Advertisement

The impossible gallbladder: aspiration as an alternative to conversion

  • Natallia KharytaniukEmail author
  • Gary A. Bass
  • Bogdan D. Dumbrava
  • Paul P. Healy
  • Dylan Viani-Walsh
  • Tej N. Tiwary
  • Tahir Abassi
  • Matthew P. Murphy
  • Emma Griffin
  • Thomas N. Walsh
Dynamic Manuscript
  • 46 Downloads

Abstract

Background

Laparoscopic cholecystectomy is the standard of care for symptomatic gallstone disease but when laparoscopic removal proves impossible the standard advice is to convert to open surgery. This jettisons the advantages of laparoscopy for a procedure which surgeons no longer perform routinely, so it may no longer be the safest practice. We hypothesised that gallbladder aspiration would be a safer alternative when laparoscopic removal is impossible.

Methods

A retrospective analysis was performed of all laparoscopic cholecystectomies attempted under one surgeon’s care over 19 years, and the outcomes of gallbladder aspiration were compared with the standard conversion-to-open procedure within the same institution.

Results

Of 757 laparoscopic cholecystectomies attempted, 714 (94.3%) were successful, while 40 (5.3%) were impossible laparoscopically and underwent gallbladder aspiration. Interval cholecystectomy was later performed in 34/40 (85%). Only 3/757 (0.4%) were converted to open. No aspiration-related complications occurred and excessive bile leakage from the gallbladder was not observed. During this time 1209 laparoscopic cholecystectomies were attempted by other surgeons in the institution of which 55 (4.55%) were converted to open and 22 (40%) had procedure-associated complications. There was a significant difference in the mean (± SEM) post-operative hospital stay between laparoscopic gallbladder aspiration [3.12 (± 0.558) days] and institutional conversion-to-open cholecystectomy [9.38 (± 1.04) days] (p < 0.001), with attendant cost savings.

Conclusion

Laparoscopic gallbladder aspiration is a safe alternative to conversion when inflammation makes cholecystectomy impossible laparoscopically, especially in the sickest patients and for surgeons with limited open surgery experience. This approach minimises morbidity and permits laparoscopic cholecystectomy in the majority after a suitable interval or referral of predicted difficult cases to specialist hepatobiliary centres.

Keywords

Damage-control Gallbladder aspiration Conversion-to-open Cholecystectomy 

Notes

Authors contributions

Due to a long time span of the study and frequent rotations of surgical trainees, the study was carried out over several years, involving several authors who performed data collection and drafting of the manuscript at various stages of this study. Their contribution is acknowledged by their authorship (BDD, PPH, TNT, TA, MPM, EG). NK carried out the literature search, data collection and analysis, and wrote the paper. GAB gave statistical advice, supervised data analysis, contributed to writing the paper, and commented on the manuscript drafts. DVW carried out the literature search and contributed to data analysis and to writing the section on Methodology. TNW was the consultant in charge of the unit, had the original idea for the paper, formulated the study protocol, and supervised the writing of the paper. All the authors were asked to offer advice and comments on various drafts of the paper. The final version of the manuscript was revised by all the authors prior to its submission.

Funding

No funding was sought nor obtained for the conduct of this study.

Compliance with ethical standards

Disclosures

The authors (N Kharytaniuk, GA Bass, BD Dumbrava, PP Healy, D Viani-Walsh, TN Tiwary, T Abassi, MP Murphy, E Griffin, TN Walsh) declare to have no competing interests.

Supplementary material

Description of the laparoscopic gallbladder aspiration procedure. Supplementary material 1 (MP4 28692 kb)

