Verres needle decompression of distended gallbladder to facilitate laparoscopic cholecystectomy in acute cholecystitis: a prospective study

BACKGROUND/AIMS: Grasping a thick and distended gallbladder is one of the most common technical difficulties of laparoscopic cholecystectomy in acute cholecystitis. This prospective study was conducted to investigate the use of the Verres needle decompression method to facilitate laparoscopic cholecystectomy in acute cholecystitis. METHODOLOGY: Between April 1998 and April 2002, patients with acute cholecystitis scheduled to receive laparoscopic cholecystectomy emergently were included. A Verres needle was applied through the subcostal area to decompress the acute inflamed distended gallbladder after establishing pneumoperitoneum. RESULTS: In total 54 patients, 30 male and 24 female with mean age 53.50 years (range 21-80), consented to the operation. Laparoscopic cholecystectomy was performed successfully in 44 patients. The conversion of laparoscopic cholecystectomy to open surgery was needed in 10 patients (conversion rate: 18.5%). The failure to identify the triangle of Calot is the only risk factor associated with conversion. The more severe acute cholecystitis is, the higher the conversion rate is (11.5% in uncomplicated cholecystitis, 31.6% in complicated cholecystitis). No bile duct injury was noted. Postoperative morbidity happened in three cases: two port-site discharge and one subphrenic abscess. No mortality occurred. CONCLUSIONS: Verres needle decompression of the acute inflamed gallbladder did facilitate laparoscopic cholecystectomy in acute cholecystitis with low conversion rate.     

Laparoscopic versus open treatment of patients with acute cholecystitis.

BACKGROUND/AIMS: The studies published so far mention a high rate of complication and conversion in laparoscopic surgical treatment of acute cholecystitis. Considering the relatively high conversion rate in cases of acute cholecystitis, it is necessary to pre-operatively estimate the chance of successful laparoscopic cholecystectomy. One of the aims of this study was to determine the factors that influence the chance of success of this technique. Another aim was to define possible advantages of the method. METHODOLOGY: From 1991 through to 1995, a total of 295 patients in whom acute cholecystitis had been diagnosed on the basis of clinical examination, laboratory data, ultrasonography and pathohistological examination, underwent operative therapy. The laparoscopic approach was attempted in 49 of these patients. Since the patients who underwent primary open surgery were markedly handicapped with regard to severity of inflammation and co-morbid factors, we identified a sub-group of these patients who were comparable to those who underwent laparoscopic cholecystectomy in accordance of the above-mentioned criteria. RESULTS: The rate of conversion (44.9%) correlated with the severity of inflammation, which was determined on the basis of leukocytosis > 10 x 10(9)/l (p = 0.004) and the pathohistological diagnosis (p = 0.005). Hence, the rate of conversion was 71.4% in cases of empyema of the gallbladder but only 29.2% in cases of edematous cholecystitis. In patients whose leukocyte count decreased within 4 days of conservative treatment, a successful laparoscopic cholecystectomy (LC) was performed in 91.7% (11/12) of cases, while 8 patients whose leukocyte count increased or showed no reduction during this time required conversion to open cholecystectomy (p = 0.0001). In cases of acute cholecystitis, the complication rate after LC is lesser in respect of wound infection (p = 0.07) and pneumonia (p = 0.04). In all patients, obesity was a risk factor for wound infection (p = 0.04). Injury to the small intestine was registered in 1 case but in no case was LC associated with injury to the bile duct. CONCLUSIONS: The degree of inflammation and its response to conservative treatment, which are determined on the basis of leukocytosis and clinical improvement, are clear indications of the chance of successful delayed laparoscopic cholecystectomy within the first week. Hence, all patients whose leukocyte count does not decrease after antibiotic treatment should be treated with open cholecystectomy (OC). The complication rate following LC is less than that following OC. Although no injury to the bile duct has been observed in cases of acute cholecystitis, major complications are possible and should not be excluded.     

