The impossible gallbladder: aspiration as an alternative to conversion
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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.
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.
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.
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.
KeywordsDamage-control Gallbladder aspiration Conversion-to-open Cholecystectomy
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.
No funding was sought nor obtained for the conduct of this study.
Compliance with ethical standards
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.
Description of the laparoscopic gallbladder aspiration procedure. Supplementary material 1 (MP4 28692 kb)
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