Evaluation of fundus-first laparoscopic cholecystectomy.

OBJECTIVES: Laparoscopic cholecystectomy is the gold standard for gallbladder surgery. Cholecystectomy from the fundus to the cystic duct may be advantageous when cystic duct exposure becomes difficult due to adhesions on Calot's triangle. The aim of this study was to compare conventional laparoscopic cholecystectomy with the fundus-first procedure and to evaluate whether the fundus-first technique can prevent conversion in difficult cases.
METHODS: The study included 145 patients treated over 18 months. The inclusion criterion was the presence of ultrasound proven gallstones. Patients were excluded from the study if there was evidence of common bile duct stones, a bilioenteric fistula, or carcinoma of the gallbladder.
RESULTS: The fundus-first approach was started in 45 patients; all procedures were completed laparoscopically. Conventional laparoscopic cholecystectomy was begun in 100 patients. Twenty-seven of the 100 patients were converted to fundus dissection (adhesions within Calot's triangle). Four of the 27 were further converted to open surgery. One patient had a drop in blood pressure on creation of pneumoperitoneum. Time taken for severely inflammatory and noninflammatory cases was significantly greater (P<0.05) in the fundus-first group. The average hospital stay was 48 hours in both groups. No major complications were observed.
CONCLUSION: The rate of conversion in the conventional laparoscopic cholecystectomy group decreased from 18.75% (27/144) to 2.08% (3/144). The fundus-first technique has the potential to decrease conversion in difficult cases.

RCT Entities:   Population Interventions Outcomes

INTRODUCTION

Laparoscopic cholecystectomy today is regarded as the gold standard for cholecystectomy. Dissection at Calot's triangle is sometimes difficult or not feasible because of adhesions or anatomical abnormalities. The incidence of bile duct injury is 0.5% to 3% compared with 0.1% to 0.5% in open cholecystectomy.[1] Even today, the major reasons for conversion to open surgery remain difficult anatomy at Calot's triangle and dense adhesions making separation of the cystic duct from the common bile duct (CBD) both difficult and dangerous. Cholecystectomy using the opposite direction of dissection, from the fundus to the cystic duct, may be advantageous when cystic duct exposure becomes difficult. The basis for the use of the fundus-first approach in open surgery is well documented in the literature. In the Lahey Clinic, indications were specified for the use of this approach[2]:

In all cases in which a marked induration and thickening exists about the junction of the common and cystic duct and the common bile duct, and their relation does not exist

All gallbladders possessing such thick walls that traction upon the ampulla or pelvis of the gallbladder necessary to expose the ducts would result in possible rupture of the structures and soiling from septic contents

Clear exposure of the cystic duct and the common duct cannot be made out

Extending these very indications into the laparoscopic arena, we believe that the rate of conversion can be reduced using the fundus-first technique.

The aim of the study was to compare conventional cholecystectomy with the fundus-first procedure and to evaluate whether the fundus-first technique is useful in preventing conversion in difficult cases.

METHODS

The study was carried out in a departmental unit of the Department of Surgery, Maulana Azad Medical College, over 18 months. Outpatients (145) presenting to the clinic with symptoms of chronic cholecystitis and ultrasound proven gallstones were included. The cohort included 22 male patients. The age distribution of the group was 14 to 65 years with an average of 32 years. Forty-five patients underwent fundus-first laparoscopic cholecystectomy. The inclusion criterion was the presence of ultrasound proven gallstones. Patients were excluded from the study if there was evidence of CBD stones, a bilioenteric fistula, or carcinoma of the gallbladder.

The workup of the patients included a hemogram, alkaline phosphatase, serum amylase, blood sugar, blood urea, urine examination, and a chest skiagram. All patients underwent an ultrasonographic examination in our own institution. The procedures were explained and a written informed consent obtained.

Patients were randomly allotted to the 2 groups, and the following parameters were studied: time taken for the procedure (time from insertion of the first port to the withdrawal of the last port); rate of conversion to either procedure and to open procedure; injuries to viscera, viscus, and vessels; injury of the gallbladder leading to bile and stone spillage; effect of bile spillage on hospital stay; and distribution of severely inflamed cases in the 2 groups and rate of conversion in them.

OPERATIVE PROCEDURE

Fundus-First Laparoscopic Cholecystectomy (FFLC)

After insertion of the standard 4 ports, the gallbladder is retracted at the fundus and dissected from the liver fossa to create a space to insert the triflange liver retractor. With the retractor in position, the gallbladder is now easily dissected off the liver bed till it hangs at the junction of the cystic duct with the CBD. At this stage, the gallbladder is divided between clips of Endoloops. In certain situations in very severely inflamed cases, the EndoGIA stapler (Ethicon, Somerville, NJ) is used.

Conventional Laparoscopic Cholecystectomy (CLC)

The gallbladder is dissected at Calot's triangle to divide the cystic duct and artery between clips. The organ is then dissected off the liver bed.

RESULTS

The study group comprised 145 patients; 22 of these were males. Forty-five patients underwent fundus-first laparoscopic cholecystectomy. Of these 45 patients, 22 had severely inflamed gallbladders. Of the 99 patients in the conventional group, 36 had severely inflamed gallbladders. (1 patient was converted to an open procedure due to a sudden fall in blood pressure on creation of pneumoperitoneum.)

