Failed or difficult laparoscopic cholecystectomy: can preoperative ultrasonography identify potential problems?

A prospective study was performed to assess the role of preoperative ultrasonography in predicting failed or difficult laparoscopic cholecystectomy. Fifty patients underwent detailed preoperative ultrasound examinations. The number and size of calculi, evidence of acute or chronic cholecystitis, gallbladder morphology, and the presence or absence of aberrant anatomy were documented. A comparison was made of the surgical outcome and the ultrasound findings in each patient. Six patients were converted to open cholecystectomy because of inflammatory changes in the gallbladder. The preoperative ultrasound studies in 5 of these patients demonstrated evidence of cholecystitis and cholelithiasis. Gallbladder wall thickening and contraction were also seen. Five gallbladder resections had intraoperative difficulties; preoperative ultrasonography demonstrated a thickened gallbladder wall in 2. Of 31 uneventful cases, 7 had evidence of gallbladder wall thickening and/or contraction. There were no ultrasound features that identified between the unsuccessful, difficult, or uneventful laparoscopic cholecystectomies. We conclude that detailed preoperative ultrasound evaluation of the gallbladder in patients destined for laparoscopic cholecystectomy is of little value in screening for difficult or unsuitable cases.     

Comparison of laparoscopic ultrasonography and fluorocholangiography in 300 patients undergoing laparoscopic cholecystectomy

BACKGROUND: This study compares laparoscopic ultrasonography to fluorocholangiography in detecting common bile duct (CBD) stones and delineating biliary anatomy. METHODS: A prospective nonrandomized study of 300 consecutive patients undergoing laparoscopic cholecystectomy in a university hospital was performed. After port placement but before dissection, laparoscopic ultrasonography of the extrahepatic CBD was performed in both transverse and longitudinal planes. Cystic duct fluorocholangiography was attempted in all patients. RESULTS: Of 300 patients, CBD stones were detected in 26 (9%) with 25 of these (96%) detected on laparoscopic ultrasonography. Sonography identified the location and size of the CBD as well as anomalous anatomy prior to dissection. No CBD injuries were encountered. End-fire transducers were easier to use than rigid or flexible side-fire transducers; all gave excellent image quality. CONCLUSIONS: In this large study, laparoscopic ultrasonography and fluorocholangiography were equally sensitive in detecting CBD stones. Sonography delineates the biliary anatomy noninvasively and does not require dissection or opening of the biliary system. Laparoscopic ultrasonography may improve the safety of laparoscopic cholecystectomy, especially in cases of acute inflammation or distorted anatomy.     

Selected versus routine use of intraoperative cholangiography during laparoscopic cholecystectomy

Routine use of intraoperative cholangiography during laparoscopic cholecystectomy is still widely advocated and standard in many departments, however, this is discussed controversially. We have developed a new diagnostic strategy to detect bile duct stones. The concept is based on an ultrasound examination and on a screening for the presence of six risk indicators of choledocholithiasis. 120 consecutive patients undergoing laparoscopic cholecystectomy were prospectively screened for the presence of six risk indicators of choledocholithiasis: history of jaundice; history of pancreatitis; hyperbilirubinemia; hyperamylasemia; dilated bile duct; unclear ultrasound findings. The sensitivity of ultrasound and of intraoperative cholangiography in diagnosing bile duct stones was also evaluated. For the detection of bile duct stones, the sensitivity was 77% for ultrasound and 100% for intraoperative cholangiography. 20% of all patients had at least one risk indicator. The presence of a risk indicator correlated significantly with the presence of choledocholithiasis (p < 0.01, chi-square-test). The negative predictive value of the total set of risk indicators was 100%. Following our diagnostic concept, we would have avoided 80% of intraoperative cholangiographies without missing a stone in the bile duct. This study lends further support to the view that the routine use of intraoperative cholangiography in patients undergoing laparoscopic cholecystectomy is not necessary.     