References

  1. 1.
    Zacks SL, Sandler RS, Rutledge R, Brown RS Jr (2002) A population-based cohort study comparing laparoscopic cholecystectomy and open cholecystectomy. Am J Gastroenterol 97(2):334–340CrossRefGoogle Scholar
  2. 2.
    Keus F, de Jong JA, Gooszen HG, van Laarhoven CJ (2006) Laparoscopic versus open cholecystectomy for patients with symptomatic cholecystolithiasis. Cochrane Database Syst Rev 18(4):CD006231Google Scholar
  3. 3.
    Chau CH, Siu WT, Tang CN, Ha PY, Kwok SY, Yau KK et al (2006) Laparoscopic cholecystectomy for acute cholecystitis: the evolving trend in an institution. Asian J Surg 29(3):120–124CrossRefGoogle Scholar
  4. 4.
    Wijsmuller AR, Leegwater M, Tseng L, Smaal HJ, Kleinrensink GJ, Lange JF (2007) Optimizing the critical view of safety in laparoscopic cholecystectomy by clipping and transecting the cystic artery before the cystic duct. Br J Surg 94(4):473–474CrossRefGoogle Scholar
  5. 5.
    Rattner DW, Ferguson C, Warshaw AL (1993) Factors associated with successful laparoscopic cholecystectomy for acute cholecystitis. Ann Surg 217(3):233–236CrossRefGoogle Scholar
  6. 6.
    Livingston EH, Rege RV (2004) A nationwide study of conversion from laparoscopic to open cholecystectomy. Am J Surg 188(3):205–211CrossRefGoogle Scholar
  7. 7.
    Visser BC, Parks RW, Garden OJ (2008) Open cholecystectomy in the laparoendoscopic era. Am J Surg 195(1):108–114CrossRefGoogle Scholar
  8. 8.
    Ballal M, David G, Willmott S, Corless DJ, Deakin M, Slavin JP (2009) Conversion after laparoscopic cholecystectomy in England. Surg Endosc 23(10):2338–2344CrossRefGoogle Scholar
  9. 9.
    Sakpal SV, Bindra SS, Chamberlain RS (2010) Laparoscopic cholecystectomy conversion rates two decades later. JSLS 14(4):476–483CrossRefGoogle Scholar
  10. 10.
    McGillicuddy EA, Schuster KM, Barre K, Suarez L, Hall MR, Kaml GJ et al (2012) Non-operative management of acute cholecystitis in the elderly. Br J Surg 99(9):1254–1261CrossRefGoogle Scholar
  11. 11.
    Kaafarani HM, Smith TS, Neumayer L, Berger DH, Depalma RG, Itani KM (2010) Trends, outcomes, and predictors of open and conversion to open cholecystectomy in Veterans Health Administration hospitals. Am J Surg 200(1):32–40CrossRefGoogle Scholar
  12. 12.
    Lengyel BI, Panizales MT, Steinberg J, Ashley SW, Tavakkoli A (2012) Laparoscopic cholecystectomy: what is the price of conversion? Surgery 152(2):173–178CrossRefGoogle Scholar
  13. 13.
    Bass G, Walsh TN (2012) Non-operative management of acute cholecystitis in the elderly. Br J Surg 99(1254):1261 (Br J Surg. 2012;99(12):1742; author reply) Google Scholar
  14. 14.
    Sirinek KR, Willis R, Schwesinger WH (2016) Who will be able to perform open biliary surgery in 2025? J Am Coll Surg 223(1):110–115CrossRefGoogle Scholar
  15. 15.
    CholeS Study Group WMRC (2016) Population-based cohort study of outcomes following cholecystectomy for benign gallbladder diseases. Br J Surg 103(12):1704–1715CrossRefGoogle Scholar
  16. 16.
    McCain S, Jones C, Taylor M, Morris-Stiff G (2015) Trainee experience of open cholecystectomy in the laparoscopic era. Ulster Med J 84(1):53–54PubMedGoogle Scholar
  17. 17.
    McNamee L, Quinn EM, Boland M, Kirby J, Walsh TN (2017) Percutaneous cholecystostomy in critically Ill patients. Irish J Med Sci 186:S87Google Scholar
  18. 18.
    von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP et al (2007) The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet 370(9596):1453–1457CrossRefGoogle Scholar
  19. 19.
