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Complications of Laparoscopic Cholecystectomy. Richard Greco D.O. PGY-1. Similar case in 1992.

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similar case in 1992
Similar case in 1992
  • A patient with gangrenous acalculous cholecystitis removed by laparoscopy, developed hypotension 8 hrs post-op. He was re-examined via laparoscopy in the OR and found to have a lot of blood intraperitoneally and subsequently was opened to control the bleeding of an omental vessel.
indications for laparoscopic cholecystectomy

Symptomatic cholelithiasis Biliary colic Acute cholecystitis Gallstone pancreatitisAsymptomatic cholelithiasis Sickle cell disease TPN Chronic immunosuppression No immediate access to health care facilities Acalculous cholecystitis (biliary dyskinesia)Gallbladder polyps >1 cm in diameterPorcelain gallbladder

Indications for Laparoscopic Cholecystectomy

contraindications to lc
Contraindications to LC
  • Absolute
  • Unable to tolerate general anesthesia
  • Refractory coagulopathy
  • Suspicion of gallbladder carcinoma
  • Relative
  • Previous upper abdominal surgery
  • Cholangitis
  • Diffuse peritonitis
  • Cirrhosis and/or portal hypertension
  • Chronic obstructive pulmonary disease
  • Cholecystoenteric fistula
  • Morbid obesity
  • Pregnancy
advantages and disadvantages of lc compared to oc
Advantages and Disadvantages of LC Compared to OC

Advantages

  • Less pain
  • Smaller incisions
  • Better cosmesis
  • Shorter hospitalization
  • Earlier return to full activity
  • Decreased total costs

Disadvantages

  • Lack of depth perception
  • View controlled by camera operator
  • More difficult to control hemorrhage
  • Potential CO2 insufflation complications
  • Adhesions/inflammation limit use
  • Slight increase in bile duct injuries
complications of lc
Complications of LC
  • Hemorrhage
  • Bile duct injury/leak
  • Retained stones
  • Pancreatitis
  • Wound infection
  • Incisional hernia
  • Pneumoperitoneum related:
    • CO2 embolism
    • Vaso-vagal reflex
    • arrhythmias
    • Hypercarbic acidosis
  • Trocar related:
    • Bleeding: vascular injury/abdominal wall injury
    • Visceral injury
conversion to open cholecystectomy
Conversion to Open cholecystectomy:
  • Higher rate with acute cholecystitis
    • Rate increased significantly after 72 hours
    • Do not hesitate to convert if significant adhesions or inflammation are identified during laparoscopy.
  • If > 72 hrs after onset of Sxs
    • No significant comorbodities
      • laparoscopy may be attempted
    • Significant comorbid illnesses
      • antibiotics and possibly a percutaneous cholecystostomy tube and subsequent elective LC 6 to 8 weeks later.
case study 1
Case Study1:
  • 5/106 (4.71%) cases were converted
  • Operative time:
    • No complications - 50 mins
    • Complications - 1 hr 50 mins
  • Reasons:
    • bleeding,
    • dense adhesion of gallbladder
    • perforated gall bladder with biliary peritonitis
    • and pasted adhesion of gall bladder with Calot’s triangle
patient selection
Patient Selection:
  • Serious complications more likely:
    • Acute cholecystitis w/ active inflammation
    • Chronic cholecystitis w/ fibrosis