Conversión de colecistectomía laparoscópica a abierta: análisis de factores de riesgo con base en parámetros clínicos,de laboratorio y de ultrasonido

Introduction and aimsThe standard of care for gallbladder disease is laparoscopic cholecystectomy. Difficult dissection of the hepatocytic triangle and bleeding can result in conversion to open cholecystectomy, which is associated with increased morbidity. Identifying risk factors for conversion in the context of acute cholecystitis will allow patient care to be individualized and improve outcomes.Materials and methodsA retrospective case-control study included all patients diagnosed with acute cholecystitis, according to the 2018 Tokyo Guidelines, admitted to a tertiary care academic center, from January 1991 to January 2012. Using logistic regression, we analyzed variables to identify risk factors for conversion. Variables that were found to be significant predictors of conversion in the univariate analysis were included in a multivariate model. We then performed an exploratory analysis to identify the risk factor summation pathway with the highest sensitivity for conversion.ResultsThe study included 321 patients with acute cholecystitis. Their mean age was 49 years (±16.8 SD), 65% were females, and 35% were males. Thirty-nine cases (12.14%) were converted to open surgery. In the univariate analysis, older age, male sex, gallbladder wall thickness, and pericholecystic fluid were associated with a higher risk for conversion. In the multivariate analysis all of the variables, except pericholecystic fluid, were associated with conversion. Our risk factor summation model had a sensitivity of 84%.ConclusionsPreoperative clinical data can be utilized to identify patients with a higher risk of conversion to open cholecystectomy. Being aware of such risk factors can help improve perioperative planning and preparedness in challenging cases.     

How I do it — Laparoscopic Cholecystectomy

Abstract: One thousand consecutive patients underwent a laparoscopic cholecystectomy from September 1990 to January 1993 at our institution. A total of 435 presented with complications acute cholecystitis (83), common bile duct stones (61), or previous abdominal surgery (321). Of the 1,000 patients, 37 (3.7%) were converted to an open cholecystectomy, usually because of marked inflammation and unclear anatomy. There were no deaths and the total postoperative complication rate was 91 of 1,000 (9.1%). Major complications (1.1%) included 3 bile duct injuries, 2 postoperative bleedings, 5 residual common duct stones and 1 case of peritonitis caused by stone spillage. All bile duct injuries were detected and suspected in the operating room and repaired by a Roux-en-Y hepaticojejunostomy. Minor complications occurred in the remaining 80 patients(8.0%). The most common complication encountered was urinary retention (6.1%). Intraoperatively, the two-hand technique, electrosurgical dissection, selective cholangiography and selective use of closed drainage were used. When common bile duct stones were encountered during the performance of laparoscopic cholecystectomy, they were primarily managed by a simultaneous laparoscopic choledochotomy. These experiences suggested that the immediate detection of operative injury was very important to prevent later serious complications, and wider operative indications can be applied safely and carefully by trained general surgeons.     

Laparoscopic cholecystectomy for acute cholecystitis

The application of laparoscopic cholecystectomy (Lap. C) for acute cholecystitis (AC) remains controversial from the viewpoint of its higher rate of morbidity, and conversion to open surgery, in spite of the worldwide acceptance of Lap. C as the gold standard for the treatment of patients with symptomatic gallbladder diseases. The conversion rate has been reported to decrease with experience. Local and overall complication rates were shown to correlate with the time delay between the onset of acute symptoms and the operation. Although percutaneous gallbladder drainage (PGBD) has been reported to be a safe and effective procedure for the treatment of AC, it should be limited to high‐risk groups such as elderly or critically ill patients. Early cholecystectomy within 4 days from the onset is strongly recommended to minimize surgical complications and to increase the chance of a successful laparoscopic approach.     