    Takada T, Strasberg SM, Solomkin JS, Pitt HA, Gomi H, Yoshida M et al (2013) TG13: updated Tokyo Guidelines for the management of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci 20(1):1–7CrossRefGoogle Scholar
  20. 20.
    Yamashita Y, Takada T, Kawarada Y, Nimura Y, Hirota M, Miura F et al (2007) Surgical treatment of patients with acute cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 14(1):91–97CrossRefGoogle Scholar
  21. 21.
    Wakabayashi G, Iwashita Y, Hibi T, Takada T, Strasberg SM, Asbun HJ et al (2018) Tokyo Guidelines 2018: surgical management of acute cholecystitis: safe steps in laparoscopic cholecystectomy for acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci 25(1):73–86CrossRefGoogle Scholar
  22. 22.
    Hirota M, Takada T, Kawarada Y, Nimura Y, Miura F, Hirata K et al (2007) Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat 14(1):78–82CrossRefGoogle Scholar
  23. 23.
    Henneman D, da Costa DW, Vrouenraets BC, van Wagensveld BA, Lagarde SM (2013) Laparoscopic partial cholecystectomy for the difficult gallbladder: a systematic review. Surg Endosc Other Interv Tech 27(2):351–358CrossRefGoogle Scholar
  24. 24.
    Berber E, Engle KL, String A, Garland AM, Chang G, Macho J et al (2000) Selective use of tube cholecystostomy with interval laparoscopic cholecystectomy in acute cholecystitis. Arch Surg 135(3):341–346CrossRefGoogle Scholar
  25. 25.
    Elshaer M, Gravante G, Thomas K, Sorge R, Al-Hamali S, Ebdewi H (2015) Subtotal cholecystectomy for “difficult gallbladders”: systematic review and meta-analysis. JAMA Surg 150(2):159–168CrossRefGoogle Scholar
  26. 26.
    Le Blanc-Louvry I, Coquerel A, Koning E, Maillot C, Ducrotte P (2000) Operative stress response is reduced after laparoscopic compared to open cholecystectomy: the relationship with postoperative pain and ileus. Dig Dis Sci 45(9):1703–1713CrossRefGoogle Scholar
  27. 27.
    Demirer S, Karadayi K, Simsek S, Erverdi N, Bumin C (2000) Comparison of postoperative acute-phase reactants in patients who underwent laparoscopic v open cholecystectomy: a randomized study. J Laparoendosc Adv Surg Tech A 10(5):249–252CrossRefGoogle Scholar
  28. 28.
    Karayiannakis AJ, Makri GG, Mantzioka A, Karousos D, Karatzas G (1996) Postoperative pulmonary function after laparoscopic and open cholecystectomy. Br J Anaesth 77(4):448–452CrossRefGoogle Scholar
  29. 29.
    Lord RV, Ling JJ, Hugh TB, Coleman MJ, Doust BD, Nivison-Smith I (1998) Incidence of deep vein thrombosis after laparoscopic vs minilaparotomy cholecystectomy. Arch Surg 133(9):967–973CrossRefGoogle Scholar
  30. 30.
    Ambe PC, Jansen S, Macher-Heidrich S, Zirngibl H (2016) Surgical management of empyematous cholecystitis: a register study of over 12,000 cases from a regional quality control database in Germany. Surg Endosc 30(12):5319–5324CrossRefGoogle Scholar
  31. 31.
    Blackbourne LH (2008) Defining combat damage control surgery. US Army Med Dep J 36:67–72Google Scholar
  32. 32.
    Chovanes J, Cannon JW, Nunez TC (2012) The evolution of damage control surgery. Surg Clin North Am 92(4):859–875CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Natallia Kharytaniuk
    • 1
    Email author
  • Gary A. Bass
    • 1
    • 2
  • Bogdan D. Dumbrava
    • 1
  • Paul P. Healy
    • 1
  • Dylan Viani-Walsh
    • 1
  • Tej N. Tiwary
    • 1
  • Tahir Abassi
    • 1
  • Matthew P. Murphy
    • 1
  • Emma Griffin
    • 1
  • Thomas N. Walsh
    • 1
    • 2
  1. 1.Department of Surgery, Connolly HospitalRCSI Academic CentreDublin 15Ireland
  2. 2.Royal College of Surgeons in IrelandDublin 2Ireland

Personalised recommendations