTIVES: Gallbladder carcinoma is found in 0.2% to 5% of patients undergoing cholecystectomy, and gallstones are found in 70% to 98% of patients with gallbladder carcinoma. Early diagnosis of carcinoma is difficult because of the absence of specific symptoms and the frequent association with chronic cholecystitis and gallstones. At present, laparoscopic cholecystectomy is the gold standard for the surgical treatment of symptomatic cholelithiasis and other benign gallbladder diseases. The aims of this study were to evaluate retrospectively the incidence of occasional and occult gallbladder carcinomas to ascertain the effect of laparoscopy on diagnosis and treatment of unexpected extrahepatic biliary tree carcinomas and to assess possible guidelines that can be taken into consideration when the problem is encountered. METHODS: Clinical records of 3900 patients undergoing laparoscopic cholecystectomy were reviewed. Patients with occasional (intraoperative = Group A) or occult (postoperative = Group B) diagnosis of gallbladder or common bile duct carcinoma entered the study group. Follow-up data were obtained in June 2000. RESULTS: A total of 14 patients (0.35%), 3 men and 11 women, mean age 60.8 years (range 37 to 73) with extrahepatic biliary tree carcinoma were found. Occasional carcinomas occurred in 8 patients, occult carcinomas in 6. No deaths occurred in either group. The overall survival at mean follow-up of 30.5 months is 50%. Five patients are disease free, and 2 are alive with evidence of recurrence. DISCUSSION: In 2 large series of unselected consecutive laparoscopic cholecystectomy, only 14 unsuspected malignant tumors of the extrahepatic biliary tree were found (0.35%). The limits of the preoperative workup and the difficult diagnosis of biliary tract carcinoma during laparoscopic cholecystectomy, has led to the present retrospective study and several significant recommendations.     

Surgical treatment of gallbladder cancer

Gallbladder cancer is usually a fatal illness because early stages of this carcinoma cause no specific signs or symptoms. Although the best chance of cure for gallbladder cancer remains incidental discovery, radical resection of the gallbladder, with the adjacent liver, adherent structures, plus a regional lymphadenectomy, has been suggested to improve survival. We retrospectively analyzed all patients with gallbladder cancer who were treated surgically at Mayo Clinic (Rochester) between 1984 and 2000. There were 131 patients for whom complete survival information was available. Patients who underwent a radical cholecystectomy had a significantly longer median survival (24 months) than patients who had a simple cholecystectomy (6 months) or noncurative treatment (4 months) (P < 0.0001). The radical cholecystectomy group had significantly longer survival than the simple cholecystectomy group for all American Joint Committee on Cancer (AJCC) stages except stage I. Of the different variables tested in a univariate analysis (sex, surgical treatment modality, AJCC stage, tumor grade, jaundice, hyperbilirubinemia, and adjuvant therapy), all variables except sex, tumor grade, and adjuvant therapy were statistically significant predictors for the survival of patients with gallbladder cancer. AJCC stage and surgical treatment modality were the only significant predictors in a multivariate analysis. Our results support radical surgical resection for the treatment of gallbladder cancer to improve patient survival. Presented at the Forty-Fourth Annual Meeting of The Society for Surgery of the Alimentary Tract, Orlando, Florida, May 18–21, 2003 (oral presentation).     

Intraabdominal contamination after gallbladder perforation during laparoscopic cholecystectomy and its complications

Background: Gallbladder perforation often occurs during laporoscopic cholecystectomy. Methods: The frequency and causes of gallbladder perforation as well as the relevant clinical background factors were investigated in 110 patients undergoing laparoscopic cholecystectomy. We also evaluated intraperitoneal contamination by bacteria and gallstones at the time of gallbladder perforation and investigated whether perforation caused early or late postoperative complications. Results: Intraoperative gallbladder perforation occurred in 29 of the 110 patients (26.3%). It was caused by injury with an electric knife during dissection of the gallbladder bed, injury during gallbladder retraction with grasping forceps, injury during gallbladder extraction from the abdomen, and slippage of cystic duct clips (potentially causing bile and stone spillage). Perforation was more frequent in patients with positive bile cultures and in those with pigment stones (p<0.02), but not in patients with cholecystitis or cystic duct obstruction. The peritoneal cavity was contaminated by bacteria in 11/29 patients (37.9%) and by spilled stones in 3/29 patients (10.3%). There was no difference in the incidence of postoperative complications between the patients with and without perforation either in the early postoperative period or during follow-up for 24–42 months. Only one patient developed abdominal pain and fever in the early postoperative period, and they were probably related to perforation. Conclusions: Although gallbladder perforation is sometimes unavoidable during laparoscopic cholecystectomy, the risk of severe complications appears to be minimized by early closure of perforation, retrieval of as many of the spilled stones as possible, and intraperitoneal lavage.     

Unsuspected carcinoma of the gallbladder

Laparoscopic cholecystectomy is the treatment of choice for gallstones. A formal contraindication is gallbladder cancer. However, in a great number of cases, this is a previously unsuspected intraoperative finding, and sometimes its first appearance is in acute cholecystitis. We present the case of 67-year-old woman, which presented an unsuspected carcinoma of the gallbladder that developed abdominal wall implants at the umbilical and left hypocondrium site. The success of LC favors the observation of cases similar to that described in this article. Surgeons who operate using laparoscopic techniques should bear this possibility in mind and practice an extemporaneous biopsy at the slightest suspicion of malignancy, and, if it is confirmed, the operation should be continued as an open one.     

Gallbladder Dyskinesia in Children

Background and Objectives:

The purpose of this study was to describe clinico-pathological characteristics in a group of children with motility disorders of the gallbladder and correlate the findings with cases receiving surgical treatment for gallstone during the same period.

Methods:

Retrospective chart analysis of all cholecystectomies from January, 1990 to June, 1995. Analysis of demographics, symptoms and duration, associated illnesses, diagnostic studies, pathological stratification, length of stay, complications, follow-up and patient satisfaction. Statistical comparison of clinical variables between gallstone and dyskinesia patients was analyzed using chi-square, and analysis of variance (ANOVA).

Results:

Twelve children (14%) of 85 underwent laparoscopic cholecystectomy during a 66-month period for gallbladder dyskinesia. Their mean age was 14 ± 3 years (range 7 to 18). Ten patients were female and two were males for a 5:1 ratio. Classic biliary symptoms (RUQ abdominal pain and FFI) predominated for a mean of 48 weeks. A predisposing factor was previous family history of gallstones in five cases (42%). The diagnosis was obtained after gallbladder non-visualization in one child and low ejection fractions after CCK stimulated hepatobiliary scan studies in the remainder. Mean ejection fraction was 16.8%. Ten cases (83%) had mild to moderate chronic cholecystitis, and two children had unremarkable pathologic changes. These changes correlated with the mean duration of symptoms, not with ejection fraction volumes. After a mean follow-up of 17 months, 11 children are free of symptoms, and one continues with intermittent diarrhea. Comparison between calculous and dyskinesia patients showed that biliary dyskinesia children suffer more dyspepsia, undergo more diagnostic studies and have a significant family history of gallstones.

Conclusions:

Gallbladder dyskinesia (GD) is a motility disorder causing symptoms similar to those of gallstones, although the clinical picture is more protracted. Diagnosis is confirmed using CCK stimulated hepatobiliary scan ejection fractions after thorough diagnostic work-up for other gastrointestinal causes. Laparoscopic cholecystectomy is the treatment of choice. Most children present with mild to moderate changes of chronic cholecystitis depending on duration of symptoms. Clinical improvement is seen in most cases after surgery.