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LAPAROSCOPIC CHOLECYSTECTOMY – 14 YEARS OFEXPERIENCE IN THE SECOND SURGICAL CLINIC
CLUJ - NAPOCA
156
Journal of Experimental Medical & Surgical Research
Cercetãri Experimentale & Medico-Chirurgicale
Year XIV · Nr.4/2007 · Pag. 156-166C e r c e t a r ie x p e r i m e n ta le &
m edico-chirurgicale
)
Correspondence to: Asist. Univ. Dr. STANCU BOGDAN M.D.Surgical Clinic IIUniversity of Medicine and Pharmacy“IuliuHaþieganu” Cluj NapocaStr. Clinicilor, Nr. 4 – 6400006 Cluj Napoca, ROMÂNIA. E-mail: [email protected]
ABSTRACT: Since its discovery, on the 1st of March 1987, by Philippe Mouret from Lyon, thelaparoscopic cholecystectomy (LC) has become the main treatment of symptomatic gallbladerlithiasis. In the Second Surgical Clinic Cluj Napoca, the first LC was performed in february 1994 by a surgical team led by Prof. Dr. Aurel Andercou. The paper aims to present an analiticretrospective study of 901 patients, who underwent LC in our service between 1994 and 2007.Our study included all patients with acute or chronic cholecystitis, with or without lithiasis whounderwent LC or where LC was only attempted. From our study group we found the highestincidence of chronic lithiasic cholecystitis on female patients, age between 40 and 59 years. Of all laparoscopic techniques, the retrograde LC is the most used procedure in our service. We noticethe high incidence of acute lithiasic cholecystitis in our study group (23,3%), the conversion,intraoperative incidents and accidents as well as postoperative complications being morefrequent in those cases. The LC is a safe surgical intervention under the circumstances of a proper selection of patients, an adequate intraoperative surveillance and a perfect surgical techniquebeing followed by a simple and favourable postoperative evolution; regarding the quality of lifeand the economical aspects, LC is preferable to the classical procedure. KEYWORDS: Laparoscopic cholecystectomy, acute cholecystitis, complications.
COLECISTECTOMIA LAPAROSCOPICÃ – 14 ANI DE EXPERIENÞÃ ÎN CLINICA CHIRURGIE IICLUJ NAPOCA
REZUMAT De la introducerea sa, la 1 martie 1987, de cãtre Philippe Mouret din Lyon,colecistectomia laparoscopicã a devenit tratamentul chirurgical de referinþã al litiazei vezicularesimptomatice. În Clinica Chirurgie II Cluj Napoca, prima colecistectomie laparoscopicã seefectueazã în februarie 1994 de cãtre o echipã operatorie condusã de cãtre Prof. Dr. AurelAndercou. Lucrarea de faþã îºi propune sã prezinte un studiu retrospectiv analitic realizat pe 901pacienþi, la care s-a practicat colecistectomie laparoscopicã în serviciul nostru, în perioada 1994– 2007.Criteriul de includere în studiu a fost stabilit pentru pacienþii cu diagnosticul de colecistitãacutã sau cronicã respectiv litiazicã sau alitiazicã la care s-a practicat colecistectomialaparoscopicã sau la care s-a tentat colecistectomia laparoscopicã efectuându-se apoi conversiala colecistectomia clasicã. Din lotul de 901 pacienþi studiat se evidenþiazã incidenþa crescutã acolecistitei cronice litiazice la sexul feminin, mai ales în decadele 4 ºi 5 de viaþã. Dintre tehnicilelaparoscopice, colecistectomia retrogradã laparoscopicã este tehnica cea mai frecvent utilizatãîn cadrul serviciului nostru. De remarcat incidenþa crescutã a colecistitei acute litiazice în lotulstudiat (23,3%), conversia, incidentele ºi accidentele intraoperatorii cât ºi complicaþiilepostoperatorii fiind mai frecvente în cazul acesteia.Colecistectomia laparoscopicã este ointervenþie chirurgicalã sigurã în condiþiile unei selecþii adecvate a pacienþilor, a unei monitorizãriintraoperatorii adecvate ºi a unei tehnici chirurgicale desãvârºite fiind urmatã de o evoluþiepostoperatorie mai simplã, mai favorabilã, atât în ceea ce priveºte calitatea vieþii pacienþilor cât ºi din punct de vedere economic faþã de pacienþii la care s-a practicat tehni ca clasicã.