Endoscopic ultrasonography immediately prior to laparoscopic cholecystectomy: a prospective evaluation

BACKGROUND AND STUDY AIMS: In patients who are highly likely to have common bile duct (CBD) stones, it seems necessary to image the biliary tract before laparoscopic cholecystectomy, and endoscopic ultrasonography (EUS) is one way of doing this. The aim of this study was to compare immediate preoperative EUS to intraoperative cholangiography for imaging the CBD and for the diagnosis of CBD stones, in a population with a high risk of choledocholithiasis (as assessed by clinical, biochemical, and ultrasound criteria). PATIENTS AND METHODS: From January 1993 to August 1995, EUS was carried out in the operating room in 50 patients (11 men, 39 women; mean age 57 years) before laparoscopic cholecystectomy for symptomatic choledocholithiasis. A diagnosis of CBD stones by EUS or intraoperative cholangiography was always confirmed by instrumental exploration. An absence of stones in the CBD was established by a negative EUS and intraoperative cholangiography, as well as normal findings at clinical monitoring three months after laparoscopic cholecystectomy. RESULTS: EUS visualized the CBD in 100% of cases. Intraoperative cholangiography was successful in 94% of cases (n = 47 of 50), and after conversion to open laparotomy in eight patients. CBD stones were found in 12 patients (24%). The sensitivity, specificity, and positive and negative predictive values for EUS were 100%, 97%, 92%, and 100%, respectively. CONCLUSIONS: Immediate preoperative EUS may make it possible to select the best form of treatment in patients with CBD stones, avoiding inappropriate laparoscopic instrumental CBD exploration.     

Hemodynamic changes during laparoscopic cholecystectomy

Hemodynamics during laparoscopic cholecystectomy under general anesthesia (isoflurane in N2O/O2 (50%)) were investigated in 15 nonobese ASA Class I patients by using invasive hemodynamic monitoring including a flow-directed pulmonary artery catheter. During surgery, intraabdominal pressure was maintained automatically at 14 mm Hg by a CO2 insufflator, and minute ventilation was controlled and adjusted to avoid hypercapnia. Hemodynamics were measured before anesthesia, after the induction of anesthesia, after tilting into 10 degrees head-up position, 5 min, 15 min, and 30 min after peritoneal insufflation, and 30 min after exsufflation. Induction of anesthesia decreased significantly mean arterial pressure and cardiac index (CI). Tilting the patient to the head-up position reduced cardiac preload and caused further reduction of CI. Peritoneal insufflation resulted in a significant increase (+/- 35%) of mean arterial pressure, a significant reduction (+/- 20%) of CI, and a significant increase of systemic (+/- 65%) and pulmonary (+/- 90%) vascular resistances. The combined effect of anesthesia, head-up tilt, and peritoneal insufflation produced a 50% decrease in CI. Administration of increasing concentrations of isoflurane, via its vasodilatory activity, may have partially blunted these hemodynamic changes. These results demonstrate that laparoscopy for cholecystectomy in head-up position results in significant hemodynamic changes in healthy patients, particularly at the induction of pneumoperitoneum.     

Retrieval of spilled stones during laparoscopic cholecystectomy

Laparoscopic cholecystectomy is now widely practised in the Western world. One of the more common and often neglected complications is perforation of the gallbladder and spillage of bile and stones. With careful attention to technique this should be a rare complication. The effect of bile and stone spillage may depend on the presence or absence of biliary infection at the time of operation. When stone spillage occurs a number of options are available for the retrieval of stones and these are highlighted in this paper.     

Ultrasonography in the preoperative assessment of candidates for laparoscopic cholecystectomy: examination technique and results]

We have investigated the use of a microwave cavity (Labwell AB, Sweden) to improve the radiochemical yield of 2-[18F]fluoro-2-deoxyglucose (2-[18F]FDG). After characterizing the heating properties of the cavity, three steps of the Hamacher 2-[18F]FDG synthesis which require heating--azeotropic distillation of the target water, nucleophilic substitution, and hydrolysis of the product--were investigated separately. The average radiochemical yield of 2-[18F]FDG for the microwave synthesis, using the phase transfer reagent tetrabutylammonium bicarbonate, was 62 +/- 4% (72 +/- 5%, decay corrected, synthesis time = 31 min).     

