Rate of Conversion of Laparoscopic Cholecystectomy in Patient with Previous upper Abdominal Surgery

INTRODUCTION

The gold standard treatment for symptomatic gallstones is laparoscopic cholecystectomy. Reduced postoperative discomfort and problems, quicker ambulation, shorter hospital stay, and improved cosmoses are all advantages over open cholecystectomy.¹ LC has a number of advantages over open surgery, including a shorter hospital stay (and hence a quicker return to daily activities and work), less postoperative pain, a faster recovery, better cosmesis, and a cheaper cost ² During LC, a number of issues may develop, some of which are unique to this approach and others which are common to laparoscopic surgery in general.

Anesthesia-related complications, peritoneal access complications (e.g., vascular injuries, visceral injuries, and port-site hernia formation), pneumoperitoneum complications (e.g., cardiac complication, pulmonary complications, and gas embolism), and thermocoagulation complications are just a few of them. ³ Many difficulties have been documented during LC, including anaesthesia, Peritoneal access, pneumoperitoneum, surgical exploration, and thermocoagulation are all concerns that may need conversion from LC to open cholecystectomy, along with a variety of additional factors (OC). ⁴ Conversion should not be regarded as a technical failure when it is appropriate, but rather as a superior surgical practise by both the patient and the doctor.⁵

Regardless of the fact that different studies have revealed varying rates of the reasons of this global medical problem, every institution must be completely aware of the rate and causes of conversion to open surgery depending on culture and geography, as well as inside the institution .⁶ A history of abdominal operations has traditionally been considered a contraindication to the laparoscopic approaches, but recently new ones have been involved to help reduce Open cholecystectomy in comparison with laparoscopic cholecystectomy.⁷

Previous abdominal surgery has long been thought to add to the complexity of subsequent laparoscopic surgeries. Patients who have had previous abdominal surgery are typically treated with a cholecystectomy. Patients affected by various gastrointestinal malignancies often develop metastases to the gall bladder, and Cholecystectomy has gained wide acceptance as a potentially curative treatment after primary surgery.⁸ The aim of the present study was to evaluate the rate of Conversion from laparoscopic cholecystectomy in patient with previous upper abdominal surgery.

PATIENTS AND METHODS

This was a retrospective study included collected records of 50 patients underwent cholecystectomy with previous upper abdominal surgery to detect rate of conversion among them in Al-Azhar University Hospitals & Damanhour Hospital.The study protocol was approved by the Ethical Committee of the Al- Azhar University Faculty of Medicine. Informed consent was taken from each participant before being involved in the study.

Inclusion criteria: Age 18-65+, sex: male & female, and Patients with cholelithiasis/cholecystitis symptoms identified by abdominal ultrasonography after previous upper abdominal surgery. Exclusion criteria: Patients with CBD calculus, dilated CBD, CBD investigation required, and patients with obstructive jaundice symptomsMalignant gall bladder disease is suspected.Patient is unable to have laparoscopic surgery due to a medical condition., and cardiac, renal and hepatic patients.Study Procedures: We collected records about the rate of Conversion from laparoscopic to open cholecystectomy in patient with previous upper abdominal surgeryby collecting:

All patients were subjected to the following:

