Incidental carcinoma gall bladder during laparoscopic cholecystectomy for symptomatic gall stone disease

Introduction  Carcinoma gall bladder (CaGB) is a disease with high mortality and is usually diagnosed as an incidental case among patients undergoing laparoscopic cholecystectomy (LC) for symptomatic gall stone disease. Methods  A total of 3205 LC done between January 2004 and August 2007 for symptomatic gall stone disease were retrospectively searched for incidental CaGB (detected on histopathology). None of these cases had preoperative suspicion of malignancy and their whole data was analyzed with special attention to preoperative and intraoperative findings which could raise suspicion of CaGB. In November 2007, patients were followed up telephonically about their present status of health. Results  Nineteen patients (14 female and 5 male) with incidental CaGB (incidence 0.59%) were detected. Mean age of the patients was 56 years. Only two of these patients had clinical jaundice and both had common bile duct (CBD) stones. The majority of the patients were in early pathological stages (pT) and none was in pT3 and pT4 stage. Seventeen patients could be followed up telephonically in November 2007 and of those 14 patients were alive at a mean follow-up duration of 21.2 months, with one of them having evidence of metastatic disease. Conclusion  Gall bladder (GB) malignancy may be curable if diagnosed in early stages as an incidental finding and LC may not worsen the prognosis in such cases. In our series, incidental CaGB was detected in 0.59% patients undergoing LC. No association could be found between preoperative and intraoperative findings that could raise a suspicion of malignancy of gall bladder and so use of retrieval bag as a routine measure in cases with bile spillage may reduce the incidence of port-site metastasis.     

Predicting iatrogenic gall bladder perforation during laparoscopic cholecystectomy: a multivariate logistic regression analysis of risk factors

BACKGROUND: Seventeen independent risk factors were examined using multivariate logistic regression analysis to develop a profile of patients most likely at risk from iatrogenic gall bladder perforation (IGBP) during laparoscopic cholecystectomy. METHODS: Since 1989, a prospectively maintained database on 856 (women, 659; men, 197) consecutive laparoscopic cholecystectomies by a single surgeon (R. J. F.) was analysed. The mean age was 48 years (range, 17-94 years). The mean operating time was 88 min (range, 25-375 min) and the mean postoperative stay was 1 day (range, 1-24 days). There were 311 (women, 214; men, 97) IGBP. Seventeen independent variables, which included sex, race, history of biliary colic, dyspepsia, history of acute cholecystitis, acute pancreatitis and jaundice, previous abdominal surgery, previous upper abdominal surgery, medical illness, use of intraoperative laser or electrodiathermy, performance of intraoperative cholangiogram, positive intraoperative cholangiogram, intraoperative common bile duct exploration, presence of a grossly inflamed gall bladder as seen by the surgeon intraoperatively and success of the operation, were analysed using multivariate logistic regression for predicting IGBP. RESULTS: Multivariate logistic regression analysis against all 17 predictors was significant (chi(2) = 94.5, d.f. = 17, P = 0.0001), and the variables male sex, history of acute cholecystitis, use of laser and presence of a grossly inflamed gall bladder as seen by the surgeon intraoperatively were individually significant (P < 0.05) by the Wald chi(2)-test. CONCLUSION: Laparoscopic cholecystectomy, using laser, in a male patient with a history of acute cholecystitis or during an acute attack of cholecystitis is associated with a significantly higher incidence of IGBP.     

胆囊结石并肝硬化行腹腔镜与开腹胆囊切除比较

目的对比合并肝硬化的胆囊结石症行腹腔镜胆囊切除与开腹胆囊切除术的疗效。方法回顾性分析我院1999～2004年25例合并肝硬化的症状性胆囊结石患者,其中13例行LC,12例行OC。结果13例LC患者1例出现肺部感染;12例OC患者术后切口感染1例,肺部感染3例,切口渗液4例,尿路感染3例;术中出血量LC组明显少于OC组P<0.0.5;术后住院时间LC组明显短于OC组P<0.0.5。结论LC治疗合并肝硬化的症状性胆囊结石症,具有明显的优点,与OC相比,LC手术时间短,手术出血量少,术后并发症发生率低,同时缩短了住院时间,在肝硬化ChildA鄄B级病人中安全可靠。     

Laparoscopic cholecystectomy in the treatment of patients with gall bladder cancer

