Does the Difficulty of Laparoscopic Cholecystectomy Differ Between Genders?

Development and validation of a nomogram to predict the need for bailout procedure in laparoscopic cholecystectomy: A multicenter study of 1,898 cases

BACKGROUND

Laparoscopic cholecystectomy is the standard treatment for benign gallbladder disease. A bailout procedure is recommended for patients with severe inflammation. This study identified the preoperative factors that predict bailout procedures and developed a predictive nomogram.

METHODS

A total of 1,898 patients with laparoscopic cholecystectomy from 5 institutions (2015-2020) were divided into training (n = 1,518) and validation (n = 380) sets. Logistic regression was employed to predict bailout procedures and to develop a nomogram on the basis of the training set. The accuracy of the nomogram was evaluated using receiver operating characteristic curve analysis of the validation set. Postoperative outcomes were compared between qualified surgeons certified by the Japanese Society for Endoscopic Surgery and residents who had graduated from a medical university within the past 5 years.

RESULTS

Bailout procedures were performed in 262 (13.8%) patients. Multivariate analysis identified several significant predictors, including sex, age, gallbladder drainage, severity of acute cholecystitis, stone impaction of the gallbladder neck, and serum C-reactive protein. The nomogram achieved an area under the curve of 0.788 in the training set and 0.769 in the validation set. Intraoperative complications were significantly fewer in the qualified surgeon group than in the nonqualified surgeon group.

CONCLUSION

The nomogram aids surgeons in identifying high-risk patients and making informed decisions about bailout procedures, thereby ensuring patient safety. Involving qualified surgeons in case predicted to be difficult cholecystectomies may help prevent help to avoid intraoperative complications.

A Study of Factors Leading to Difficult Laparoscopic Cholecystectomy at a Tertiary Care Center in Northeastern India

BACKGROUND

Laparoscopic cholecystectomy (LC) is currently the gold standard of care for managing gallstone disease. The time taken to perform LC depends on both patient-related and surgeon-related factors. Recognizing factors associated with difficult LC (DLC) can aid in appropriate surgeon selection and judicious scheduling of cases.

METHODS

This prospective study was conducted to identify preoperative factors (clinical and ultrasonographic) and intraoperative factors that can help predict or prepare for DLC. The study took place in the Department of General Surgery, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, India. A total of 100 cases of LC were enrolled over a two-year period. All patients had symptomatic cholelithiasis and were scheduled to undergo elective LC. The time taken to perform LC was compared against individual parameters of interest, including clinical features, ultrasonography (USG), and intraoperative findings.

RESULTS

Forty-one LCs were classified as difficult and 59 as non-DLC (NDLC), based on the time limit set by the mean operating time for all LC cases. Seven out of the 41 difficult LCs required conversion to open cholecystectomy (OC). Patient, USG, and intraoperative factors were found to have a significant correlation with difficult LC. Patient factors included male gender, body mass index (BMI), number of past attacks, and previous abdominal surgery. USG factors included calculi number, calculi size, impaction of calculi, and a thick gallbladder (GB) wall. Intraoperative factors included pericholecystic adhesions, Calot's triangle dissection, GB mobilization from the liver bed, and GB specimen extraction.

CONCLUSION

Preoperative identification of difficult LC cases can guide rational allocation of cases based on surgeon experience, leading to better utilization of operating theatre time and reducing the probability of conversion and complications.

Pre-Operative Group and Save in Elective and Emergency Laparoscopic Cholecystectomy: Necessity, Cost-Effectiveness, and Own Experience

