Could preoperative sonographic criteria predict the difficulty of laparoscopic cholecystectomy?

The efficacy of laparoscopic cholecystectomy vs. non-invasive gallstone dissolution to manage cholelithiasis: clinical outcomes and quality of life

BACKGROUND

This retrospective study aims to compare the clinical efficacy and impact on the quality of life of laparoscopic cholecystectomy with medication dissolution of gallstones.

METHODS

Clinical data of 86 cholelithiasis patients admitted to our hospital from January 2021 to December 2022 were retrospectively analyzed. The patients were divided into a conservative group of 40 cases and a surgical group of 46 cases based on different treatment methods. The conservative group received ursodeoxycholic acid combined with compound cholecystokinetic granules for gallstone dissolution, while the surgical group underwent laparoscopic cholecystectomy. The clinical efficacy, recovery indicators, complications, pre- and post-treatment Short-Form 36 Health Survey (SF-36) scores, and recurrence rates were observed.

RESULTS

In the surgical group, the total effective rate was higher, the time to symptom relief and length of hospital stay were shorter, but the hospitalization costs were higher than conservative group. The incidences of complications and the recurrence rate were lower in the surgical group than in the conservative group. However, the SF-36 scores for post-treatment physiological function, physical role function, bodily pain, vitality, and general health were higher in the surgical group than in the conservative group.

CONCLUSIONS

Compared to medication dissolution, laparoscopic cholecystectomy demonstrates superior efficacy in the treatment of cholelithiasis, promoting symptom relief, reducing hospitalization duration, decreasing the incidence of complications, improving quality of life, lowering recurrence rates, and therefore deserves wider clinical application.

Frequency and Predictors of Conversion From Laparoscopic to Open Cholecystectomy: A Single-Center Observational Study

OBJECTIVE

The study aimed to investigate the rate of conversion from laparoscopic cholecystectomy (LC) to open cholecystectomy (OC) in our population and determine the potential risk factors associated with it. Understanding these factors helps surgeons predict complex cases and plan surgeries, reducing patient risks and improving outcomes.

METHODOLOGY

A cross-sectional observational study was conducted from June 1, 2022, to May 31, 2023, at Hayatabad Medical Complex, Peshawar, on 349 patients undergoing elective LC. Data on demographics, clinical history, laboratory values, and imaging findings were recorded using a standardized proforma. Intraoperative findings, surgical outcomes, and complications were noted, with statistical analysis performed using IBM SPSS Statistics for Windows, Version 23.0 (Released 2015; IBM Corp., Armonk, New York, United States). Chi-squared, Mann-Whitney U, and logistic regression tests assessed the associations and risk factors of conversion to open surgery.

RESULTS

 The rate of conversion from LC to OC was found to be 13 (3.7%). The multivariate analysis revealed several significant risk factors associated with the conversion. These included male gender, history of jaundice due to gallbladder stones, history of pancreatitis, gallbladder wall thickness greater than 3 mm, white blood cell counts greater than 1000 per microliter of blood, difficulty in handling the gallbladder with instruments intraoperatively, and dense adhesions with surrounding tissues (p<0.05). The risk factor summation pyramid showed a sensitivity of 84.6% and a specificity of 63.8% in predicting the likelihood of conversion, emphasizing the importance of considering each risk factor individually.

CONCLUSION

The rate of conversion to OC was 3.7%. Factors such as male gender, history of jaundice due to gallbladder stones, history of pancreatitis, thick gallbladder wall, high white blood cell count, difficulty in handling the gallbladder, and dense adhesions with surrounding tissues were significantly associated with conversion to OC.

Assessment of Predictors of Difficult Laparoscopic Cholecystectomy by Clinico-Radiological Parameters at a Tertiary Hospital in Eastern India

BACKGROUND

Laparoscopic cholecystectomy has become the standard treatment for gallbladder (GB) stones, favored for its minimally invasive approach. Despite its benefits, the procedure sometimes requires conversion to open cholecystectomy due to intra-operative challenges, with conversion rates varying between 1% and 13%. There are various preoperative predictors that help in identifying such difficult cases and help to proceed safely. This study aims to identify the preoperative factors that could predict the difficulty of laparoscopic cholecystectomy, thus anticipating the need for conversion to open surgery.

METHODS

A prospective observational study was conducted at RIMS Ranchi, India, from May 2023 to May 2024, including a total of 93 patients with gallstone disease who underwent laparoscopic cholecystectomy. Clinical history including age, gender, presence of acute cholecystitis, previous attacks, and previous upper abdominal surgery; biochemical markers including white blood cell (WBC) count, total bilirubin and alkaline phosphatase (ALP), and ultrasonographic findings such as GB wall thickness, stone impacted at the neck of GB, contracted or distended GB, presence of pericholecystic fluid collection, Mirizzi's syndrome and others were analyzed to identify predictors of conversion.