Cholecystectomy using celioscopy: analysis of 368 operations]

The management of calculous disease of the biliary tract has undergone significant changes during the past decade. Yet, the only radical method of treatment remains cholecystectomy. The surgical option has been improved by the development of laparoscopic cholecystectomy. From February 1990 to February 1991, we performed 368 laparoscopic cholecystectomies, with no mortality and a morbidity rate of 3.8%. There were 283 women and 85 men, with a mean age of 56.2 years (range 18 to 92 years). Two patients were asymptomatic but presented with a growing gallbladder polyp. All the other patients were symptomatic: biliary colic (63.8%), dyspepsia (18.6%), or acute cholecystitis (17.6%); 36 patients had an history of stone migration to the main biliary tract. Mean operating time was 58.3 minutes (22 to 180 minutes) and mean postoperative stay was 3.4 days. There were four systemic complications and 10 local technically related complications: two have been controlled by a laparoscopic approach (one hemorrhage and one biliary leak), one by laparotomy (bile duct injury). The other 7 local complications resolved spontaneously (4 biliary fistulas) or by percutaneous punction (3 subphrenic abscesses). Twenty-six patients (7%) required conversion to open cholecystectomy because of technical difficulties with the dissection or main biliary tract stones. We conclude that laparoscopic cholecystectomy is a safe and effective procedure.     

老年人腹腔镜胆囊切除术521例临床分析

目的探讨腹腔镜胆囊切除在治疗老年人胆囊良性疾病中的应用价值。方法回顾性分析５２１例老年患者胆囊切除术的结果。结果５２１例中，单纯慢性结石性胆囊炎４５９例，其中继发胆总管结石２例，急性胆囊炎２４例，胆囊息肉３８例。术中因炎性粘连、疑胆囊癌等改做开腹手术１８例（３．５％），发生严重并发症３例（０．６％），治愈４９９例（９５．８％），死亡１例。结论为老年人施行腹腔镜胆囊切除术，如医生经过充分的训练并了解可能发生的困难，仍是安全可行的手术方法。     

Timing of laparoscopic cholecystectomy for acute cholecystitis with cholecystolithiasis

BACKGROUND/AIMS: Laparoscopic cholecystectomy is now used in the treatment of acute cholecystitis. The aim of this study is to define the optimal timing for laparoscopic cholecystectomy treated with cholecystolithiasis in patients with acute cholecystitis. METHODOLOGY: A retrospective analysis of 73 patients with acute cholecystolithiasis who were treated by either early laparoscopic cholecystectomy within 72 hours after initial onset or initial conservative treatment followed by delayed laparoscopic cholecystectomy 4 days later. RESULTS: There were 31 patients in the early group and 42 in the delayed group. There was no significant difference in the rate of conversion from laparoscopic to open surgery (6.4% vs. 20.0%), postoperative complications. However the early group had significantly shorter operation time (103 vs. 135 min, p<0.01) and shorter postoperative hospital stay (6.2 vs. 9.6 days, p<0.01). CONCLUSIONS: We advocate early laparoscopic cholecystectomy within 72 hours of onset of symptoms to decrease conversion rates from laparoscopic to open surgery. This decreased conversion rate results in decreasing the length of operation time and postoperative and total hospital stay.     

Laparoscopic Cholecystectomy: 111 Consecutive Cases

Laparoscopic cholecystectomy removes the gallbladder through three or four puncture wounds in the abdominal wall. The technique reduces the recuperative time to full activity, from as long as 4 wk to as little as 3 days, compared with conventional cholecystectomy. We herein present our initial experience with this procedure. In this series of 111 laparoscopic cholecystectomies, there were no mortalities and only one morbidity. Thirty-nine patients (35%) had a history of prior abdominal surgery. Fourteen underwent laparoscopic lysis of adhesions. Intraoperative cholangiograms were performed in 24 patients (21%), demonstrating choledocholithiasis in three. Two of the three patients underwent postoperative endoscopic retrograde cholangiopancreatography (ERCP); in the other, laparoscopic common bile duct exploration was performed. In each case, the common bile duct (CBD) was completely cleared of stones. Incidental laparoscopic appendectomy was also performed in three patients. The average time for completion of laparoscopic cholecystectomy in cases of chronic cholecystitis was 40 min. If the gallbladder was acutely inflamed, the procedure took a mean of 126 min. This series had a higher percentage of patients (19%) with acute cholecystitis then previously reported; therefore, the 2% conversion rate in this series emphasizes the broad applicability of the technique. The average length of stay in the hospital was 1.4 days, and patients returned to work in about 7 days.     