Background: Laparoscopic cholecystectomy is associated with a high safety profile. This study seeks to quantify the incidence of blood transfusion in both the elective and emergency settings, examine related patient outcomes, and investigate selection criteria for pre-operative Group and Save (G&S) sampling. Methods: A prospective multi-centre observational study was conducted to investigate patients undergoing either elective or emergency laparoscopic cholecystectomy in the UK between January 2020 and May 2021. Multivariate logistical regression models were used to identify patient factors associated with the risk of transfusion and explore outcomes linked to pre-operative G&S sampling. Results: This study comprised 959 patients, with 631 (65.8%) undergoing elective cholecystectomy and 328 (34.2%) undergoing emergency surgery. The median age was 48 years (range: 35-59), with 724 (75.5%) of the patients being female. Only five patients (0.5%) required blood transfusions, receiving an average of three units, with the first unit administered approximately six hours post-operatively. Among these cases, three patients (60%) had underlying haematological conditions. In adjusted models, male gender was significantly associated with the need for a blood transfusion (OR 11.31, p = 0.013), while the presence of a pre-operative Group and Save sample did not demonstrate any positive impact on patient outcomes. Conclusions: The incidence of blood transfusion following laparoscopic cholecystectomy is very low. Male gender and haematological conditions may present as independent risk factors. Pre-operative G&S sampling did not yield any positive impact on patient outcomes and could be safely excluded in both elective and emergency cases, although certain population subsets will warrant further consideration.

Availability of laparoscopic surgery in Mexico's public health system: a nationwide retrospective analysis

Background

Laparoscopic surgery remains limited in low-resource settings. We aimed to examine its use in Mexico and determine associated factors.

Methods

By querying open-source databases, we conducted a nationwide retrospective analysis of three common surgical procedures (i.e., cholecystectomies, appendectomies, and inguinal hernia repairs) performed in Mexican public hospitals in 2021. Procedures were classified as laparoscopic based on ICD-9 codes. We extracted patient (e.g., insurance status), clinical (e.g., anaesthesia technique), and geographic data (e.g., region) from procedures performed in hospitals and ambulatories. Multivariable analysis with random forest modelling was performed to identify associated factors and their importance in adopting laparoscopic approach.

Findings

We included 97,234 surgical procedures across 676 public hospitals. In total, 16,061 (16.5%) were performed using laparoscopic approaches, which were less common across all procedure categories. The proportion of laparoscopic procedures per 100,000 inhabitants was highest in the northwest (22.2%, 16/72) while the southeast had the lowest (8.3%, 13/155). Significant factors associated with a laparoscopic approach were female sex, number of municipality inhabitants, region, anaesthesia technique, and type of procedure. The number of municipality inhabitants had the highest contribution to the multivariable model.

Interpretation

Laparoscopic procedures were more commonly performed in highly populated, urban, and wealthy northern areas. Access to laparoscopic techniques was mostly influenced by the conditions of the settings where procedures are performed, rather than patients' non-modifiable characteristics. These findings call for tailored interventions to sustainably address equitable access to minimally invasive surgery in Mexico.

Funding

None.

Port Site Consequences After Laparoscopic Cholecystectomy Using an Open Versus Closed Approach of Pneumoperitoneum

Introduction: Laparoscopic surgery is the standard method for cholecystectomy, and pneumoperitoneum is performed either in a closed or open technique. However, exposure to the consequences of the port site may increase the patient's morbidity. Therefore, this study was conducted to compare both approaches in terms of complications at the port site of each procedure and potential risk factors.

Methods: A prospective study was conducted in the department of surgery, in hospitals affiliated with Kirkuk and Diyala governorates in Iraq, from January 2019 to March 2022. The participating patients (200) were electively divided into two groups, each group comprising 100 patients. The pneumoperitoneum was established in the first group by an open technique (Hasson) while in the second group it was by using a closed technique (Veress needle). A comparison was made between the two techniques for intraoperative and postoperative complications that may have occurred due to port insertion up to 18 weeks.

Results: According to the results, the highest percentage was for the following: females (84.0%), ages between 50 and 59 years (43.5%), and body mass index (BMI) range 25-30 kg/m² (49.0%). No significant difference was observed between those variables for the two surgical techniques (p-value > 0.05). No death was recorded in the study. Consequences at the port site were observed in 10.5% of patients, the majority reported in the open approach (8.5%) as follows: bleeding (3.0%), hematoma (2.0%), wound infection (1.5%), hernia (1.5%), and vascular injury (0.5%).