B. Stancu 1,A. Andercou 1, A. Mironiuc 1, O. Andercou 1, D. C. Leucuþa 2
Received for publication:
05.09.2007
Revised: 21.11.2007
1- Surgical Clinic II, “Iuliu Haþieganu” University of Medicine and Pharmacy, Cluj-Napoca2 - Informatics Department, “Iuliu Haþieganu” University of Medicine and Pharmacy, Cluj-Napoca
E x p e r i m e n t a l
M e d i c a l S u r g i c a l
R E S E A R C H
J O U R N A L o f
INTRODUCTION
Since its introduction on the 1st of March 1987 by Dr.
Philippe Mouret from Lyon, the LC has become the main
treatment of symptomatic gallblader lithiasis.
The laparoscopic approach allows us to reduce the
postoperative pain and the consumption of painkillers,
the decrease of the length of hospitalization associated
with a more precocious resumption of the patient’s active
life; also we must remind the esthetic advantage of this
surgical procedure.
The first LC in Romania was performed in 1991 in
Constanþa by a french surgical team led by Prof. Dr. B.
Descot. The first LC completed by a romanian surgical
team was performed on 14th of December 1992 by a team
led by Prof. Dr. Sergiu Duca in The Third Surgical Clinical
Clinic Cluj Napoca. (1)
The first LC in the Second Surgical Clinic Cluj Napoca,
was performed in February 1994 by a surgical team led
by Prof. Dr. Aurel Andercou. (2)
MATERIAL AND METHOD
The aim of this paper is to present an analitic
retrospective study of 901 patients, who underwent LC in
our service between 1994 and 2007.
The inclusion criteria in our study were: patients with
acute or chronic cholecystitis, with or without lithiasis
who underwent LC and the cases where LC was
attempted and conversion to classic cholecystectomy
performed.
The exclusion criteria were: patients without
diagnosis of cholecystitis, respectively the patients with
cholecystitis who underwent classical cholecystectomy
without initial attempt to perform laparoscopic
technique.
The characteristics studied in our paper were: gender,
age, patient’s origin, length of hospitalization,
cholecystitis type, associated diseases, type of surgical
procedure performed, intraoperative detection of
cholecystic anatomical variants, intraoperative and
immediate postoperative complications.
The objectives of our study were:
n The evaluation of the associated factors that
influenced the type of cholecystitis;
n The evaluation of the association between the type
of cholecystitis and the type of the surgical
procedure, intraoperative and immediate
postoperative complications;
n The evaluation of differences connected with the
length of hospitalization depending on the type of
the surgical procedure respectively the type of
cholecystitis;
Data was analyzed using the chi-square Test, the
Exact Fisher’s Test, Mann-Whitney Test and One-Way
ANOVA Test, all tests performed with the SPSS 13.0
software. (3,4)
157
Fig. 1 Distribution of the type of cholecystitis depending on patients’ gender
RESULTS
In the first stage of the study our aim was to evaluate
the factors which were associated with the type of
cholecystitis, thus we estimated the distribution of the
type of cholecystitis relying on the patients’ gender and
we found the following results (Fig. 1.).
Chi - square Test was used to study this association
and it was found a a p value of 0.002.
We also analyzed the distribution of the type of
cholecystitis depending on patients’ age and found a high
incidence of chronic lithiasic cholecystitis in the 5th and
6th decades as pictured in Fig. 2.
158
Fig. 2 Age groups and the type of cholecystitis
Fig. 3 Patients’ origin and the type of cholecystitis
As a part of our study we evaluated the distribution of
the type of cholecystitis relying on the patients’ origin and
we obtained the results from Fig. 3. Chi - square Test was
used to study this association and we found a p value of
0.31.
Among the associated diseases we looked for the
distribution of the type of cholecystitis depending on the
existence of the obesity at the patients from our study
and we obtained the results from Fig. 4.
The Chi - square Test was used in this case and we
found a p value of 0.005 which is statistical eloquent.
In the second stage of our study we tried to evaluate
the association between the type of cholecystitis and the
type of surgical procedure, intraoperative complications
and immediate postoperative complications.
The analysis of the distribution of the type of surgical
procedure depending on the type of cholecystitis
revealed the results from Fig. 5.
Using Fisher's Exact test and we found a p value of
0.29.
159
Fig. 4 The obesity and the type of cholecystitis
Fig. 5 Type of cholecystitis and the type of surgical procedure
We also studied the distribution of the presence of
intraoperative adherences relying on the type of
cholecystitis and the results are presented in Fig. 6.
The chi - square test was used to study this
association and we found p value of < 0.001, which is
statistically significant.
We evaluated the distribution of the presence of
anatomical variants of the gallbladder depending on the
type of cholecystitis an we found the results from Fig. 7.
