By Dr. Narotam Dewan.
Most of the serious complications are likely to land up for compensation through a court of law or otherwise.
Absolute Contraindications: Inability to tolerate general anesthesia, portal hypertension, uncontrolled coagulopathy, general peritonitis, or suspected gallbladder carcinoma.
Well, Prepared-Half Done: Success lies in treating a patient and not merely gallstones. Meticulous preoperative workup saves the day. Diseases like acid peptic disease, hiatus hernia, hepatitis, pancreatitis, kidney stones, ca. biliary system, basal pneumonia, IHD, etc. can present like cholecystitis while actually the gall stones are silent. Diseases like HT, LVF, DM, asthma, CRF, deranged LFT, Ac. MI and choledocholithiasis are often associated.
Choledocholithiasis: a high index of suspicion is it in about 5% of patients. MRCP often resolves the matter when US fails. ERCP is invasive but, provides simultaneous clearance of the ducts. Early LC decreases the possibility of another stone entering CBD. Although laparoscopic techniques for CBD clearance are now available, most surgeons are not proficient in the procedure. Lap. Choledocholithotomy in selected cases is good for the patient since it achieves both objectives in one sitting; under one anesthesia and the complications of ERCP are avoided.
Gall Stone Pancreatitis: Since the risk of recurrent disease is about 30% (in 6 weeks) if the patient is discharged without LC, in patients with mild edematous disease with rapid resolution of symptoms LC must precede discharge. In a controlled clinical trial by Kelly, billary surgery during the initial 48 hours in patients with severe pancreatitis was followed by 82% morbidity and 47% mortality. On deferring the surgery until pancreatitis had subsided, morbidity fell to 17.8% and mortality to 11.8%.
Acute Cholecystitis: It is difficult to exert adequate traction on a friable and edematous organ. At least 30% of patients present in acute stage and 20% out of these present with GB mass. It becomes a significant risk factor ifTLC is above 20,000/mm3, the GB wall on the US is more than 3mm thick or patient is above 65 yrs of age. We have to be alert to the possibility of gangrenous cholecystitis, perforation, cholangitis or associated pancreatitis. The decision to convert must be made prior to a complication. Free perforation with bile peritonitis, s/a perforation with pericholecystic abscess or presence of gas due to clostridial infection in the elderly, diabetic or immunocompromised patients mandate the choice of an open procedure. Patients with significant cholangitis can be candidates for emergency biliary decompression by endoscopy of surgery and cholecystectomy should wait.
Obese Patient: Thick abdominal wall makes trocar placement difficult and risky, and ample intra-abdominal fat impairs visualization. Modifications include angling of ports toward the operative field to improve instrument mobility.
Pregnancy: Approximately 0.2% of pregnant mothers require intra-abdominal surgery during the period. The surgeon must consider the gestational age of the fetus for timing of surgery. A common error is to pursue ‘conservative management in these patients. Intervention should be avoided during the first trimester due to the risk of teratogenicity and spontaneous abortion. The third trimester is also perilous because of pre-term labor, premature delivery, limited exposure offered by the gravid uterus, and potential injury to the enlarged uterus upon entering the abdomen. For these reasons, we should delay the surgery until the second trimester or until the delivery of the baby. Pneumoperitoneum, which is necessary for laparoscopic surgery, may cause fetal tachycardia, fetal hypertension, or maternal and/or fetal acidosis. Despite these observations, the overall risk to the mother and fetus in the second trimester is relatively low. Certain precautions including fetal and uterine monitoring, deep venous thrombosis prophylaxis, low pneumoperitoneum pressures should be observed.
Previous Abdominal Surgery: Approximately 20% of patients have undergone previous abdominal surgery. Intra-abdominal adhesions or scarring from the prior procedure may interfere with entry into the abdomen and the performance of the cholecystectomy. Laparoscopic adhesionolysis is often necessary to allow adequate access to the operative field. Central transverse and midline incisions pose more problems as opposed to peripheral ones. With the correct technique, the closed method of insertion is safe for patients with peripheral scars, but the open technique is preferred for central incisions. If a closed peritoneum is created in a previously operated abdomen, the Veress needle insertion should be far removed from the scar. The most popular measure used to ensure that the Veress needle is placed in free intraperitoneal space is the saline drop test.