Laparoscopic cholecystectomy in the treatment of acute cholecystitis. Prospective non-randomized study

OBJECTIVES: To evaluate the results of laparoscopic cholecystectomy in patients with acute cholecystitis and to determine the optimal timing. PATIENTS AND METHODS: From January 1993 to December 1999, 168 patients (91 women and 77 men with a mean age of 57.3 years) underwent laparoscopic cholecystectomy for acute cholecystitis confirmed by histopathological examination. Patients were divided into 2 groups (similar in age and ASA classification): group 1 (106 patients) underwent laparoscopic cholecystectomy within 3 days after the onset of symptoms of acute cholecystitis and group 2 (62 patients) underwent laparoscopic cholecystectomy after 3 days. RESULTS: There was no death. Conversion rates were 30.9%. Surgery lasted 141.3 min, postoperative morbidity was 12.5%, and the postoperative length of hospital stay was 6.9 days. The conversion rates in patients who underwent surgery before and 3 days after the onset of symptoms were respectively 21.7% and 46.7% (P=0.0007). There was no statistical difference between early and delayed surgery for time to surgery and postoperative complications. On the other hand, the total hospital stay was significantly shorter in group 1. CONCLUSION: Laparoscopic cholecystectomy for acute cholecystitis is safe and associated with a shorter postoperative stay, a lesser morbidity and a lesser mortality compared to "open" surgery. Laparoscopic cholecystectomy should be carried out soon as the diagnostic of acute cholecystitis is established and preferably before 3 days after the onset of the symptoms. Early laparoscopic cholecystectomy allows a reduction of the conversion rate and a reduction of total hospital stay that are medical and economic benefits.     

急性结石性胆囊炎腹腔镜手术252例

目的:探讨急性结石性胆囊炎腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)的手术操作要点．方法:回顾性分析本院1995-10／2005-10收治的252例胆囊结石并急性胆囊炎LC病例．结果:应用熟练的镜下操作技术,仔细解剖 Calot三角、近胆囊断离胆囊动脉、恰当处理术中出血、灵活应用电凝止血与钛夹止血相结合,顺利完成腹腔镜胆囊切除术244例,中转开腹胆囊切除术8例,系因合并胆囊癌、十二指肠球部巨大溃疡、Mirizzi综合征、胆囊壶腹部与胆总管粘连严重、胆囊十二指肠致密粘连及内瘘形成等原因而中转开腹,无术中大出血、肝外胆管损伤而中转开腹的病例．无术后胆漏、腹腔内出血等严重并发症发生．近期随访无胆管狭窄并发症发生．结论:急性胆囊炎行LC安全可行,关键是术者必须充分了解LC操作要点和熟练掌握操作技术．     

困难性腹腔镜胆囊切除术围手术期处理体会

目的探讨困难类型腹腔镜胆囊切除围手术期的处理方法及并发症的预防。方法利用回顾性分析临床资料的方法,选择广东省中山大学附属东华医院1999年-2013年10月82例因急性胆囊炎、Mirizzi综合征、腹部手术史伴腹腔严重粘连、萎缩性胆囊炎、合并肝硬化等困难类型腹腔镜胆囊切除术的临床资料,总结经验和教训。结果除6例中转开腹(占7.31%)外,余均用腹腔镜成功完成手术;术后胆道损伤、胆瘘2例,再次手术后治愈;术后出血4例,保守治疗后痊愈;术后不明原因、不同程度胆漏者10例,经引流后自愈。结论对于困难类型腹腔镜胆囊切除术,虽然手术操作难度大,风险高,只要围手术期处理方法适当,仍可以在腹腔镜下完成手术。     

