Laparoscopic cholecystectomy in empyema of gall bladder : An experience at Liaquat University Hospital , Jamshoro , Pakistan

in mind a slightly increased risk of complications even in the best hands.However, the experience of the surgeon Objective: To find out the safety profile of plays a key role in the overall outcome. laparoscopic cholecystectomy in empyema of gallbladder. Background: Empyema of gall bladder


Original Article
Laparoscopic cholecystectomy in empyema of gall bladder: An experience at Liaquat University Hospital, Jamshoro, Pakistan

INTRODUCTION
LC was attempted in 67 patients of empyema of gallbladder within 24h.However in few cases there The laparoscopic cholecystectomy (LC) has presentation of this disease is often difficult to these, 67 (6.90%) patients were diagnosed to have distinguish from acute cholecystitis. [1]pyema gall bladder.LC successfully completed suggesting diagnosis and seriousness of this disease are few. [2]5][6][7] It is also considered one of the commonest reasons for the conversion. [8][11][12][13] There can be various reasons and factors which can however, lead to conversion. [14]Obscured local anatomy, uncontrolled ) .

Features
Malik, et al.: Laparoscopic cholecystectomy in empyema of gall bladder bleeding and damage to nearby vital structures are the common factors responsible for conversion. [15]espite various encouraging reports, the role of laparoscopic surgery in such acute conditions is still under evaluation.This study aimed to find out safety and outcome of LC in empyema gallbladder.patients while remaining 25 (37.31%)patients were needle.In case of thick pus the gallbladder was incised identified during surgery.All of these patients were and the suction cannula directly introduced into gall operated laparoscopically within 24h of the bladder to aspirate pus.At times the suction cannula admission.Fifty-four (80.59%)LC were completed was also used to dissect the dense adhesions in the successfully while in 13 (19.40%)patients the area of Calot's triangle.The thickened wall of the procedure was converted to OC due to various reasons gallbladder was also incised to apply the graspers as shown in Table 2. Conversion was found more properly in cases where it was difficult to get hold of common in those who had history of repeated attacks the thick, edematous gallbladder.Data of each patient of acute cholecystitis in the past.Total operating time was recorded on a data form including demographic ranged from 60-160 minutes with a mean of 87 operative findings, intraoperative minutes.Maximum patients (70.14%) were operated complications, post operative complications and duration of hospitalization.The results were analyzed included in the study regardless of age and gender.

Exclusion criteria
Patients with major medical problems in which pneumoperitoneum was thought to be unsafe and those with overwhelming sepsis were excluded from the study.

RESULTS
Nine hundred and seventy LC were performed for gallstone disease, of which 319 (32.88%) patients were found to have complicated gallstone disease.][24] The nature of the study population between 60-90 minutes.Operative complications of must also be known as suggested by Gouma. [25]The varying degrees and severity occurred in 12 (22.22%)study population in this report is mainly from poor out of 54 successfully operated cases [Table 3A].The socio-economic background, coming from remote overall rate of postoperative complications was areas of rural Sindh province of Pakistan.There is a 18.51% in successfully completed LC and 61.53% in general reluctance for surgery in these patients the converted population [Table 3B].Majority of the fibrosis and firm adhesions.These are the common three (5.55%)patients were discharged in two weeks factors producing distortion of local anatomy. [26,27]