BACKGROUND: Surgical procedures based on the depth of the primary tumor invasion (pT category) have been proposed in the treatment of gallbladder cancer (GBC). Trocar site metastases have been reported in patients who underwent laparoscopic cholecystectomy (LC) for preoperatively undiagnosed GBC. STUDY DESIGN: The aim of this study was to clarify the role of LC as a surgical strategy for GBC. From 1986 to 1998, 56 patients with GBC underwent surgical resection. Survival rates were compared retrospectively according to pT category and use of LC. RESULTS: Five-year survival was 91% for pT1 (n = 13), 64% for pT2 (n = 25), 34% for pT3 (n = 14), and 0% for pT4 tumors (n = 4; p<0.0001). LC was performed on 11 patients (4 with pT1, 5 with pT2, and 2 with pT3 tumors). Of the seven patients with pT2 or pT3 tumors, three underwent a second radical operation, three had an open radical operation to which the procedure was converted from LC, and one underwent no additional procedures. For pT1 tumors, one patient died of trocar site metastasis from bile spillage after LC. For pT2 or pT3 tumors, 5-year survival was 63% for radical surgery (n = 35) and 0% for cholecystectomy alone (n = 4; p<0.05). For pT2 or pT3 tumors treated by radical surgery, 5-year survival was 75% for laparoscopic approach (n = 6) and 60% for open surgery (n = 29; not significant). CONCLUSIONS: LC may help to establish the diagnosis and to determine the surgical strategy for undiagnosed GBC. It is important to prevent spillage or implantation of malignant cells during LC. For pT2 or pT3 tumors diagnosed laparoscopically, a second or converted open radical surgery is necessary.     

Laparoscopic cholecystectomy in situs inversus totalis with left-sided gall bladder

Symptomatic gallstones in patients with situs inversus pose diagnostic and therapeutic challenges. The presentation and management of one such patient is discussed with an emphasis on operative technique.     

Absorbable clips for cystic duct ligation in laparoscopic cholecystectomy

Background The efficacy and applicability of an absorbable polydioxanone (PDS) clip for cystic duct ligation were evaluated in 297 patients undergoing laparoscopic cholecystectomy. Methods The indications for cholecystectomy were symptomatic gallstones (179 patients), acute cholecystitis (67), biliary pancreatitis (23), acute cholangitis (24), and gallbladder polyp (4). Results Twenty-five patients required conversion to open surgery (8.4%). The conversion rate was 2.7% for uncomplicated and 17.5% for complicated gallbladder diseases. Of the 272 patients with laparoscopic cholecystectomy, the cystic ducts were successfully ligated with PDS clips in 227 patients (83.5%). The success rate was higher in uncomplicated (163/178) than in complicated (64/94) gallbladder diseases (chi square = 24.6,P < 0.001). There was no clip-related complication on follow-up (range 0.4–39.2, median 17.5 months). In 45 patients, PDS clip failed. They were treated with endoloop (14 patients), Roeder slip knot (13), metallic clips and endoloop (8), metallic clips alone (6), and intracorporeal tie (4). Conclusions The PDS clip is effective and applicable to the majority of patients. It should be attempted first because of the ease of application. This study is not supported by any grant.     

腹腔镜意外胆囊癌外科治疗体会

目的总结意外胆囊癌腹腔镜胆囊切除的经验。方法回顾性分析连续1037例腹腔镜胆囊切除术中的4例意外胆囊癌患者的临床特征、病理分期、手术及术后处理措施。结果术后病理分期2例为T1aNM,1例为00T1bNM,1例为TisNM,其中3例肿瘤位于体部,1例位于胆囊颈部息肉癌变。术后随访1～3年,无切口种植,腹腔0000及远处转移。结论LC只要注意技术操作,勿分破胆囊,并不会增加肿瘤扩散的机会;术后应根据PTNM分期及肿瘤部位决定是否行淋巴清扫。     

T-tube placement during laparoscopic cholecystectomy

Summary The management of common bile duct stones during laparoscopic cholecystectomy can pose a challenge to the surgeon as no definitive management plan is universally accepted at this time. We present a case where a common bile duct exploration was performed through a choledochotomy, describing how the t-tube was placed.The contents of this article do not necessarily reflect the views of the Department of the Army or the Department of Defense     

Laparoscopic ultrasonography during laparoscopic cholecystectomy

Background: This study assessed the effectiveness of laparoscopic ultrasonography in demonstrating biliary anatomy, confirming suspected pathology, and detecting unsuspected pathology. Methods: Laparoscopic ultrasonography was performed on 48 patients (17 M:31 M) who underwent laparoscopic cholecystectomy. An Aloka 7.5-MHz linear laparoscopic ultrasound transducer was used for scanning. Results: Gallbladder stones were confirmed by laparoscopic ultrasonography in all patients and unsuspected pathology was found in five patients. Two patients were found to have common bile duct stones by laparoscopic ultrasonography and this was confirmed by laparoscopic cholangiography. Laparoscopic ultrasound was found to be helpful during dissection in four patients, particularly in a patient with Mirizzi syndrome. The entire common bile duct was visualized by laparoscopic ultrasonography in 40 patients but was poorly seen in eight patients. The mean time taken for the examination was 9 min (range 4–18 min). Conclusion: Laparoscopic ultrasound is useful during laparoscopic cholecystectomy. Received: 8 November 1995/Accepted: 5 May 1996     