RESULTS

Of the 93 patients included in our study, there were 28 males and 65 females with a ratio of 1:2.3. The age group varied from 14 to 72 years with conversion to open cholecystectomy seen between the age group of 31-70 (mean age 49 years). We observed that 10 patients (conversion rate of 10.75%) underwent conversion from laparoscopic to open cholecystectomy. Significant predictors included acute cholecystitis, multiple previous attacks, and ultrasonographic findings of contracted GB.

CONCLUSION

Preoperative identification of patients at higher risk for conversion can enhance surgical planning and patient counseling, potentially improving outcomes in laparoscopic cholecystectomy.

Current state of minimally invasive general surgical practice in Africa: A systematic review and meta-analysis of the laparoscopic procedures performed and outcomes

BACKGROUND

Minimally invasive surgery, including laparoscopy and robotics, has significantly improved general surgical (GS) practice globally. While robot-assisted GS practice is yet to be adopted in the majority of Africa, laparoscopy has been utilized to improve surgical outcomes. This study aims to review the laparoscopic GS procedures (LGSPs) performed and evaluate outcomes such as conversion to open surgery, morbidity, and mortality in Africa.

METHODS

Four databases (PubMed, Google Scholar, WoS, and AJOL) were searched, identifying 8022 publications. Following screening, 40 studies across Africa that reported LGSPs (n ≥ 2) performed and outcomes met the inclusion criteria. A meta-analysis conducted using R statistical software estimated the pooled prevalences with the 95% CI of conversion, morbidity, and mortality.

RESULTS

A total of 6381 procedures performed in 15 African countries were analyzed in this study. Majority, 72.89%, of the procedures were performed in Senegal, South Africa, and Nigeria. The major procedures performed were cholecystectomy (37.09%), appendicectomy (33.36%), and diagnostic laparoscopy (9.98%). The meta-analysis revealed a conversion rate of 5% [95% CI: 4, 7]. Adhesion (28.13%), hemorrhage (16.67%), technical difficultly (12.50%), and equipment failure (11.46%) were the predominant indications for conversion. Surgical site infection (42.75%) was the major cause of morbidity. The prevalences of morbidity and mortality were 7% [95% CI: 5, 10] and 0.12% [95% CI: 0, 0.29], respectively.

CONCLUSION

A wide range of basic and advanced LGSPs were performed. The outcomes obtained indicate successful implementation of the laparoscopic approach. Importantly, this study serves as a foundational work for further research on minimally invasive surgery in Africa.

Analysis of the sonographic predictors of difficult laparoscopic cholecystectomy in symptomatic cholelithiasis

BACKGROUND

Laparoscopic cholecystectomy (LC) is one of the most common laparoscopic procedures performed by young surgeons nowadays. Sometimes, LC could be challenging, especially for junior surgeons leading to serious complications. Therefore, this study aims to investigate the preoperative ultrasonographic features that could predict difficult LC.

METHODS

In this prospective study, patients (n = 204) who underwent LC for symptomatic cholelithiasis from January 2020 to August 2022 were included. Preoperative parameters, including the ultrasonographic findings, were evaluated for their ability to predict difficult LC.

RESULTS

The difficulty of LC was evaluated using two intraoperative scores. Among the ultrasonic parameters that were assessed preoperatively, thickened gallbladder (GB) wall, contracted GB, and impacted stone in the GB neck were associated with difficult LC. However, an impacted stone in the GB neck was the only independent predictor of difficult LC according to both difficulty scores in the multivariate analysis (odds ratio [OR] = 7.56, p = .001; OR = 8.42, p = .001).

CONCLUSIONS

The impacted stone in the GB neck is an ultrasonographic sign of difficult LC. It should alert the surgeon for a more appropriate preoperative preparation, and the patient should be informed about the increased risk of complications, including conversion to open cholecystectomy.

Defining Critical View of Safety During Laparoscopic Cholecystectomy: The Preoperative Predictors of Failure

Background Defining critical view of safety (CVS) is one of the most crucial steps during laparoscopic cholecystectomy (LC). This study aimed to determine the preoperative predictors of failure to achieve CVS during LC. Methods All patients undergoing LC from December 2020 to July 2022 were prospectively included. Results There were 180 females and 93 males. CVS was achieved during LC in 238 (87.2%) patients. Conversion to open surgery was performed for 11 patients. Bile leak occurred in three patients which resolved spontaneously. No patient developed bile duct injury. On univariate analysis, age, male sex, American Society of Anaesthesiologists (ASA) grading, Murphy's sign, emergency surgery, neutrophil percentage, lymphocyte percentage, gallbladder wall thickness > 3mm, and impacted gallstone on abdominal ultrasound were predictors of failure to achieve CVS. On multivariate analysis, neutrophil and lymphocyte percentages were independent predictors of failure to achieve CVS. Patients in whom CVS could not be achieved had significantly longer operative time, higher blood loss, complications, and hospital stays. Discussion Inability to achieve CVS during LC can be predicted preoperatively using various parameters including neutrophil and lymphocyte percentages. Such cases must be operated by senior surgeons or referred to experienced general or hepatobiliary surgeons for cholecystectomy to avoid bile duct injury. The proposed algorithm can help in intraoperative decision-making in difficult cases.