Conclusions: Thus, we concluded that port site complications are lowest in closed laparoscopic surgery which was not shown to be statistically significant but values showed less complications. Furthermore, samples could be used to gain a good statistical significance.

Predictors of Difficult Laparoscopic Cholecystectomy on Humanitarian Missions to Peru Difficult LC in Surgical Missions

BACKGROUND

Laparoscopic cholecystectomy (LC) is the gold standard treatment of gallstone disease. On short-term surgical missions (STSMs), it is unclear what factors can predict safety of LC. This study evaluates patient risk factors of difficult LC in Northern Peru, towards optimizing outcomes.

MATERIALS AND METHODS

A retrospective review was performed of patients who underwent LC during short-term surgical missions to Peru from 2016-2019 under the International Surgical Health Initiative (ISHI). Difficult and routine LC groups were compared for: age, weight, gender, symptom duration, pain on presentation, history of abdominal or pelvic surgery, diabetes and hypertension.

RESULTS

68 of 194 patients underwent LC; 42 patients (62%) were classified as difficult with OR (operating room) time > 70 min (90%), 2 cases converted to open (5%) and 2 aborted cases (5%). Higher weight class was found to correlate with difficult LC.

CONCLUSION

Increased patient weight was correlated to longer operative time during STSMs. Patients undergoing LC must be selected carefully to mitigate risks of difficult operations on STSMs.

Sex Disparities in the Presentation of Gallbladder Disease

INTRODUCTION

Although gallbladder disease is more common in women, there is a trend toward more complicated cases in male patients.

METHODS

All cholecystectomies captured by the National Surgical Quality Improvement Program database for the year 2016 were reviewed. This encompassed 38 736 records. Records were reviewed for age, sex, procedure performed, operative time, postoperative diagnosis, functional status, American Society of Anesthesiologists (ASA) class, preoperative lab values (total bilirubin, alkaline phosphatase, white blood cell count, and aspartate aminotransferase. Descriptive and inferential statistical analyses were conducted.

RESULTS

Male patients are more likely to undergo cholecystectomy for a diagnosis of cholecystitis, gallstone pancreatitis, or cholangitis than women who are more likely to carry a diagnosis of biliary dyskinesia. The average operative time increases for both sexes as the patients become older. The average operative time is higher for men than women in all age groups and the variance becomes greater as the patients become older. Age, sex, postoperative diagnosis, ASA class, and functional status were all independently significant in predicting operative time. There was no difference in need for cholangiogram between the sexes. Female patients were more likely to have their cholecystectomy completed laparoscopically and they were more likely to have their surgery performed as an outpatient.

CONCLUSION

These data show that women were more likely to present with uncomplicated gallbladder disease, while men were more likely to present with complicated gallbladder disease. This suggests that male patients present at a more advanced stage of disease.

Factors that Predict the Need for Subtotal Cholecystectomy

BACKGROUND

Subtotal cholecystectomy is a "damage control" or "bailout procedure" that is used in difficult gallbladder cases when severe inflammation distorts the local anatomy resulting in increased risk in damage to surrounding structures. Subtotal cholecystectomy rates increased nationally over the past decade. We aimed to determine provider experience and patient factors associated with the performance of subtotal cholecystectomies.

METHODS

All cholecystectomies from 2016 to 2019 were reviewed. Patient demographics, laboratory values, imaging, preoperative diagnosis, surgical technique (fenestrating vs. reconstituting), and years of attending and resident experience were collected. Multivariable regression analysis was performed to evaluate for factors that increase the likelihood of subtotal cholecystectomy.

RESULTS

Of 916 cholecystectomies, 86 were subtotal. The likelihood of subtotal cholecystectomy did not increase based on attending experience of ≤5 vs. > 5 years (odds ratio (OR) .66, P = .09). Older age (adjusted odds ratio (aOR) 1.23, P = .03), male sex (aOR 2.59, P < .01), white blood cells (WBC) above 10.3 (aOR 2.02, P = .02), and preoperative diagnosis of acute on chronic cholecystitis (aOR 5.47, P < .01) were associated with increased likelihood of subtotal cholecystectomy.