History taking: Demographic date: name, age, residence, consanguinity. Routine history from All individuals with symptomatic gallbladder disease who come in for treatment.A brief history of anesthesia-related complications.During LC, there have been reports of peritoneal access, pneumoperitoneum, surgical exploration, and thermal Coagulation.. Medical history: diabetes, hypertension, anemia, Preeclampsia, others. History of previous upper abdominal operations, and general examination: heart rate, blood pressure (bp), respiratory rate (rr), temperature of patient.Laboratory investigation: Routine laboratory investigations and liver profile.Complete general examination: Vital signs, signs of (Pallor, Cyanosis, Jaundice, and Lymph node enlargement), and body mass index. Abdominal Examination:(1) For an abdominal inspection and subsequent palpation, lie the patient flat on the bed with their arms by their sides and their legs uncrossed. Examination of the patient's abdomen for symptoms of gastrointestinal disease. (2) Abdominal palpation: Check each of the nine abdominal regions for clinical evidence of gastrointestinal pathology using a superficial palpation. (3) Abdominal deep palpation: Palpate each of the nine abdominal locations once more, this time applying more pressure to detect any deeper lumps. Keep an eye on the patient's face for signs of discomfort (as they may not vocalise this). (4) Abdominal percussion: Percussing the liver. (5) Abdominal auscultation: Auduible intestinal perstalisis.Transabdominal Ultrasound: Transabdominal ultrasound was performed with a low-frequency probe, with a large convex footprint. (1) Finding in acute cholecystitis: U/S showing GB A picture of acute cholecystitis has sludge, numerous stones, a thicker wall, and a tiny amount of pericholecystic fluid.. (2) Finding in chronic cholecystitis: Gall bladder is normal in size, pear shape, thichened wall and multible or single stone, no wall oedema or pericholecystic collection.CT scan: The liver, bile ducts, gall bladder, and pancreas can all be seen using this imaging technique. It is the modality of choice in the staging of malignancies of the liver, gall bladder, bile ducts, and pancreas, and is particularly helpful in detecting hepatic and pancreatic lesions. It can determine the primary tumor's size and location in respect to other organs and blood arteries. Additionally, enlarged lymph nodes or metastatic disease may be visible. Standard computerised tomography (CT) is not a very useful examination for benign biliary disorders. MRCP stands for magnetic resonance cholangiopancreatography.

The gall bladder and biliary system are imaged using magnetic resonance cholangiopancreatography (MRCP), a technique based on nuclear magnetic resonance principles. It is non-invasive and can produce images in cross-section or projection. Contrast is not necessary, and good pictures of the biliary tree can be acquired using proper procedures, demonstrating ductal blockage, strictures, or other intraductal abnormalities. Images produced with endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography are comparable (PTC), but without the risks associated with either procedure. If there was dilated CBD by U/S or elevated alkaline phosphatase enzyme, the patients were subjected to MRCP to exclude the presence of obstructing lesion or stones in biliary system.Intra-operative data that were assessed: Operative difficulties that faced the surgeon during the operation were assessed as difficulty of creation of pneumoperitonium, 1^st trocar insertion, excessive adhesions with obscured anatomy, difficult dissection, injury to viscera, bleeding; operation time which was recorded from first port insertion to last port site closure, conversion to open cholecystectomy was estimated.Post-operative management:

Postoperative analgesia was carried out with ketorolac during the first 24 hours postoperatively and thereafter at the request of the patient. Postoperative pain was assessed by using the visual analog score (VAS) within 24 hours postoperatively, zero equaled no pain and 10 was the worst pain. Patients were observed for sepsis, bleeding, intestinal leak, and jaundice and bile leak. These complications could occur usually within 24 hours postoperatively.All patients had warm oral liquids at the evening, provided there was normal bowel movement and no nausea nor vomiting (ileus). The majority of patients were discharged from the hospital after 24 hours. Otherwise hospital stay was assessed. Patients were reviewed at weeks one and four postoperatively in the surgical outpatient clinic.

Statistical analysis:

SPSS (Statistical Package for Social Sciences) version 22 for Windows® was used to code, process, and analyse the obtained data (IBM SPSS Inc, Chicago, IL, USA). The Shapiro Walk test was used to determine if the data had a normal distribution. Frequencies and relative percentages were used to depict qualitative data. To calculate the difference between two or more sets of qualitative variables, use the Chi square test (2). The mean and standard deviation (SD) were used to express quantitative data (Standard deviation). To compare two independent groups of normally distributed variables, the independent samples t-test was used (parametric data). Mann The Whitney test was used to calculate the difference between quantitative variables in two groups of data that were not regularly distributed. To compare the proportion of outcome between the two groups, use the Z-test for percentages.The chances or risk of a disease occurring among persons who had a certain characteristic or who have been exposed to a risk factor were compared to the odds or risk of the disease occurring among individuals who did not have the characteristic or who had not been exposed to the risk factor. Significant was defined as a P value of less than 0.05.