Conversion factors in laparoscopic cholecystectomy for acute cholecystitis

BACKGROUND/AIMS: Although laparoscopic cholecystectomy already occupies an important role in acute cholecystitis, a high rate of conversion continues to be referred to in the series published. One of the objectives of this study is to assess the preoperative factors that might lead to conversion. METHODOLOGY: 100 laparoscopic cholecystectomies for acute cholecystitis were studied of which 24 were converted. Several parameters are taken into consideration: age, sex, ASA, echographic data, bacteriological examination of the bile, time elapsing between diagnosis and surgery, morbidity and mortality. RESULTS: The analysis made in relation to the preoperative, predetermining factors with regards to the converted cases provided the following elements in unvaried analysis: Preoperative existence of: "plastron" gallbladder (P < 0.002), temperature above 38 degrees C (P < 0.04), leucocytosis (P < 0.02)), time elapsing between diagnosis and surgery (P < 0.005), presence in the echography of pericholecystic liquid (P < 0.0005) and edema (P < 0.001); Klebsiella in the gallbladder bile (P < 0.005). Age (P = 0.136), sex (P = 0.992), associated diseases (P = 0.961), and gallbladder pathology (P = 0.282) did not present statistical differences that would prevent valid conclusions. In multi-varied analysis it was only possible to consider as independent factors the leucocytosis and the time between diagnosis and surgery. CONCLUSIONS: Laparoscopic cholecystectomy is a safe and efficient technique in the treatment of acute cholecystitis, which should constitute the first choice of treatment for this disease. However, it should be carried out within the first 4 days following surgical diagnosis.     

Surgical treatment of patients with acute cholecystitis: Tokyo Guidelines

Cholecystectomy has been widely performed in the treatment of acute cholecystitis, and laparoscopic cholecystectomy has been increasingly adopted as the method of surgery over the past 15 years. Despite the success of laparoscopic cholecystectomy as an elective treatment for symptomatic gallstones, acute cholecystitis was initially considered a contraindication for laparoscopic cholecystectomy. The reasons for it being considered a contraindication were the technical difficulty of performing it in acute cholecystitis and the development of complications, including bile duct injury, bowel injury, and hepatic injury. However, laparoscopic cholecystectomy is now accepted as being safe for acute cholecystitis, when surgeons who are expert at the laparoscopic technique perform it. Laparoscopic cholecystectomy has been found to be superior to open cholecystectomy as a treatment for acute cholecystitis because of a lower incidence of complications, shorter length of postoperative hospital stay, quicker recuperation, and earlier return to work. However, laparoscopic cholecystectomy for acute cholecystitis has not become routine, because the timing and approach to the surgical management in patients with acute cholecystitis is still a matter of controversy. These Guidelines describe the timing of and the optimal surgical treatment of acute cholecystitis in a question-and-answer format.     

Endoscopic naso-gallbladder drainage in the treatment of acute cholecystitis: alleviates inflammation and fixes operator's aim during early laparoscopic cholecystectomy

In 1984, Kozarek first reported the use of endoscopic retrograde cholangiopancreatography (ERCP) to perform selective cannulation of the cystic duct, and since then this procedure has also been reported by others. With this procedure, disorders in the gallbladder can be examined in detail, using, for example, selective cytology, and drainage for acute cholecytitis can also be performed. With this procedure, we were able to successfully perform early laparoscopic cholecystectomy (LC). Although surgery is often problematic in patients with acute cholecystitis because of inflammation, making Callot's triangle difficult to distinguish, the use of endoscopic naso-gallbladder drainage (ENGBD) during surgery enables us to identify the cystic duct for catheter cannulation. We performed early LC for acute cholecystitis in 18 of 22 patients, while 18 other patients underwent open cholecystectomy during the same period (retrospective study). These two groups were then compared. The LC group had shorter pre- and postoperative periods and shorter hospitalization (P < 0.05). ENGBD resulted in very little bleeding. None of the ENGBD patients required conversion to open surgery, whereas 11.1% of the non-ENGBD patients were converted. ENGBD was successfully employed in 18 of the initial 22 (81.8%) patients. The favorable points in using ENGBD with LC were that (i) the gallbladder inflammation was alleviated even if patients had ascites, and (ii) use of ENGBD normally improved visualization and made cystic duct identification easier. However, if ERCP cannot be carried out, the performance of ENGBD must also be ruled out.     