DISCUSSION

Older age, male sex, WBC above 10.3, and preoperative diagnosis of acute on chronic cholecystitis were associated with the increased likelihood of subtotal cholecystectomies. The performance of subtotal cholecystectomy was not impacted by attending years of experience. In cases of severe gallbladder pathology, this technique is being used as an operative strategy among all surgeon levels.

Is a difficult gallbladder worth removing in its entirety? - Outcomes of subtotal cholecystectomy

Background:

Laparoscopic Cholecystectomy one of the commonest procedures performed worldwide isn't spared from the risks of disastrous iatrogenic complications. In patients with obscured anatomy, the idea of performing a safe total cholecystectomy can be hindered with a high risk of biliovascular injuries. In such a situation STC (subtotal cholecystectomy) comes to the rescue, where the diseased organ can be tackled fairly, without any further damage.

Aims and Objectives:

The primary aim was to look at the immediate and long-term outcomes of subtotal cholecystectomy. Subgroup analysis was done based on demographics, indications and surgical approach.

Materials and Methods:

We reviewed our prospectively maintained computerized operation database over nine years. STC was defined as leaving behind any portion of gallbladder other than the cystic duct. They were subclassified as per the description given by Palanivelu. Patients were evaluated with laboratory and radiological assessment.

Results:

A total of 70 out of 602 patients (11.6%) underwent STC. Dense adhesion at the calot's was the most important reason for STC. Subtype B was the most common. Nine patients (12.85%) had a bile leak in the postoperative period. There were no biliary/vascular injuries and 30-day mortality was zero. 22.8% developed SSI (surgical site infection). Over a median follow up of 38 months (range 5-98), clinical examination, LFT and USG revealed no abnormality in any of the patients.

Conclusion:

Subtotal cholecystectomy is a useful alternative during difficult gallbladder surgery. It should be considered early into the procedure preferably prior to conversion to an open procedure. Biliovascular injuries can be avoided and the Immediate and long-term outcomes are acceptable.

¿Es más difícil la colecistectomía laparoscópica después de una colangiopancreatografía retrógrada endoscópica? Experiencia en un hospital de tercer nivel

Introducción. La colecistectomía laparoscópica es el tratamiento estándar para la colecistitis aguda. En pacientes con coledocolitiasis, la colangiopancreatografía retrógrada endoscópica es el tratamiento de elección. Se ha reportado que, después de este procedimiento endoscópico, la colecistectomía laparoscópica es más difícil y son mayores las tasas de conversión, hemorragia y tiempo operatorio. El objetivo de este estudio fue determinar si en nuestro medio las colecistectomías laparoscópicas posteriores a este procedimiento endoscópico presentan más complicaciones posquirúrgicas y mayor dificultad técnica. Métodos. Estudio de cohorte prospectivo, en el que se comparó un grupo de pacientes sometidos a colecistectomía laparoscópica previa colangiopancreatografía retrógrada endoscópica, contra un grupo homogéneo de pacientes sin colangiografía previa, para evaluar la dificultad en la colecistectomía laparoscópica, la conversión, la reintervención y las complicaciones. Resultados. El 45,4 % de las cirugías fueron difíciles. No hay relación entre la realización previa de colangiopancreatografía retrógrada endoscópica y la dificultad de la colecistectomía laparoscópica. Con el modelo de regresión logística, se encontraron como factores predictores para una cirugía difícil, la edad, el sexo masculino, la cirugía abdominal previa, la colecistitis aguda y la mayor gravedad de la colecistitis aguda.  Conclusión. La colangiopancreatografía retrógrada endoscópica en nuestro medio no constituye un factor de riesgo para dificultad en la colecistectomía laparoscópica. Debe prestarse especial cuidado al sexo masculino, la gravedad de la colecistitis aguda, los antecedentes de cirugía abdominal y la presencia de comorbilidades a la hora de planear una colecistectomía laparoscópica, tomando precauciones adicionales en estos casos para prevenir complicaciones.