Ventilatory requirements during laparoscopic cholecystectomy

The purpose of this clinical study was to determine: (1) the increase in minute ventilation required to maintain preinsufflation arterial carbon dioxide tension (PaCO₂) during laparoscopic cholecystectomy, and (2) whether end-tidal PCO₂ (PetCO ₂) can be used as an index of PaCO₂ and, therefore, of the adequacy of minute ventilation during the pneumoperitoneum. We measured PaCO₂,PetCO ₂, expired minute volume (V_exp) standardized for body surface area (SA), airway and intra-abdominal pressure (Paw, Pabd) during general anaesthesia for laparoscopic cholecystectomy just before and 30 min after the creation of a CO₂ pneumoperitoneum in 28 healthy (ASA class 1 and 2) consenting adults. They were in the reverse Trendlenburg position (20°) with a 5° lateral tilt. Expired minute volume was increased from 3.75 (SEM ± 0.12) to 4.19 (0.15) L·min^?1·m^?2 to maintain PaCO₂ close to control levels: 38.9 (0.8) vs 40.1 (0.6) mmHg 5.19 (0.1) vs 5.35 (0.08) kPa). In most of the patients (23/28),PetCO ₂ was less than 41 mmHg with a correlation between PaCO₂ andPetCO ₂. In ten of these patients, (Pa-Pet)CO₂ was greater than the normal range. In 5/28, (Pa-Pet)CO₂ was negative. The “driving pressure” (Paw-Pabd) increased from 8.7 (1.0) to 10.4 (1.1) cm H₂O, without any correlation between the increase in Paw-Pabd and that in \(\dot Vexp\) . The results indicate the need for extra ventilatory requirement during laparoscopy and thatPetCO ₂ is an imperfect index of PaCO₂ under these circumstances.     

Grasper trauma during laparoscopic cholecystectomy

BACKGROUND: The present study characterized the histopathological nature of laparoscopic grasper trauma during laparoscopic cholecystectomy in a prospective, blinded trial in order to establish a model for laparoscopic grasper trauma. The null hypothesis that graspers cause no histologically distinct tissue injury was tested. METHODS: The gall bladders of 19 patients undergoing laparoscopic cholecystectomy were examined. The area of gall bladder that had been grasped by Debakey laparoscopic forceps was excised (sample), along with an area of gall bladder that had not been grasped (control). Paired specimens were examined by a pathologist (blinded) to identify which was 'sample' and which was 'control' and to assess for histological markers of crushed tissue injury. The data were analysed by chi-squared or Fisher's exact tests. RESULTS: The pathologist was able to identify the sample (gripped) specimen in 13 of the 19 cases. In the remaining six cases the pathologist was unable to determine the specimen that had been gripped due to either absence of damage (four cases), or severe inflammation precluding assessment (two cases). The ability of the pathologist to distinguish the sample from the control specimen was significant (chi-squared test, P = 0.003). Of the histological markers of crushed tissue injury, focal thinning of the gall bladder wall and epithelial loss were present in significantly more sample (gripped) specimens than control specimens (chi-squared test, P = 0.0002 and P < 0.0001, respectively). CONCLUSIONS: Laparoscopic graspers cause tissue trauma that can be assessed histologically. The current study presents a relevant, reproducible, ethically acceptable human model for assessing the interaction between laparoscopic graspers and soft tissues.     

Spilled gallstones during laparoscopic cholecystectomy

Introduction

Incidental gallbladder cancer is found in 0.6–2.1% of patients undergoing laparoscopic cholecystectomy for symptomatic gallstones. Patients with Tis or T1a tumours generally undergo no further intervention. However, spilled stones during surgery may have catastrophic consequences. We present a case and suggest aggressive management in patients with incidental gallbladder cancer who had spilled gallstones at surgery.

Case History

A 37-year-old woman underwent a laparoscopic cholecystectomy for symptomatic gallstones, during which some stones were spilled into the peritoneal cavity. Subsequent histological examination confirmed incidental pT1a gallbladder cancer. Hepatopancreatobiliary multidisciplinary team discussion agreed on regular six-monthly follow-up. The patient developed recurrent pain two years after surgery. Computed tomography revealed a lesion in segment 6 of the liver. At laparotomy, multiple tumour embedded gallstones were found on the diaphragm. Histological examination showed features (akin to the original pathology) consistent with a metastatic gallbladder tumour.