The chi - square test was used in this case and it was
found p value of<0.001 which is statistically significant.
160
Fig. 6 Type of cholecystitis and the presence of intraoperative adherences
Fig. 7 Type of cholecystitis and the presence of anatomical variants of the gallbladder.
We also studied the incidence of intraoperative
hemorrhage, as a complication during the intraoperative
dissection, depending on the type of cholecystitis and
we found the results corresponding to Fig. 8, with a p
value of 0.001.
161
Fig. 8 Type of cholecystitis and the presence of intraoperative bleeding
Fig. 9 Type of cholecystitis and the presence of immediate postoperative wound infection / granuloma
162
Fig. 10 Type of cholecystitis and the presence of postoperative haemorrhage
Fig. 11 The differences of the length of hospitalization depending on the type of surgical procedure
As an immediate postoperative complication, we
followed the distribution of the appearance of wound
infection and granuloma, relying on the type of
cholecystitis; the results are shown in Fig. 9.
By using Fisher's Exact test we found a p value of
0,68.
Looking at the distribution of postoperative
haemorrhage, as another immediate postoperative
complication, depending on the type of cholecystitis, we
found the results from Fig. 10.
Fisher's Exact test was used to study this association
and we found a p value of 0,032, showing the existence
of a connection between the two variables.
In the third part of our study we tried to evaluate the
differences in connection with the patient’s length of
hospitalization depending on the type of surgical
procedure an we found the results from Fig. 11.
The Mann-Whitney test was used in this case and we
found a p value of < 0,001, showing the existence of a
connection between the two variables.
We also followed the differences between the
duration of hospitalization relying on the type of
cholecystitis; the results are shown in Fig. 12.
The One-Way ANOVA test was used to found if there
are differences between the length of hospitalization
concerning the type of cholecystitis and it was found a p
value of <0,001 (F=6,765), showing the existence of a
connection between the two variables.
DISCUSSIONS
The female patients represent 81,2% of the study grop.
Using the chi- square test we found a p value of 0,002
which shows the existence of a connection between the
female gender and the apperarance of cholecystitis.(
Regarding the distribution of the cholecystitis’ type
relying on the age of patients we found a high incidence
of chronic lithiasic cholecistitis in the 5th and 6th
decades, observation which corresponds to data from
medical literature. In older patients the risk of
complications was higher because of the associated
diseases with difficult anesthesia.(6,7)
About the patient’s origin we remark a higher
incidence of patients from urban areas in 65,7% of cases.
Considering the aetiology of cholecystitis the chronic
lithiasic cholecystitis prevailed (64,5%), followed by the
163
Fig. 12 The differences of the length of hospitalization depending on the type of cholecystitis
acute lithiasic cholecystitis (22,1%), non-lithiasic
chronic cholecystitis (12,2%) and acute non-lithiasic
cholecystitis (1,2%).(9)
Arterial hypertension was found as associated disease
in 31,6% patients, diabetes melitus type II in 8,9%
patients and hypercholesterolemia in 13,1% cases.
Among associated diseases, only obesity found in
25,1% cases, has been prooved, using the chi- square
test, to be associated with the type of cholecystitis
(p=0,005) (10)
In our study group we performed in 97,4% cases
retrograde LC.The percentage of conversion to classic
cholecystectomy represented 2,33% of cases. In medical
literature the conversion was necessary in 2,8% cases
(Alecu L., Bucureºti) respectively 1,99% cases (Radu H.,
Cluj Napoca). (11,12,13,14)
In the group of patients with acute cholecystitis,
23,3% of cases, the conversion rate was 3,8%.
We analyzed the association between the type of
cholecystitis and several intraoperative complications;
we observed the presence of intraoperative adherences
at 61,2% patients. Using the chi - square test we found p
< 0,001, showing the existence of a connection
between the two variables. This is explainable from the
point of view of the physiopathological evolution of the
cholecystitis with severe and repeated accesses, with
the appearance of the oedema of th gallbladder wall
followed by the inflammatory infiltrate and latter, by
fibrosis or chronic inflammatory infiltrate. (10,13)
The presence of the anatomic variants of the
gallbladder (bifid, with septum or 'intrahepatic'
gallbladder) was identified with preoperative and
intraoperative ultrasound in 7% of cases. We studied the
association between the presence of gallbladder
malformation and the type of cholecystitis using chi -
square test and we found a p value < 0,001, showing the
existence of a connection between the two variables.
The malformations of gallbladder seems to play a
favourable role for the appearance of cholecystitis in
patients with chronic forms of cholecystitis (6,3% of
cases).
Another anatomical variant of the biliary ducts - a short
cystic duct was identified in 10,9% cases.