Time Taken

The time taken during FFLC for noninflamed cases was significantly greater than that in CLC. The converse occurs in cases where inflammation was present. The time taken during surgery on noninflammatory cases was 50.2±11.4 minutes and 60.95±18.1 minutes for the conventional laparoscopic cholecystectomy and fundus-first laparoscopic cholecystectomy group, respectively. The same procedures performed on the severely inflamed group took 104.8±18.6 minutes and 89.8±14.05 minutes, respectively. The results are significant at 95% interval limits.

None of the patients who underwent the fundus-first method required conversion either to the cystic duct method or to an open procedure (. However, 27 patients in the CLC group required conversion to the FFLC method. Of these, 3 were further converted to an open procedure. One patient had a small duodenal perforation during the procedure and had dense adhesions. She was opened and cholecystectomy along with repair of duodenal perforation was performed. The other 2 were converted due to dense adhesions.

One patient was excluded from the study because she had severe hypotension on creation of pneumoperitoneum. The procedure was immediately terminated and an open procedure performed satisfactorily.

Injuries

One patient had a small duodenal perforation, caused during separation of the gallbladder from the duodenum in the CLC group. Due to dense adhesions and fear of injury, she was converted to an open procedure. The rent was repaired and a cholecystectomy performed.

Injuries of the Gallbladder Leading to Bile Spillage

The incidence of gallbladder injury was greater in the conventional group (. The difference was significant at 95% interval limits. In both groups, the incidence of injury was greater in the severely inflamed group.

Effect of Gallbladder Injury and Bile Spillage on Hospital Stay

The duration of postoperative hospital stay was not affected by bile leakage from gallbladder injury (with injury, 28 of 144 patients, 2 days; without injury 118 of 144 patients, 1.9 days). The small difference shown is not statistically significant. However, the first group did receive antibiotics for a longer period (3 days versus 1 day for the second group).

DISCUSSION

Laparoscopic cholecystectomy today is regarded as the gold standard for cholecystectomy. The chief causes for the increased rate of conversion to open surgery has been nonvisualization of anatomy at Calot's triangle due to dense adhesions.[1,3-5]

During the study, hook scissors and dissectors were used. We did not have the benefit of a Harmonic scalpel. The obvious advantage of fundus-first laparoscopic cholecystectomy is evident in the above study by simple observation of the reduction in conversion to the open procedure. None of the patients started by the fundus-first laparoscopic cholecystectomy technique required conversion to either cystic duct dissection or the open procedure. On the other hand, 27 of the 98 patients who started with the conventional laparoscopic cholecystectomy method required conversion. Twenty-three of these 27 were of the severely inflamed group. All of these patients were first treated with the fundus dissection method. Only 3 of these patients required conversion to an open procedure, the rest being completed laparoscopically. Conversions were required in the severely inflamed group only. Thus, the rate of conversion in the conventional laparoscopic cholecystectomy group has decreased from 18.75% (27/144) to 2.08% (3/144). One patient (hypertensive and asthmatic) was excluded because she had to be converted to an open procedure; as soon as pneumoperitoneum was created, she experienced sudden hypotension.

The time taken during surgery on noninflammatory cases was 50.2±11.4 minutes and 60.95±18.1 minutes for the conventional laparoscopic cholecystectomy and fundus-first laparoscopic cholecystectomy group, respectively. The same procedures performed on the severely inflamed group took 104.8±18.6 minutes and 89.8±14.05 minutes, respectively. This indicates that in the noninflammatory group, fundus-first laparoscopic cholecystectomy technique does not add much; it is in the severely inflamed cases that the technique really adds to the armamentarium of the surgeon.

During the study, 1 injury occurred during dissection of a severely inflamed gallbladder to the duodenum. A pinhead perforation occurred, which was repaired after conversion to open surgery.

Twenty-eight of 144 patients had injury to the gallbladder and subsequent bile leakage and stone spillage. The incidence was higher in the severely inflamed cases and in the conventional laparoscopic cholecystectomy group. The difference is statistically significant within 95% interval limits. This figure compares favorably with that of other studies, some of which have reported up to a 33% injury rate.[6, 7]

The bile spillage did not increase the hospitalization rate, the patients being discharged on an average of 2 days. This group was however given a good saline wash laparoscopically and antibiotics for a period of 3 days on a prophylactic basis. No complication has occurred in the follow-up of these patients.

No patient required blood transfusion, and no injury to the CBD has been reported.

CONCLUSION

It is thus evident that the technique of fundus-first laparoscopic cholecystectomy is a very useful one. It has a role in the management of severely inflamed patients and brings down the rate of conversion. It has provided us with the safety and confidence to tackle difficult cases more than is afforded with the open arena.

Table 1.

Conversion Rate

Fundus-First Laparoscopic Cholecystectomy
With cholecystitis	0/22
Without cholecystitis	0/23
Conventional Laparoscopic Cholecystectomy
With cholecystitis	23/36 converted to FFLC; 3 further converted to open
Without cholecystitis	4/62 converted to FFL

* 1 patient in Conventional Laparoscopic Cholecystectomy group excluded because her blood pressure fell immediately on creation of pneumoperitoneum; the anesthetist did not allow further continuation of the process.

Table 2.

Injuries of the Gallbladder Leading to Bile Spillage

Fundus-First Laparoscopic Cholecystectomy
With cholecystitis	19/36
Without cholecystitis	3/63
Conventional Laparoscopic Cholecystectomy
With cholecystitis	5/22
Without cholecystitis	1/23