Controlling complications in laparoscopic cholecystectomy: diffuse parenchyma hemorrhage in the liver parenchyma

The inflammatory pericholecystic reaction to acute or subacute cholecystitis results in the involvement in the inflammatory process of connective tissue within the liver bed, with subsequent neovascularization. The inflamed wall of the gallbladder and the surrounding connective tissue also involved in the inflammatory process become fused together thus preventing dissection in this plane. As a result, the gallbladder affected by acute cholecystitis frequently has to be dissected directly out of the liver parenchyma. The resulting diffuse parenchymal bleeding proves difficult to control by cauterization. In addition, there is a danger of postoperative bile leakage occurring. Today, the use of fibrin sealing is accepted practice in the treatment of oozing haemorrhage from the resection surface of the liver following resective surgery, and for the prevention of postoperative biliary fistulae. Using special application systems, the two-component fibrin sealing can now also be employed under video-endoscopic control. Through direct application of the adhesive to the parenchyma in the liver bed using a flexible catheter, diffuse oozing bleeds can be effectively arrested. In addition, coagulation-related parenchymal necroses associated with the development of biliary fistulae can be avoided. The technique of video-endoscopic controlled fibrin sealing is an important method of preventing and controlling complications arising during video-endoscopic surgery.     

Transoesophageal echocardiographic assessment of haemodynamic function during laparoscopic cholecystectomy

We have measured cardiovascular changes associated with insufflation of carbon dioxide and the reverse Trendelenburg position during laparoscopic cholecystectomy, using transoesophageal echocardiography in 13 healthy patients. End-tidal carbon dioxide values increased after insufflation of carbon dioxide, with values significantly (P < 0.05) increased after lateral tilt positioning. Creation of a pneumoperitoneum was associated with increases (P < 0.05) in left ventricular end-systolic wall stress, concomitant with increases (P < 0.01) in peak airway pressure and systemic arterial pressure. In addition, left ventricular end-diastolic area decreased (P < 0.05) after reverse Trendelenburg positioning. Left ventricular ejection fraction was maintained throughout the study.     

The case for routine operative cholangiography during laparoscopic cholecystectomy

The debate over routine versus selective intraoperative cholangiography during laparoscopic cholecystectomy continues because of a paucity of objective data to support or refute the case for either approach. The introduction of fluoroscopic techniques during the performance of cholangiography is an important step forward because it decreases the operative time for the technique and because real-time visualization may also diminish the number of false-positive and false-negative results. Routine cholangiography improves the surgeon's ability to delineate the biliary anatomy when the need arises and undoubtedly facilitates the development of skills useful for the laparoscopic management of common bile duct calculi. Normal results on intraoperative cholangiography are also reassuring to the surgeon, given the current visual and tactile limitations of laparoscopy. As a result of these considerations as well as our procurement of a digital fluoroscopic system and the need to train surgical residents in cholangiographic techniques, we have adopted a policy of routine fluoroscopic intraoperative cholangiography on all patients undergoing laparoscopic cholecystectomy.     

Transcutaneous PCO2 monitoring during laparoscopic cholecystectomy in pregnancy

The management of narrowing spinal fragments in the operative treatment of spinal fractures remains an open question, in particular when the procedure is performed by a posterior approach. This article describes the use of intraoperative ultrasonography during spinal surgery. From 1990 to 1997, 116 spinal fractures were treated operatively at our clinic. Stabilization of the spine was achieved with the AO fixateur interne and the AO USS, respectively (Synthes, D-79224, Umkirch, Germany). For 60 cases who had a fractured posterior vertebral surface dislocated into the spinal canal, we used intraoperative ultrasonography to monitor the repositioning of the narrowing fragments. The patients underwent pre- and postoperative computed tomography scans (CT). In six cases, color-coded duplex sonography was performed intraoperatively to view the A. spinalis anterior. In 58 cases, the spinal canal and the fractured posterior surface of the vertebrae were visualized successfully. The sonographic image was inconclusive in two cases with severely damaged fragments. Identical findings were observed on the intraoperative ultrasound image after completion of repositioning and on the postoperative CT scan. In six cases, the A. spinalis anterior was viewed by color-coded duplex sonography with a different flow before and after fracture repositioning. Intraoperative ultrasound is a valuable means of monitoring the restoration of the spinal canal by a posterior approach. The method is easy to perform and can be repeated as often as required. Color-coded duplex sonography allows further visualization of the A. spinalis anterior.     