Cystic duct and cystic artery should be identified

if not --> convert to open

dissection
Dissection:
  • Calot's triangle:
    • Boundaries:
      • cystic duct, cystic artery, and common hepatic duct.
  • Adhesions of omentum or viscera adjacent to the gallbladder are divided with sharp dissection or electrocautery. Meticulous dissection and positive identification of the cystic duct, its entry into the common bile duct, and the cystic artery are absolutely mandatory and significantly reduce the likelihood of bile duct injury
gallbladder adhesions
Gallbladder Adhesions
  • Adhesions between the gallbladder and
    • hepatic flexure
    • and/or duodenum
    • omentum
      • generally avascular and may be lysed bluntly by grabbing attachment to gallbladder wall and gently stripping them down toward the infundibulum.
intraoperative gallbladder perforation
Intraoperative Gallbladder Perforation
  • Perforation of the gallbladder with bile or stone leakage should not ordinarily require conversion to OC.
  • Perforation may occur
    • secondary to traction
    • electrosurgical thermal injury during removal
  • Patients with a bile leak
    • No increased incidence of infection, prolongation of hospitalization or postoperative disability, nor adverse long-term complications
    • only difference was operating time b/c the bile should be aspirated completely and irrigated
spilled gallstone
Spilled Gallstone
  • Incidence - 10-30%
  • Mostly aSx;
    • if Sx - usually seen < 29 months post-op
  • Low morbidity of spilled stones
    • conversion to open not justified
  • Complications:
    • Mostly seen with pigmented stones
      • postulated to be due to the release of bacteria from within the stones as the body breaks down the stone matrix2.
    • Intra-abdominal abscess
    • Abd wall infection or permanent sinus
spilled stones
Spilled stones
  • According to Papasavas, et. Al
    • of all patients undergoing laparoscopic cholecystectomy, only 0.6% - 0.8% develop complications due to retained gallstones2.
  • Thus, the increased morbidity of an open procedure, solely for the purpose of retrieving spilled gallstones, is not justified.
  • Copious lavage and careful stone removal will prevent post-op difficulties
omentum
Omentum:

Function:

Fibrofatty aprons that provide support, coverage, and protection of peritoneal contents.

blood supply to the omentum
Blood Supply to the omentum
  • Right gastroepiploic
    • branch of the gastroduodenal artery
  • Left gastroepiploic
    • branch of the splenic artery.
  • The right and left gastroepiploic arteries:
    • usually anastomose along the greater curvature
    • Form the arc of Barkow through their right and left epiploic branches in the posterior omental layer.
      • The arc of Barkow is reinforced by anterior epiploic arches which spring from the right and left gastroepiploic arteries and from posterior epiploic branches from the pancreatic vessels.
lesser omentum
Lesser Omentum
  • Boundaries:
    • Superior: porta hepatis and lig venosum
    • Inferior: lesser curvature of the stomach and the proximal 2 cm of D1
  • Divided into two ligaments:
    • hepatogastric
    • hepatoduodenal
  • Contains:
    • hepatic triad
      • common bile duct, portal vein, and hepatic artery
    • branches of the anterior vagus nerve,
    • some lymph nodes,
    • right and left gastric arteries.
bleeding
Bleeding
  • Uncontrolled bleeding incidence - 0.1 - 1.9 %
  • Sites:
    • Liver
      • Usually occurs during final removal of gallbladder from fossa
      • requires conversion to open
    • Arterial
    • Port insertion sites
resources
Resources:

1: N.A.O’Rourke. Laparoscopic cholecystectomy for acute cholecystitis. Aust n.z.j. Surg. 1992, 62, 944-946

2: Papasavas PK, Caushaj PF, Gagne DJ. Spilled gallstones after laparoscopic cholecystectomy. J Laparoendosc Adv Surg Tech. 2002; 12:383–386.

3: Atta H. Soomro, Aijaz A. Memon, Khalid Ahsan Malik et al. Role of Laparoscopic cholecystectomy in the management of acute cholecystitis. JLUMHS MAY – AUGUST 2005

4: Maingot's Abdominal Operations. www.Accesssurgery.com. Chapters 22, 32, 34

resources23
Resources:

5: Todd B. Wright, et. Al. Laparoscopic Chole- cystectomy and Their Interventional Radio- . 1 logic Management RadloGraphics 1993; 13:119-128

6: A. Shamiyeh. Laparoscopic cholecystectomy: early and late complications and their treatment. Langenbecks Arch Surg. 2004; 389; 164-171

7: Nezam H Afdhal, MD. Complications of laparoscopic cholecystectomy.www.utdonline.com/utd/content/topic.do?topickey=biliaryt/6036&view=text