Laparoscopic Cholecystectomy in Biliary Pathology33 [621402]

Laparoscopic Cholecystectomy in Biliary Pathology33
Abstract
Objectives: The main objective of this study is to
present the different surgical options in biliary pathology
and, particularly, the laparoscopic cholecystectomy.
Methods: This is a retrospective study over a 5 year
period, 2010-2014, of patients hospitalised with various
biliary pathologies, who underwent cholecystectomy.
Results: In the period 2010-2014, 6,706 patients
with biliary pathology were hospitalised in the County Clinical Hospital Oradea, from which 5,421 were hospitalised in the surgical wards, with 4,228 patients undergoing various surgical procedures.
Of the total surgical interventions performed, classical
cholecystectomy had a share of 1,761, with conversion
after the laparoscopic attempt performed in 35 cases.
Laparoscopic cholecystectomy was performed in
2,297 subjects, of whom 14 subjects required
laparoscopic cholecystectomy with extraction of the
common bile duct calculus through the cystic duct.
Conclusions: In the pathology of gallbladder and
biliary ducts, of the subjects studied, laparoscopic
cholecystectomy was the elective surgical option, even in cases of choletithiasis with acute gallbladder
inflammationIn the selected cases, duct stones, it can be suitable
to associate two mini-invasive procedures: laparoscopic
cholecystectomy and endoscopic retrograde cholangio-pancreatography.
Keywords: laparoscopic cholecystectomy, biliary
pathology
Introduction
Billiary pathology represents a major public health
problem, due to social and economic factors. Most
common pathologies are: cholelithiasis, acute lithiasis
cholecystitis, acute cholecystitis without lithiasis, biliary dyschinesia, gallbladder carcinoma, postcholecystectomy
syndrome, laparoscopic cholecystectomy complications.
The presence of gallstones is one of the most prevalent
digestive diseases, affecting different life decades, from 20 to 74 years of age. Cholelithiasis risk factors are: age, female
gender, pregnancy, obesity, sedentary lifestyle, biliary strictures, severe and rapid loss of weight. Frequently, cholelithiasis is asymptomatic, discovered accidentally
after an abdominal ultrasound. When the disease becomes
symptomatic, it manifests through biliary colic.
In 50% of cases, billiary colics are recurrent and
require surgery. Gallstone complications are: acute ORIgInAL ARTIcLEs
lApArosC opiC CHoleC ysteC tomy in BiliAry pAtHology
Mariana Ungur1, Zoltán Csiki2, Bogdan Feder3
1Department of Surgery, Faculty of Medicine and Pharmacy, University of Oradea, 2Medical and Health Science Center,
Institute of Medicine, Faculty of Medicine, University of Debrecen, 3Clinical Emergency Hospital Oradea, Department of
Surgery, Faculty of Medicine and Pharmacy, University of Oradea
Address for correspondence:
Dr. Mariana Ungur, assistant professor Department of Surgery, Faculty of Medicine and Pharmacy, University of Oradea 1 Decembrie Street, no. 10, 410068, Oradea, Romania E-mail: [anonimizat] Received: 01.09.2015 Accepted: 30.09.2015 Med Con October 2015 Vol 10, No 3, 33-38

Original articles
Ungur et al34
MEDICAL CONNECTIONS • NUMBER 3 (39) • OCTOBER 2015cholecystitis, choledocolithiasis, Mirizzi syndrome and
biliary ileus.
Acute lithiasis cholecystitis is the most frequent
complication. Positive diagnosis is based on clinical examination, laboratory and imaging data. Diagnostic
criteria are defined using the guide Tokyo in three
different degrees of severity: grade I- reduced gallbladder inflammatory process, grade II describes a milder form of the disease, grade III corresponds to a pronounced
gallblader inflammatory process, adding at least one
another organ dysfunction. The degree and the severity
of the inflammatory process will determine the surgical
approach method. In the acute period is not recommended surgery. A reduced and mild gallbladder
inflammatory process allows a laparoscopic surgery
approach. A severe gallbladder inflammatory process in association with evidence of an organ dysfunction will
have the surgical option of open cholecystectomy
[1,2,3].
The actual trend is laparoscopic cholecystectomy
[4], despite the possible cystic duct injuries. The advantages of mini-invasive surgical approach are undeniable. The laparoscopic cholecystectomy is safety
even in the selected cases of acute cholecystitis associated
with choledocholithiasis [5].