Injuries to Major Vessels: These are rare but serious, life-threatening complications. the distal abdominal aorta and vena cava, as well as the large pelvic vessels, are especially susceptible to injury when the Veress needle and trocars are inserted into the abdomen. Aorta and iliac vessels were perforated in up to 0.6% of the cases, 10% of them serious. Some fatalities were reported.
Difficulties in Dissection of GB and Calot’s triangle: GB wall thickness, presence of adhesions, contracted GB, impaction of gallstones at the neck of GB, liver size and GB size are significant predictors of overall difficulty. Extensive edema in the region of calot’s triangle and excessive friability can be dealt with by cholecystostomy leaving cholecystectomy for future when the things cool down.
Intraoperative Cholangiography: Is mandatory when anatomical structures are not clearly distinguishable during surgery. It gives us billiary road map.
Bile Duct Injuries: Occur in about 0.7% of patients. Iatrogenic common bile duct injury is the worst complication of laparoscopic cholecystectomy. Many of these injuries occur in the hands of experienced surgeons during an easy cholecystectomy. With increased awareness of the problem and its consequences of surgeons can keep one alert. Most of the cases get involved in malpractice litigation. In the majority of cases, litigation is resolved in favor of plaintiffs by settlement or verdicts.
Anatomically, the most common variation is in the junction between the CD and CHD. CD may join CHD at a very high point of may be closely adherent to the CHD running with it in a common sheath to join it very low. At times CD is very short. The surgeon the can easily mistake CBD for a long CD and can ligate and remove the CBD along with the GB. Other types of injuries include- transactions, excisions, lacerations, clip impingements, burns, bile leaks, and cystic duct leak. Most of these injuries are not detected at the initial surgery. The average delay in diagnosis is 6 days. Complications are worse in patients with delayed diagnosis. Prominent abdominal pain and tenderness dose not develop in majority of patients with abdominal bile collections. Surgeons must watch for the clinical manifestations of bile ascites after laparoscopic cholecystectomy. This diagnosis should be suspected whenever persistent bloating and anorexia last for more than a few days; failure to recover as smoothly as expected is the most common early symptom of bile ascites. A primary surgeon has less successful outcomes from repairs than referral surgeons (27% versus 79%). Serious illness like septicemia and multiorgan failure are associated with a longer period of undrained bile.
Dense fibrosis in the area of calot’s triangle should lead to a change in technique. Fundus first dissection of GB can be done slowly by staying close to the GB. In unprecedented difficulty at the neck of the GB partial cholecystectomy can be done. Excessive traction on the GB should be avoided because it can cause tenting of theCBD-CHD junction and put these at risk of ligation or excision.
Mirzzi Syndrome: A nightmare for the surgeon. There is jaundice caused by impacted GB stone leading to extrinsic compression or to inflammatory stricture of the CHD. The stone can be located in the cystic duct itself, in a cystic duct remnant, or in the gallbladder neck. The stone can cause erosion of the bile ducts and may enter the periductal tissues and the lumen of the common HEPATIC duct, thereby creating a tissue cavity and provoking regional inflammatory changes. Sonography usually reveals the impacted stone in the cystic duct, signs of dilatation of the billiary duct system including the CHD, abrupt narrowing of the CHD at the level of the stone and normal caliber of the CBD below the stone. Cholangiography demonstrates the narrowing of the distal CHD and, in some instances, the dilatation of the proximal billiary duct system. The features may be indistinguishable from those of cholangiocarcinoma. The removal of the GB results in an opening into the CHD or inadvertent removal of a portion of CHD.
Faced with unforeseeable factors, the conversion of LC into an open procedure is never-never a failure. A sound judgment it keeps the surgeon free to perform more and still more laparoscopic cholecystectomies.
Dr. Narotam Dewan, MS, Consultant Laparoscopic & General Surgeon, Dewan Hospital, Ludhiana.Formerly—*Resident surgeon, GOMCO Patiala; *Sr. resident surgeon, CMCH, Ludhiana.; *Consultant surgeon, SJH, New Delhi & Central Hospital, Al-Khoms, Libya; and *Sr. Lecturer, DMCH, Ludhiana.