Conclusions

This case highlights the potential for recurrence of early stage disease resulting from implantation of dysplastic or malignant cells carried through spilled gallstones. It is therefore important to know if stones were spilled during original surgery in patients with incidental gallbladder cancer following a laparoscopic cholecystectomy. Aggressive and early surgical management should be considered for these patients.     

Intraoperative cholangiography during laparoscopic cholecystectomy

BACKGROUND: The routine use of intraoperative cholangiography (IOC) during laparoscopic cholecystectomy remains controversial. METHODS: A retrospective review of 950 consecutive laparoscopic cholecystectomies performed during an 8-year period was performed. For the first 2 years, IOC was performed selectively, and thereafter routinely. RESULTS: Attempted in 896 patients, IOC was successful in 734 (82%). Bile duct stones were found in 77 patients (10%), dilated ducts without stones in 47 patients (6%), and anatomic variations in 4 patients (0.5%). There were four (0.4%) minor intraoperative complications related to the IOC, with no consequences for the patients. There were three (0.3%) minor injuries of the bile duct, which were identified with IOC and repaired at the time of cholecystectomy without any consequences for the patients. In two of these patients, the structure recognized and catheterized as the cystic duct was revealed by IOC to be the bile duct. Thus IOC prevented extension to a major common bile duct (CBD) injury. CONCLUSIONS: Findings show that IOC is a safe technique. Its routine use during laparoscopic cholecystectomy may not prevent bile duct injuries, but it minimizes the extent of the injury so that it can be repaired easily without any consequences for the patient. The prevention of a major bile duct injury makes IOC cost effective.     

Cardiodynamic monitoring during laparoscopic cholecystectomy

With increasing success of laparoscopy, the hemodynamic changes associated pneumoperitoneum (PPM) was described using invasive and non-invasive techniques with variable results. In the present study, we have used non-invasive cardiodynamic monitor to investigate the hemodynamic changes during laparoscopic cholecystectomy. Eleven patients who underwent laparoscopic cholecystectomy under general anesthesia were studied. Cardiodynamic monitor (thoracic bioimpedance) was used to investigate the hemodynamic changes. The following parameters were continuously monitored: Heart Rate (HR), mean arterial blood pressure (MAP), cardiac output (CO) and cardiac index (CI). For statistical purpose, five phases were identified: (A), pre-PPM, (B), 2 min post-PPM, (C), 10 min post-PPM, (D), 30 min post-PPM, and (E), after gas deflation. SPSS package, Version 9 was used for statistical analysis of the data obtained. Student's t-test for paired observations was used for comparisons of the mean values of the data obtained, where P <0.05 was considered significant. There was significant change of the mean value of MAP in phases A and C. Also significant CI changes of the mean values was found between stages A and B (P <0.05). The study showed, transient cardiac depression immediately after PPM with partial recovery after ten min, which was associated with increase in MAP.     

Simultaneous operations during laparoscopic cholecystectomy

Simultant laparoscopic operations were performed in 1993-2003 yrs period in 321 patients, including 287--using laparoscopic and 34--the combined (laparoscopic and open) access. Concurrent diseases were diagnosed preoperatively in 219 (68.2%) of patients and were disclosed while doing intraoperative revision--in 102 (31.8%). The simultant operations performance, as a rule, enhanced mildly the total duration of a basic stage, did not influence the duration of postoperative period and the patients rehabilitation essentially, as well as for frequency of the intra--and postoperative complications occurrence. The authors consider that it is expedient to perform laparoscopic intervention simultaneously for concurrent surgical diseases of abdominal cavity.     

Intraoperative cholangiography during laparoscopic cholecystectomy

An audit of routine intraoperative cholangiography in a consecutive series of 496 patients undergoing laparoscopic cholecystectomy has been performed. Cannulation of the cystic duct was possible in 483 patients (97%). The use of portable, digitized C-arm fluorocholangiography was vastly superior to the employment of a mobile x-ray machine and static films in terms of reduced time to carry out the procedure and total abolition of unsatisfactory radiological exposure of the biliary tract. Repeat of the procedure was necessary in 22% of cases when the mobile x-ray equipment was used. Aside from the detection of unsuspected stones in 18 patients (3.9%), routine intra-operative cholangiography identified four patients (0.8%) whose management would undoubtedly have been disadvantaged if intraoperative cholangiography had not been performed.