Laparoscopic Cholecystectomy for Biliary Tract Emergencies: State of the Art

Abstract

Although laparoscopic cholecystectomy is unusually safe and well tolerated in patients with routine symptomatic cholelithiasis, it can become a formidable procedure when used to manage biliary tract emergencies. Optimally, a reasoned and cautious approach and a low threshold for conversion can avoid major complications. One such emergency, acute cholecystitis, may be particularly hazardous because of the relatively common finding of severe inflammation with dense adhesions to adjacent viscera and gallbladder necrosis. Special modifications of technique may be required. Overall, urgent operation (within 72 hours) results in an acceptably low mortality (0.3%) but a somewhat higher conversion rate (16%) and longer hospital stay (3 days). Unnecessary delays may result in more adhesions and an increased level of operative difficulty. In patients who are at an especially high risk because of co-morbid disease, percutaneous cholecystostomy is an appropriate alternative strategy. Biliary pancreatitis may be associated with high mortality (9%) and has an unpredictable course. Accordingly, a multidisciplinary approach that may include both gastroenterologists and radiologists is generally advisable. Because common bile duct (CBD) stones are present in more than 20% of patients who present with biliary pancreatitis, endoscopic retrograde cholangiopancreatography (ERCP) can be used effectively on a selective basis during the preoperative or postoperative period; the preferred timing continues to be somewhat controversial. As an alternative approach, laparoscopic CBD exploration is gradually gaining wider acceptance. In eight reported series using a variety of techniques for stone extraction, major complications were infrequent (10%), and the conversion rate was low (5%). Acute suppurative cholangitis is a more fulminant problem that is best managed by expeditious ERCP with removal of all intraductal stones. Resuscitation should be continued until complete; laparoscopic cholecystectomy can follow at an appropriate interval.

A survey of the timing and approach to the surgical management of cholelithiasis in patients with acute biliary pancreatitis and acute cholecystitis in the UK

“…A delay in confirming the diagnosis by ultrasonography and in gaining access to the operating room may heighten concerns amongst surgeons that the window for a relatively easier, or perhaps less difficult, laparoscopic cholecystectomy might have been missed. 9,29 Our own experience, however, does not support this concern, as the delay in carrying out the urgent laparoscopic cholecystectomy beyond 96 hcaused by inaccessibility to the CEPOD theatre for such 'non-emergency' cases -was not associated with an increase in operating time or conversion rate (no conversions) when compared with surgery performed sooner, but considerably increased the pre-operative, and hence total, hospital stay. 30 There is clearly a need for the theatre and hospital managers to invest in what we propose as a 12-h urgent theatre facility that is separate from the emergency CEPOD theatre and analogous to the 'trauma' theatre in order to facilitate surgery for non-emergency urgent cases.…”

Laparoscopic and Open Cholecystectomy in Surgical Training

“…In a new era with emphasis on minimally invasive surgery, experience in performing open biliary surgery is diminishing [7,14,15]. Acute inflammation of the gallbladder is the most significant risk factor for biliary injury in video-assisted operations [6,13,16]. Therefore it is a reasonable option to operate using the OC technique, particularly if a surgeon is inexperienced in LC.…”

Die akute Gallenkolik

“…Die akute konkrementbedingte Cholezystitis sollte frühelektiv,möglichst innerhalb von 72 h nach Diagnosestellung,in der Regel laparoskopisch operiert werden [75,76,77].Neuere Arbeiten zeigten bei der früh-elektiven Operation gegenüber der Operation im beschwerdefreien Intervall eine Halbierung der Krankenhausverweildauer, geringere Kosten sowie eine Verringerung der Morbidität und Letalität [75].Bis zur Operation sollte der Patient konservativ mit intravenöser Flüssigkeitssubstitu-tion,Elektrolytausgleich,Analgetika nach Bedarf und Antibiotika behandelt werden. Bei diesen Patienten sollte erst eine konservative Stabilisierung mittels Antibiotikatherapie versucht werden und im beschwerdefreien Intervall,frühestens aber 6 Wochen nach Auftreten der Beschwerden,elektiv operiert werden.Kann innerhalb von 2 Tagen keine Stabilisierung erreicht werden, sollte unter fortgesetzter antibiotischer Therapie eine perkutane Cholezystotomie zur Entlastung und Drainage der Gallenblase durchgeführt werden [78,79].Allerdings wurde die Wertigkeit dieses Verfahrens bislang noch nicht in kontrollierten Studien evaluiert [80].…”