It has been proved in our group of study that the
anatomical variants of the cholecyst are statistically
important. Regardless of the perturbation created in the
physiology of the biliary system, those variants must be
well known by the surgeon to avoid major accidents
during the laparoscopic surgery. (15)
Regarding the study of intraoperative complications,
we followed the correlation of intraoperative
haemorrhage (9,7% of cases), with the type of
cholecystitis and found a p value of 0,001 which is
statistical signifficant. The bleeding results in most of the
cases by perforation of Glisson's capsule, during the
cholecyst dissection from the gallbladder’s bed. We must
not forget the possibility of bleeding from the cystic
artery because of it’s large number of division and
anatomic variation, which reach in the medical literature
a percent of 40% cases, and only in 54-60% cases the
cystic artery goes through the Calot triangle parallel with
the cystic duct. (1,2,5,16)
We also studied the distribution of the postoperative
haemorrhage as an immediate postoperative
complication, which was identified in 0,77% cases,
depending on the type of cholecystitis. Fisher's exact test
was used to study this association and we found a p
value of 0,032. We must notice that in 6 out of 7 cases
with postoperative haemorrhage, the diagnosis was
acute lithiasic cholecystitis. The explanation correspond
to incomplete hemostasis at the level of numerous
sectioned adherences and in the hepatic gallbladder’s
bed as main cause, all those postoperative bleedings
being minor and moderate, corresponding to class II A
after Clavien classification and requiring only
conservative treatment. (1,6,8,17)
Other postoperative compliactions were: wound
infection and granuloma (2,1%), postoperative bile
leakage (0,9%), peritonitis (0,55%), subhepatic absecss
(0,77%), postoperative decease (0,77%), postoperative
lithiasis (0,33%), thrombophlebitis (0,33%), angiocholitis
(0,11%) and lesions of extrahepatic bile ducts (0.33%).
The postoperative death (0,77%) occured after 24-48
hours from the surgical intervention, caused by acute
myocardial infarction or pulmonary embolia.
The appearance of the complications increased the
length of the hospitalization and the cost of treatment.
The prevention of those complications is very useful in
order to emphasize the multiple advantages of the LC.
(18)
A longer length of hospitalization was found in
patients where conversion was performed and the
explanationa are: higher pain symptoms because of the
bigger incision, later patient’s mobilization, the risk of
postoperative adherences and wound infection and also
164
the risk of incisional hernia and evisceration. Analyzing
the correlation between length of hospitalization and
surgical procedure we found a p value < 0,001.
The One-Way ANOVA test was used to see if there are
differences in regarding the length of hospitalization and
type of cholecystitis and we found a p value < 0,001
(F=6,765) which is statistical signifficant. We searched
for differences between the types of cholecystitis two by
two, and found a longer hospitalization length in case of
acute lithiasic cholecystitis with an average of
hospitalization of 10,75 days. This is explainable because
of the intensity of the local, inflammatory and
degenerative changes, the more severe symptoms, the
longer duration of the surgical procedure and more
frequent postoperative complications. (9,19)
CONCLUSIONS
Laparoscopic cholecystectomy is a safe surgical
intervention necessitating a proper selection of patients,
an adequate intraoperative surveillance and a perfect
surgical technique. LC is followed by a simple and more
favourable postoperative evolution, with signifficant
improvement of the patient’s quality of life and the
economical aspect compared with the classical
procedure.
We found a higher incidence of chronic lithiasic
cholecystitis in female patients, especially in the 5th and
6th decades, from urban origin.
In most LC performed we used the retrograde
technique.
Perihepatic adherences were found intraoperative in
61,2% cases. From the intraoperative accidents we
identified more often the haemorrhage due to the
dissection of the gallbladder from it’s hepatic bed and
because of the existence of some cystic artery anatomic
variants.
The management of the complications of LC vary from
local conservative treatment to surgical or laparoscopic
reintervention.
Statistically significant differences were found
concerning the length of hospitalization for patients who
underwent conversion in comparison with those who
underwent LC because of the more invasive incision of
the classical technique and the longer time needed for
wound healing. We searched for statistical differences
between the types of cholecystitis and we found a a
significantly longer hospitalization length in case of acute
lithiasic cholecystitis.
We remark the higher incidence of acute lithiasic
cholecystitis in our study group, conversion rate,
intraoperative incidents as well as postoperative
complications being more frequent in this cases.
In LC, the experience is the surgeon’s best quality that
leads to the decrease of intraoperative complications,
and from there to the importance of the learning curve
which must be reached during the training program for
future specialist surgeons.
165
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