The main objective of this study is to present the
different surgical options in biliary pathology to subjects
with biliary pathology, admitted in our County Clinical
Emergency Hospital.
Material and method
The retrospective study is based on a casuistry of
6,706 patients who were hospitalised in the County
Clinical Hospital Oradea in the period 2010-2014.
The research in casuistry was conducted globally, by
studying of the clinical observation sheets, operatory protocols, referring to the total number of subjects for
the general demographic aspects – age, gender, urban or rural origin, diagnostic framing, surgical methods used,
conversion rate.
Patients were grouped according to pathology:
biliary lithiasis, non-lithiasic biliary injury or injuries of
related organs and also with biliary tract obstruction.
There have also been grouped according to
treatment with invasive surgery and with minimally
invasive surgery.
The surgical methods used were: laparoscopic
cholecystectomy (Figures 1, 2, 3), open cholecystectomy, cholecystectomy with choledocotomy, cholecystectomy
with choledochotomy and performing a bilio-intestinal
anastomosis, laparoscopic cholecystectomy with
Figure 1. Laparoscopic cholecystectomy, intraoperative aspect:
transient mechanical jaundice due to vesicular microlithiasis
with the passage of transcystic calculus; it can be noticed the
clipping of dissected cystic duct, with one calculus located
between the two clips
Figure 2. Dissection, clipping the cystic artery, clipped
dissected cystic duct resulting in the preparation of cystic
artery (Acute catarrhal microlithiasis cholecystitis.
Mechanical jaundice by passage bile duct)
Figure 3. Cystic duct clipped with 2 clips; Cystic artery
clipped and dissected. (Acute catarrhal microlithiasis
cholecystitis. Mechanical jaundice by passage bile duct)
extraction of the common bile duct calculus through
the cystic duct. To a less extent were performed the
following: cholecystoduodenostomy, local excision of
tumors in the sphincter of Oddi, extraction of a calculus located in the sphincter of Oddi, oddian sphincterotomy.

Original articles
Laparoscopic Cholecystectomy in Biliary Pathology35
MEDICAL CONNECTIONS • NUMBER 3 (39) • OCTOBER 2015Others used methods are: postoperative
cholangiography, endoscopic retrograde cholangio-
pancreatography (Figures 4, 5).
Postoperative cholangiographic aspects.
Mechanical jaundice by bile duct stones, with
migrated gallstonesResults
In the period 2010-2014, 6,706 patients with
biliary pathology were hospitalised in the County Clinical Hospital Oradea; of the total number of
patients, 1,967 (29.33%) were male and 4,739
(70.67%) female; 5,421 patients were admitted to
surgical wards
The age decade best represented was 54-64 years,
accounting for 1,410 subjects with biliary pathology. The age decade 65-74 years had 1,244 subjects, and age decade 45-54 years accounted for 1,236 subjects of all cases with biliary pathology, hospitalised during that
period of time (Table I). 1,193 patients belonged to the
55-64 age decade. 1,063 patients belonged to the 65-74
age decade. 992 patients belonged to the 45-54 age
decade, 757 patients were included in the 35-44 age decade, and 661 belonged to the 75-84 age decade. Patients older than 85 years represented 82 cases.
The admitting diagnosis was lithiasic acute
cholecystitis without bile ducts obstruction in 2,027
(37.39%) cases, of which 1,514 (74.39%) were
represented by females; lithiasic acute cholecystitis with bile ducts obstruction in 2,003 (36.95%) patients; non-
lithiasic acute cholecystitis in 568 (10.47%) cases; acute
angiocholitis in 270 (4.98%) subjects and other biliary pathology in 553 (10.20%) cases (Table II).