Cost-effectiveness of laparoscopic cholecystectomy versus open cholecystectomy

To assess the cost-effectiveness of laparoscopic cholecystectomy versus open cholecystectomy from the payer's perspective, we estimated the probabilities of potential outcomes of each procedure, associated quality-of-life effects, and related direct medical charges and incorporated these estimates into a computerized simulation model. The model projects that laparoscopic cholecystectomy will be more effective than open surgery in terms of total mortality and quality-adjusted survival, for both sexes and all ages. Projected 5-year cumulative charges are lower for laparoscopic cholecystectomy than for open cholecystectomy ($5,354 versus $5,525 for 45-year-old women; $6,036 versus $6,830 for 45-year-old men), and the differences increase substantially with increasing age. We concluded that laparoscopic cholecystectomy is likely to be less costly and more effective than open cholecystectomy for most patients, as long as it does not routinely require preoperative cholangiography and is not associated with increased professional fees or increased risks of retained stones or bile duct injury.     

Cholecystocolic fistula at laparoscopic cholecystectomy: primary closure and laparoscopic caecostomy

This report suggests a strategy for managing unsuspected cholecystocolic fistula discovered during laparoscopic cholecystectomy by means of tube caecostomy.     

Respiratory mechanics during laparoscopic cholecystectomy: the effects of the abdominal wall lift

The abdominal wall lift (AWL) has been proposed for laparoscopic cholecystectomy to reduce hemodynamic effects caused by carbon dioxide (CO2) and high intraabdominal pressures (IAP). Data concerning effects of AWL on respiratory mechanics are scant. We therefore used a noninvasive method to evaluate whether the AWL could offset these effects. The PETCO2, airflow, and airway pressure were continuously measured in nine patients undergoing laparoscopic cholecystectomy using an AWL with minimal CO2 insufflation. We used a least-squares method to calculate maximal airway pressure (Pmax), elastance (Ers), and resistances (Rrs) of the respiratory system. After CO2 insufflation, the initiation of AWL resulted in a significantly decreased IAP (from 13 to 6 mm Hg; P < 0.001) and Rrs (from 20.6 to 17.8 cm H2O.L(-1).s(-1); P = 0.029), whereas Ers was partly modified (34.0 to 33.3 cm H2O/L; not significantly different). With AWL, we hypothesized that the diaphragm remained flat and stiff, outweighing the beneficial effect of the decrease of IAP on Ers. PETCO2 significantly increased after AWL and at the end of the procedure. We conclude that AWL partly reverses the impairment of the respiratory mechanics induced by CO2 insufflation during laparoscopic surgery. IMPLICATIONS: The abdominal wall lift (AWL), acting on the abdominal chest wall, had some benefits during laparoscopic surgery by limiting CO2 peritoneal insufflation and several side effects, such as hemodynamics. We examined the consequences of this technique on respiratory mechanics in nine patients undergoing laparoscopic cholecystectomy. Our findings suggest that the AWL decreases intraabdominal pressure and respiratory resistances without a significant effect on respiratory elastance.     

Complications of laparoscopic cholecystectomy: evaluation study

Laparoscopic cholecystectomy has been considered as a safe and effective procedure without randomised prospective trial. Two physician insurers associations (in France and in USA) have shown an important increase of the lawsuits after laparoscopic cholecystectomy, especially concerning common bile duct injuries. An exhaustive study of the literature demonstrates that in the rare prospective studies collecting all of the laparoscopic cholecystectomies realised in one country or one state, the percentage of biliary tract injuries is form twice to five times as big as with open surgery, and bigger in case of acute cholecystitis. It seems that diffusion of the monopolar current can explain a good number of them. These injuries are difficult for repairing because of their high localisation and the associated tissular burn. Their long term morbidity is important and their cost is huge. Three recent prospective studies comparing laparoscopic versus minilaparotomy approach demonstrate that the advantages of laparoscopic approach according to the cost and the recovery's speed are, except for the obese patients, less evident than one could believe.     