RESULTS

The mean age was 42.5 ± 15.7 years among the participants. There were 42% males and 58% females among the participants. There were 34% smokes and 66% non-smokers among the participants. Regarding BMI the mean was 25.4 ± 6.1 among the participants. There were 4% had wound infection, 2% had retained CBD stones, 4% had Trocar- site bleeding, 8% had nausea and vomiting and 2% had atelectasis (Table 1).

There were 18% had para umbilical hernia repair, 18% had sleeve gastrectomy,20% had splenectomy, 10% had exploration operation, 6% had perforated peptic ulcer, 10% had gastric bypass, 6% had fatty hernia of Linea alba repair, 2% had right nephrectomy and 2% had congenital umbilical hernia repair among the participants. Regarding type of incision there were 42% had transverse upper abdominal incision, 24% had midline incision, 18% had five port site small incisions, 8% had para median incision and 8% had left subcostal incision. Regarding techniques for safe entry to the abdomen, the Hasson's technique was used among 52%, Veress needle was used among 24%, Palmer's point was used among 18%, Visiport was used among 6% of the participants (Table 2).

Regarding intra-abdominal adhesions score, the mean was 2.3± 1.1. There were 18% scored 1, 46% scored 2, 16% scored 3 while 20% scored 4. Among our participants there were 70% needed adhesiolysis, while 30% didn’t need adhesiolysis. The mean operation time was 63.7± 22.8 min. there were 60% had operation time lower than 60 min while 40% had operation time equal or more than 60 min. The conversion rate among the participants was 10%. Among them 4% were due to failed pneumoperitoneum from massive intraperitoneal adhesions, 2% due to dense adhesions in periportal area, and 2% due to small intestine injury. Hospital stay duration, the mean duration was 2.2± 1.8 days while there were 56% stayed for less than 2 days and 44% stayed for 2 days or more (Table 3).

The mean ALT was 63.1± 11.3, the mean AST was 25.1± 8.4, the mean GGT was 18.8± 9.5, the mean serum transaminase was 38.4± 7.6, the mean alkaline phosphatase was 69.5± 13.1, the mean albumin was 3.32± 0.43 and the mean total bilirubin was 1.5± 0.83. The mean WBCs was 5.5± 1.4, the mean random blood sugar was 120.7± 15.3, the mean blood urea nitrogen was 8.7± 4.1 and the mean serum creatinine was 1.1± 0.2. The mean PT was 10.7± 0.8 seconds among the participants. The mean PTT was 33.5± 2.4 seconds while INR was 0.93± 0.3 among the participants. The mean Hb was 11.2± 1.2 among the participants.

There were 82% had cholelithiasis/cholecystitis, 14% had common bile duct stones and 4% had biliary pancreatitis. The mean gall bladder thickness was 4.6± 0.7, there were 24% had pericholecystic fluid (Table 5).

The mean post-operative pain score was 4.2 ± 2.1. While there were 24% scored 2, 22% scored 3, 28% scored 4 and 10% scored 5 among the participants (Table 6).

Table 1: Basic characteristics and postoperative complications among the participants

Table 2: Types of previous, type of incision surgeries among the participants and Techniques for safe entry to the abdomen

Table 3: Intra-abdominal adhesion score, need for adhesiolysis, conversion rate among the participants, operation time and hospital stay duration among the participants

Table 4: Liver function tests and other laboratory parameters among the participants

Table 5: Diagnosis and radiological finding among the participants

Table 6: Post-operative pain score among the participants