Other biliary pathologies with a small share in the
total number of subjects were represented by: chronic cholecystitis, choletithiasis with angiocholitis with or
without bile ducts obstruction, choletithiasis and
cholecystitis with or without bile ducts obstruction, choletithiasis without cholecystitis or angiocholitis,
gallbladder neoplasm, extrahepatic bile ducts cancer,
hydrocholecyst, gallbladder perforation, bile ducts obstruction, spasm of the sphincter of Oddi, carcinoma
of the ampulla of Vater, cholesterolosis, gallbladder fistula.Figure 4. Kehr cholangiography, cystic bound stump,
common bile duct and dilated hepatic ducts
Figure 5. Control cholangiography after 12-14 days. Note the
cystic stump, intrahepatic biliary tree, choledoch, the passage
of contrast substance through papilla to duodenum
T able I. Distribution of patients with biliary pathology by age
Age decade 35-44 45-54 55-64 65-74 75-84 >85
Total number of patients hospitalized
in surgical wards 5,421757
13.96%992
18.29%1193
22.00%1063
19.60%661
12.19%82
1.51%
T able II. The distribution of subjects hospitalized in surgical wards, depending on specific biliary pathology
Number of
patientsLithiasic acute
cholecystitis without bile
ducts obstructionLithiasic acute
cholecystitis with bile
ducts obstructionNon-lithiasic
acute cholecystitisAcute
angiocholitisOther biliary
pathology
5,421
100%2027
37.39%2003
36.95%568
10.47%270
4.98%553
10.20%

Original articles
Ungur et al36
MEDICAL CONNECTIONS • NUMBER 3 (39) • OCTOBER 2015Of the total of 5,421 (100%) patients hospitalised
on the surgical wards, 4,228 (77.99%) underwent
various surgical procedures.
Of the total surgical interventions performed,
classical cholecystectomy had a share of 1,761 cases of
which conversion after laparoscopic attempt was made
on 35 subjects (Table III).
Laparoscopic cholecystectomy was performed for
2,297 subjects, of which, in 14 cases laparoscopic
cholecystectomy with extraction of the common bile
duct calculus through the cystic duct was performed.
Cholecystectomy with choledochotomy was
performed in 56 patients, and 41 subjects required cholecystectomy with choledochotomy and performing
a bilio-intestinal anastomosis. In 15 cases of the total
number of surgical interventions, biliary-enteric anastomosis was performed. In 43 cases, cholecystoduodenostomy was performed. 10 patients
underwent cholecystectomy.
Other interventions were local excision of tumours
in the sphincter of Oddi, extraction of a calculus located in the sphincter of Oddi, Oddian sphincterotomy, but
with a small share of the total surgical interventions (Table IV).
Of the 5,421 patients admitted, there have been 22
deaths.
Discussions
Of the 5,421 patients with biliary pathology
hospitalised to the surgical wards of the County Clinical
Hospital Oradea 4,228 (77.99%) underwent various
surgical procedures. From all surgery performed, the classical cholecystectomy had a share of 1,761 cases
(41.65%), of which at 35 cases was done the conversion
after the laparoscopic cholecystectomy was attempted.
From the study of the data submitted, it appears
that in the pathology of gallbladder and biliary ducts,
laparoscopic cholecystectomy was the surgical option
chosen, 54.32 % (2,297 subjects) of the total number of cholecystectomies performed during the study period.
Laparoscopic cholecystectomy introduced in 1985
[6] significantly reduced the need for open cholecystectomy [7] and also its postoperative
complications [8].
Papi and al. [9] did not reveal significant differences
regarding postoperative morbidity and mortality after immediate cholecystectomy versus elective surgery in
cases of acute cholecystitis. That study defined
immediate intervention as the time interval from 1 to 7
days [9]. Other studies highlighted the necessity of performing laparoscopic cholecystectomy within 24 hours from installing the specific symptoms of acute
inflammation [10,11,12].
The baseline study which is the subject of this
article, also considering the specifics of emergency, fits into the modern theory of surgical approach as soon as
possible after acute biliary inflammation. The rate of conversion of laparoscopic cholecystectomy into open
cholecystectomy in the literature is reported between
1.5 and 7.7% [13,12,14]. In the baseline study, the rate of conversion was 5.33%.