Long-term consequences of intraoperative spillage of bile and gallstones during laparoscopic cholecystectomy

Laparoscopic cholecystectomy is associated with a higher incidence of iatrogenic perforation of the gallbladder than open cholecystectomy. The long-term consequences of spilled bile and gallstones are unknown. Data were collected prospectively from 1059 consecutive patients undergoing laparoscopic cholecystectomy over a 3-year period. Details of the operative procedures and postoperative course of patients in whom gallbladder perforation occurred were reviewed. Long-term follow-up (range 24 to 59 months) was available for 92% of patients. Intraoperative perforation of the gallbladder occurred in 306 patients (29%); it was more common in men and was associated with increasing age, body weight, and the presence of omental adhesions (each P < 0.001). There was no increased risk in patients with acute cholecystitis (P = 0.13). Postoperatively pyrexia was more common in patients with spillage of gallbladder contents (18% vs. 9%; P < 0.001). Of the patients with long-term follow-up, intra- abdominal abscess developed in 1 (0.6%) of 177 with spillage of only bile, and in 3 (2.9%) of 103 patients with spillage of both bile and gallstones, whereas no intra- abdominal abscesses occurred in the 697 patients in whom the gallbladder was removed intact ( P < 0.001). Intraperitoneal spillage of gallbladder contents during laparoscopic cholecystectomy is associated with an increased risk of intra-abdominal abscess. Attempts should be made to irrigate the operative field to evacuate spilled bile and to retrieve all gallstones spilled during the operative procedure.     

Laparoscopic cholecystectomy and lithiasis of the common bile duct: prospective study on the importance of preoperative endoscopic ultrasonography and endoscopic retrograde cholangiography

OBJECTIVES: Laparoscopic cholecystectomy is the standard treatment of symptomatic gallstones. At present, no consensus has been reached on the diagnostic and therapeutic methods of concomitant common bile duct stones. Systematic preoperative endoscopic ultrasonography followed, if necessary, by endoscopic retrograde cholangiography and sphincterotomy during the same anesthetic procedure could be a diagnostic and therapeutic alternative for common bile duct stones making possible a laparoscopic cholecystectomy without intraoperative investigation of the common bile duct. METHODS: One hundred and twenty-five patients underwent a prospective endoscopic ultrasonographic evaluation prior to laparoscopic cholecystectomy for symptomatic gallstones. Fourty-four patients (35%) had at least one predictive factor for common bile duct stones. Endoscopic ultrasonography and cholecystectomy were performed on the same day. Endoscopic ultrasonography was followed by endoscopic retrograde cholangiography and sphincterotomy by the same endoscopist in case of common bile duct stones on endoscopic ultrasonography. Patients were routinely followed up between 3 and 6 months and one year after cholecystectomy. RESULTS: Endoscopic ultrasonography suggested common bile duct stones in 21 patients (17%). Endoscopic ultrasonography identified a stone in 17 of 44 patients (38.6%) with predictor of common bile duct stones and only in 4 of 81 patients (4.9%) without predictor of common bile duct stone. Among these 21 patients, one patient was not investigated with endoscopic retrograde cholangiography because of the high risk of sphincterotomy, 19 patients had a stone removed after sphincterotomy, one patient had no visible stone neither on endoscopic retrograde cholangiography, nor on exploration of the common bile duct after sphincterotomy. Endoscopic ultrasonography was normal in 104 patients (83%). However, two patients in this group were investigated with endoscopic retrograde cholangiography because endoscopic ultrasonography was incomplete in one case and because endoscopic ultrasonography was normal in the second case but a stone in the left hepatic duct was detected by ultrasonography. A stone was removed after endoscopic sphincterotomy in these two patients. In the group of 102 patients without stone, 91 out of 92, continued to be asymptomatic during a median follow-up of 8.5 months. One patient with symptoms one month after cholecystectomy underwent endoscopic sphincterotomy but no stone was found. CONCLUSIONS: Systematic preoperative endoscopic ultrasonography followed, if necessary with endoscopic retrograde cholangiography and sphincterotomy is a diagnostic and therapeutic alternative for common bile duct stones making possible a laparoscopic cholecystectomy without intraoperative investigation of the common bile duct for all patients. This alternative is only justifiable in patients with predictor of common bile duct stones.