Timing of cholecystectomy for acute calculous cholecystitis: a meta-analysis

OBJECTIVES: To compare early with delayed cholecystectomy for the treatment of acute lithiasic cholecystitis: a meta-analysis of prospective randomized trials. METHODS: Pertinent studies were selected from the Medline, Embase, Cancerlit, HealthSTAR and Cochrane Library Databases, references from published articles, and reviews. Twelve prospective randomized trials (9 addressing open cholecystectomy and 3 laparoscopic cholecystectomy) were selected. Conventional meta-analysis according to the DerSimonian and Laird method was used for the pooling of the results. The rate difference (RD) (95% CI) and the number needed to treat (NNT) were used as a measure of the therapeutic effect. RESULTS: Cumulative operative and perioperative mortality and morbidity were 0.9% and 17.8%, respectively, for open cholecystectomy and 0% and 13.1%, respectively, for laparoscopic cholecystectomy. The pooled RD for operative complications in early surgery was 1.37% (95% CI =-3.78% to 6.53%; p= 0.2) for open cholecystectomy and 3.11% (95% CI =-15.10% to 8.87%; p= 0.6) for laparoscopic cholecystectomy. In laparoscopic cholecystectomy the cumulative conversion rate to open cholecystectomy was 21.5%. The pooled RD for conversion rate in early laparoscopic cholecystectomy was -7.99% (95% CI =-18.46% to 2.47%; p= 0.1; NNT = 13). Total hospital stay (mean +/- SD) was significantly shorter in the early surgery group (9.6 +/- 2.5 days vs 17.8 +/- 5.8 days; p < 0.0001). More than 20% of patients referred to delayed surgery fail to respond to conservative management or suffer recurrent cholecystitis in the interval period. CONCLUSIONS: Early operation (open or laparoscopic) does not carry a higher risk of mortality and morbidity compared to delayed operation and should be the preferred surgical approach for patients with acute lithiasic cholecystitis.     

Delayed Laparoscopic Cholecystectomy After Percutaneous Transhepatic Gallbladder Drainage Versus Emergency Laparoscopic Cholecystectomy for Acute Cholecystitis: A Meta-Analysis

Background: The purpose of this meta-analysis is to appraise the efficacy and safety of delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage (PTGBD) versus emergency laparoscopic cholecystectomy (ELC) for acute cholecystitis.Methods: The kinds of literature were searched by Web of Science, PubMed, OVID, Cochrane Library, and EMBASE between the year 2000 and 2019. RevMan 5.3 was used for meta-analysis.Results: Seventeen studies with 2135 participants were included in our study. Compared with the ELC group, delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage group (PTGBD group) had a significant better effect in intraoperative bleeding (P = .002), conversion rate to open surgery (P = .02), postoperative complications (P ＜ .00001), bile leakage (P = .01), bile duct injury (P = .02), and wound infection (P = .02). There was no significant difference between the two groups in operative time (P= 32), postoperative hospital stay (P = .30), and intraperitoneal hemorrhage (P = .39). PTGBD group had a significantly longer overall hospital stay than the ELC group (P ＜ .00001).Conclusion: Compared with the ELC group, the PTGBD group has several advantages, including bile duct injury, intraoperative bleeding, bile leakage, conversion rate to open surgery, postoperative complications, and wound infection. The only drawback in the PTGBD group is to lengthen the total hospital stay.     