Gender Disparities in the Presentation of Gallbladder Disease

Although gallbladder disease (GBD) is more common in females, we have noticed a trend toward more complicated cases in male patients. We reviewed all cholecystectomies performed at our institution over the last five years. After eliminating cases with confounding variables, we identified 1529 records. Charts were reviewed for age, gender, BMI, procedure performed, operative time, length of stay, and preoperative diagnosis. Descriptive and inferential statistical analyses were conducted along with linear regression. There were 1444 laparoscopic, 64 laparoscopic converted to open, and 21 primary open cases. Patients were 1008 (66%) females and 521 (34%) males. Average operative time was 89.8 minutes. Cholecystectomy averaged 17.7 minutes longer in males ( P = 0.0046). Two per cent of female patients and 7.9 per cent male patient converted to open. Males were more likely to have complicated GBD, whereas women had uncomplicated disease. Average age was 51.9 years for males versus 42.7 years for females. Age, gender, BMI, length of stay, and preoperative diagnosis were all independently significant in predicting operative time. In our study, women presented with uncomplicated GBD, whereas men presented with complicated GBD. This suggests that male patients present at a later stage of disease.

Surgical site infection following abdominal surgery: a prospective cohort study

Background

Surgical site infection (SSI) is one of the most common complications of abdominal surgery and is associated with substantial discomfort, morbidity and cost. The goal of this study was to describe the incidence, bacteriology and risk factors associated with SSI in patients undergoing abdominal surgery.

Methods

In this prospective cohort study, all patients aged 14 years or more undergoing abdominal surgery between Feb. 1 and July 31, 2016, at a single large academic hospital were included. Patients undergoing vascular, gynecological, urological or plastic procedures were excluded. Patients were followed prospectively for 30 days. Wound assessment was done with the Centers for Disease Control and Prevention definition of SSI. We performed multivariate analysis to identify factors associated with SSI.

Results

A total of 337 patients were included. The overall incidence of SSI was 16.3% (55/337); 5 patients (9%) had deep infections, and 25 (45%) had combined superficial and deep infections. The incidence of SSI in open versus laparoscopic operations was 35% versus 4% (p < 0.001). The bacteria most commonly isolated were extended-spectrum β-lactamase-producing Escherichia coli, followed by Enterococcus species. Only 23% of cultured bacteria were sensitive to the prophylactic antibiotic given preoperatively. The independent predictors of SSI were open surgical approach, emergency operation, longed operation duration and male sex.

Conclusion

Potentially modifiable independent risk factors for SSI after abdominal surgery including open surgical approach, contaminated wound class and emergency surgery should be addressed systematically. We recommend tailoring the antibiotic prophylactic regimen to target the commonly isolated organisms in patients at higher risk for SSI.

A Retrospective and Prospective Study to Develop a Pre-operative Difficulty Score for Laparoscopic Cholecystectomy

BACKGROUND

The objectives of this study were to develop a grading system to enable pre-operative prediction of technical difficulty of laparoscopic cholecystectomy using retrospective data and to attempt to validate our scoring system prospectively.

METHODS

Retrospective analysis was conducted of 100 consecutive patients. Pre-operative variables were collected based on a template devised by the American College of Surgeons. Outcomes were duration of surgery, conversion to open and post-operative complications. Multivariate analysis with subsequent measurement of hazard ratios was used to formulate a weighted grading system. Prospective analysis was performed of 100 consecutive patients who were scored pre-operatively. Outcomes were duration of surgery and length of stay.

RESULTS

Retrospective univariate analysis identified four variables associated with an increase in duration of surgery: male gender (p = 0.023), age (p = 0.000), body mass index (BMI) (p = 0.000) and pre-operative endoscopic retrograde cholangiopancreatography (ERCP) (p = 0.001). Prospective analysis revealed weak positive correlations between the scoring system and duration of surgery (0.34) and length of stay (0.40).

CONCLUSION

We have identified four pre-operative variables that predicted a longer duration of surgery. Preliminary results suggest a positive correlation between this scoring system and duration of surgery. An adequately powered prospective multi-centre study is needed to validate our findings.