time. The average hospital stay in patients converted
This has been the main factor in conversions in this to open operation was 10 days.Wound sepsis was series with an additional contribution of our standing found to be more common in this group, contributing on the learning curve.The conversion rate can be to an increased overall morbidity.) .
proceed with extreme caution and gentle separation LC has become a preferred and acceptable choice even of the adhesion should be done.[18] The earlier injury.The use of diathermy should be minimal and as to its safety and efficacy are being arguments [19] threshold for conversion should be kept low to ensure answered by a number of encouraging reports [9][10][11][12][13] and patients safety.We decompressed the distended more and more laparoscopic surgeons are persuaded gallbladder before proceeding to Calot's triangle to to perform LC in acute cholecystitis as suggested by facilitate dissection.Tseng et al. [28] have also favored Hunter [20] "to get it while its Hot".Very few reports ( w w w this procedure to make surgery safe and easier.have specifically assessed safety of LC in empyema of Another way of handling such life threatening the gallbladder.This study presents the details of 67 situations is to perform subtotal cholecystectomy after LC performed in empyema gallbladder within 24h of removal of all the stones to ensure safety of patients the admission to asses the safety and suitability of life instead of continuing dissection in the frozen laparoscopic approach in this condition.The Calot's triangle with totally obscured anatomy.The difficulties that we encountered in dissection in the rate of major complications is not significant in area of Calot's triangle are more or less the same as current study as to preclude the laparoscopic mentioned by other similar studies. [14]The overall approach in this condition but there should always be a word of caution while operating on such difficult conditions.This is consistent with the findings of Hobbs et al. [29] claiming that increased risk of ) is consistent with other reports. [7,21]History of recurrent acute ) .
controlled by temponade and gauze pressure, failing which we converted the cases and bleeding controlled.The duodenal perforation was identified then and there and the operation was converted with subsequent primary closure of duodenum.There is always a risk of common bile duct (CBD) injury if the operating surgeon is impatient and anatomy of the field is not clearly displayed before clipping and cutting.Undue use of diathermy is also a major factor in causing CBD injury and should be avoided in the . m e d k n o w .c o m ) .
l i c a t i o n s ( w w w .m e d k n o w .c o m was a delay because of reluctance for surgery or dramatically changed the outlook of patients with delay in giving consent etc.The procedure was symptomatic gallstone disease.Empyema of the performed by standard four-port technique with few changes made to facilitate dissection according to gallbladder is a potentially fatal complication of situation.Results: Between April 2003 to June 2006, gallstones.It is characterized by suppuration 970 LC performed for gallstone disease at surgical superimposed on acute cholecystitis.The clinical unit-1 of LUMHS by the same surgical team.Among because of economical reasons in addition to general patients (83.33%) with successful LC were discharged fear for surgery.Their presentation is therefore with in 48-96h.In six patients (11.11%), the stay in delayed and operation is technically difficult due to hospital was extended to seven days.The remaining l i c a t i o n s significantly reduced by patience, clear display and identification of the anatomy of Calot's triangle before DISCUSSION cutting or applying clips.The dissection should .m e d k n o w .c o m l i c a t i o n s ( w w w .m e d k n o w .c o m This prospective experimental study was conducted in department of surgery (Unit-1), Liaquat University Empyema gallbladder forms a major component in the complicated gallstone disease and account for 21.00% of the complicated gallstone disease in this series.Of the total laparoscopic cholecystectomies, 67 (6.90%) patients of empyema of gallbladder were identified and included in the study population.The diagnosis of empyema gallbladder was established on the basis of such findings as tender, palpable gallbladder, leucocytosis > 12000 cc, ultrasound findings and per-operative aspiration of frank pus from edematous gallbladder.The age ranged from of Medical and Health Sciences Jamshoro, a teaching 21 years to 71 with a mean of 40.82 years.There hospital in Sindh province of Pakistan, during April were nine males and 58 females in the study 2003 to June 2006.The LC was done by standard 4population with male to female ratio of 1:6.4.The port technique with few modifications depending main diagnostic criteria is shown in Table 1 A and B. upon the situation such as an additional port, Preoperative diagnosis was established in 42 (62.68%)percutaneous decompression of gallbladder by spinal

Table 1A : Diagnosis. Clinical features on
SPSS version 10.A well-informed written consent was taken from each patient prior to surgery.

Table 2 : Reasons for conversion to open cholecystectomy. No. of patients
Values in parentheses are percentages.n= 13/54 Malik, et al.: Laparoscopic cholecystectomy in empyema of gall bladder