The advantages of laparoscopic cholecystectomy are
undeniable: patient’s postoperative pain is much reduced compared with postoperative pain after open
cholecystectomy. The explanation lies in the mini-
incisions of laparoscopy, lack of traction from classical suture, reduced duration of postoperative ileus, rapid
mobilisation of the patient within a few hours of surgery
because the minimum aggression to the abdominal wall does not compel the patient to stay in bed. Natural diet
is resumed rapidly due to postoperative ileus being
greatly diminished. Also, the risks of infection, eventration or evisceration are very low. Aderential
syndrome is much lower in patients whose surgical
procedure of choice was laparoscopic cholecystectomy. The duration of hospitalisation is reduced, allowing T able III. Indications for the conversion to open
cholecystectomy
Total no. of patients 35 100%
Severe adherence syndrome 16 45.71%
Cholecystitis with pericholecystitis 925.71%
Suspicion of the main biliary duct lithiasis 514.28%
Biliary ducts injury 2 5.71%
Hemorrhagic complications 2 5.71%
Gallbladder cancer 1 2.85%
T able IV. Distribution of operated subjects by type of cholecystectomy
Number of
operated
patientsNumber of classical
cholecystectomiesNumber of
laparoscopic
cholecystectomiesNumber of cholecystectomies
associated with other surgical
interventionsOther surgical
procedures
4,228 1,761 2,297 165 5
100% 41.65% 54.32% 3.9% 0.12%

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Laparoscopic Cholecystectomy in Biliary Pathology37
MEDICAL CONNECTIONS • NUMBER 3 (39) • OCTOBER 2015rapid integration of patients in family, social and
professional life [15].
As a consequence, statistical data obtained as a
result of the research conducted in the subjects within the surgical wards of the County Clinical Hospital,
Oradea, also support existing data in the literature.
According to this literature, the laparoscopic approach is more commonly used than the classical approach by open cholecystectomy.
Sometimes, certain considerations require the
conversion of mini-invasive intervention in classical
cholecystectomy to open approach. Causes of this
conversion can be: cholecystitis with pericholecystitis, severe adhesions, suspicion of the main biliary duct
lithiasis, unclear anatomy of the biliary ducts,
hemorrhage, biliary ducts injury, the existence of biliodigestive fistula, neoplasm of the gallbladder or bile
ducts undiagnosed preoperatively, technical reasons
(instruments)
Laparoscopic cholecystectomy is elective in
uncomplicated cases with main bile ducts obstruction [1,4,5].
In the case of obstructive jaundice by calculi, the
therapeutic conduct is different. If ultrasonography shows bile duct dilatation, a percutaneous transhepatic cholangiography will be performed highlighting the level of obstruction and possibly the cause. Endoscopic
retrograde cholangiopancreatography allows exploration
of the distal end of the common bile duct.
Performing laparoscopic cholecystectomy after 3
days of therapeutic endoscopy is optimal. That will allows decreasing the post-sphincterotomy oedema.The
optimal timing should not exceed two weeks, as there is
the the risk of migration of new calculi in the biliary principal ducts, transcystically.
Laparoscopic cholecystectomy is often technically
challenging due adhesions, inflammation and not in the least, large cystic duct after calculi migration. This
requires the use of special techniques: ligation with
endoloop, ligation with intra or extra corporeal knot.
Therapeutic conduct varies from case to case,
depending on the surgeon’s option. Cholecystectomy and exploration of the main bile duct can be performed. During surgery, a cholangiography can be performed to
confirm or rule out the absence of calculi in the common
bile duct. In case there are no calculi in the common bile duct, surgery continues with classical
cholecystectomy. If there are calculi in the common bile
duct, it will be necessary to explore the common bile duct and extract the calculi. Choledochotomy will be
performed. There are situations when the calculus is
blocked in the ampulla of Vater, which requires duodenotomy and performing a sphincterotomy. The calculus will be extracted from the ampulla of Vater, with subsequent suturing of the common bile duct and
mounting a Kehr tube.
Conclusions
The actual trend in the biliary pathology is to choose
the most appropriate surgical treatment according to age, associated diseases, thereby reducing the length of
hospitalisation, postoperative complications, increasing
the patient’s quality of life.
In the pathology of gallbladder and biliary ducts,
for the subjects studied, laparoscopic cholecystectomy was the elective surgical option, even in the cases of
choletithiasis with acute gallbladder inflammation.
In the selected cases, duct stones, it can be suitable
to associate two mini-invasive procedures: laparoscopic cholecystectomy and endoscopic retrograde cholangio-pancreatography. Optimal timing for the therapeutic
endoscopic procedure in relation with the laparoscopic
cholecystectomy- before, during or after cholecystectomy – is in evaluation; this is carried out only in top centres.
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