Open versus laparoscopic cholecystectomy for gallbladder carcinoma

Laparoscopic surgery has replaced conventional open cholecystectomy for benign gallbladder disease. A major concern is how to handle gallbladder cancer in the laparoscopic era, since there are numerous case reports of port site metastases from gallbladder cancer after laparoscopic cholecystectomy. There are also many experimental studies favoring the opinion that the laparoscopic technique implies a higher risk of spreading malignant disease. This opinion has gained wide acceptance despite little previous clinical effort to determine the risk of tumor dissemination and the lack of comparisons between open and laparoscopic surgery. This report is a short summary of our own studies and present knowledge with special respect to the clinical aspects of the development and incidence of abdominal wall metastases. Among 270 patients with verified gallbladder carcinoma in whom 210 had open surgery and 60 a laparoscopic cholecystectomy, 12 patients (6.5%) in the open cholecystectomy group and 9 (15%) in the laparoscopic group developed incisional metastases. Although the sparse clinical documentation does not unavoidably mean that laparoscopic cholecystectomy has an increased risk of disseminating tumor cells, we recommend open surgery in cases of known or suspected gallbladder carcinoma.     

Laparoscopic cholecystectomy in acute cholecystitis: a proposal of safe and effective technique

Laparoscopic cholecystectomy is slowly taking its place also in an emergency setting, regardless of its initial unfortunate course when iatrogenic lesions during surgery, complications and conversion rate make the laparoscopic approach in acute cholecystitis a hazard. With the development of laparoscopic technique, the laparoscopic cholecystectomy for acute cholecystitis becomes a reality, but its role in emergency is not yet defined. From December 1998 to December 2005, 133 consecutive laparoscopic cholecystectomies for acute cholecystitis were performed in our institution by the same surgeon. The mean age of patients was 48 years old, 21 were over seventy. In the series patients in ASA III and IV were included. All procedures were performed with the same technique, developed in the examined period, which represents a standardized downwards laparoscopic cholecystectomy, easy to reproduce and safe to perform. We report our surgical technique and our results. We did not report mortality, and there was very low morbidity. Only one patient was converted, giving an extremely low conversion rate of 0.7%. The average operating time was 52 min (range 17-70 min). Analyzing the operating time and the time between the onset of symptoms to surgery, we found that these two variables seem to be alike with a linear relationship; we found that the best timing for surgery is within 60 hr from the onset of symptoms. The latter analysis is reported. Laparoscopic cholecystectomy, when performed with an adequate technique and as early as possible represents a safe procedure to treat acute cholecystitis in an emergency setting. The technique described, considering the results, lack of iatrogenic lesions and acceptable operating time, represents a standardized surgical strategy to approach acute cholecystitis (AC) in a safe, effective and reproducible manner.     

Bile duct injuries during laparoscopic cholecystectomy: an audit of 1522 cases

BACKGROUND/AIMS: Bile duct injuries during laparoscopic cholecystectomy are serious complications. The incidence of this complication increases compared with open cholecystectomy. The aim of this paper has been to audit the incidence and nature of bile duct injuries during laparoscopic cholecystectomy in a single center. METHODOLOGY: From January 1991 to September 2000, all laparoscopic cholecystectomy attempts performed in Rajavithi Hospital were analyzed. RESULTS: Of the 1522 procedures performed, there were 9 (0.59%) cases of bile duct injuries. These involved the common hepatic duct (n=3) and the common bile duct (n=6). The underlying gallbladder pathology included chronic cholecystitis (n=6), Mirizzi's syndrome (n=2), and acute cholecystitis (n=1). Transection of the duct accounted for the majority of the injuries. Six bile duct injuries were identified at the time of operation. These were primarily repaired by direct suture (n=1) or by a biliary-enteric anastomosis (n=5). In the remaining three patients, the diagnosis was delayed. Two patients presented with a large amount of bile from the drain after surgery and one patient presented with jaundice. These were repaired by direct suture over a T tube (n=1) or biliary-enteric anastomosis (n=2). One patient developed recurrent cholangitis following biliary-enteric anastomosis after delayed diagnosis. CONCLUSIONS: The experience of a 0.59% incidence of bile duct injury is comparable to the best results from most large series in the West. Inflammation/adhesion at Calot's triangle is an important associated factor for injury. Injuries identified and repaired at the time of the first operation afford good results.