Early laparoscopic cholecystectomy in acute gallbladder perforation: Single-centre experience.

BACKGROUND: Acute gallbladder perforation (GBP) is associated with significant mortality and morbidity. Percutaneous drainage followed by interval cholecystectomy has been the preferred management. The outcomes of early surgery, especially by laparoscopy, have not been well studied in GBP. We present our experience in early laparoscopic cholecystectomy in GBP.
METHODOLOGY: A retrospective analysis of patients admitted with GBP between April 2014 and December 2018 was done. Clinical presentation, preoperative imaging, surgical procedure, operative findings and the outcomes in these patients were analysed. Video of the surgeries was reviewed in case of the absence of data from the case records.
RESULTS: Fifteen patients were treated for GBP during the study period. Eleven patients were male, and the mean age was 61 years. Fourteen patients (93.3%) had associated co-morbidities. Systemic inflammatory response syndrome, sepsis, severe sepsis and septic shock were present in 3, 3, 6 and 3 patients, respectively. The location of the collection was gallbladder fossa, pericholecystic, subhepatic and diffuse in 3, 5, 4 and 3 patients, respectively. Intraoperatively, 13 patients were detected to have perforation at the fundus of the gallbladder. Cystic duct stump was managed with clip, endoloop, suturing and external drainage in 7, 2, 5 and 1 patient, respectively. Laparoscopic cholecystectomy was completed in 12 (80%) patients. Retroinfundibular technique was used in 12 (80%) patients. There was one conversion. Two patients required endoscopic retrograde cholangiogram + bile duct stenting, and one was reexplored for cystic artery bleed. There were no mortalities. The median duration of post-operative hospital stay and drain removal was 3 (1-19) and 3 (1-6), respectively.
CONCLUSION: Early laparoscopic cholecystectomy in acute GBP is feasible and can be safely performed in centres having sufficient expertise. Retroinfundibular technique of laparoscopic cholecystectomy is useful in tackling frozen Calot's triangle in GBP.

INTRODUCTION

Gallbladder perforation is a morbid complication of gallstone disease, occurring in 2%–11% of acute calculous cholecystitis patients.[12] The pathology includes ischaemia and necrosis of the gallbladder wall due to progressive necrosis.[3] There is a strong correlation of gallbladder perforation (GBP) with co-morbidities.[23] Thus, the acute derangement secondary to sepsis is compounded by the presence of underlying co-morbidities.

Differentiating Type 2 variant of GBP, involving contained collection, from uncomplicated cholecystitis may be difficult due to a significant overlap of clinical presentation. The delayed diagnosis is considered a significant risk factor for morbidity and mortality.[4] The use of cross-sectional imaging in acute cholecystitis with significant pericholecystic fluid on ultrasound has also been suggested for the early diagnosis of GBP.[15]

The management is divided between emergency cholecystectomy and percutaneous transhepatic drainage of the gallbladder and subsequent cholecystectomy.[5] Studies have found higher mortality with the latter approach. However, proponents of such an approach advocate that drainage is being performed for moribund patients unsuitable for surgery.[5] Percutaneous drainage has limitations in the event of thick pus or multiloculated collection hindering adequate drainage. In addition, the morbidity of the drain in the form of poor quality of life and persistent worry of catheter dislodgement is significant.[5]

Cholecystectomy considered once as a contraindication for acute cholecystitis has now become a norm for the condition. After establishing feasibility and safety, early intervention to avoid further biliary events during the waiting period is being preferred.[6] The improved laparoscopic expertise and instrumentation have further enhanced outcome. In addition, improved intensive care can result in a better outcome in patients undergoing early laparoscopic cholecystectomy in acute GBP.

Laparoscopic cholecystectomy has been described in GBP along with other treatment modalities and open cholecystectomy.[789] Few studies have dealt about laparoscopic management of GBP.[10] In a study of 137 patients, laparoscopic surgery was associated with improved outcomes.[9] However, the difficulties encountered and outcomes have not been dealt in detail. We routinely practise early laparoscopic cholecystectomy in patients with a GBP. This study is aimed at analysing the feasibility and outcome of early laparoscopic surgery for GBP.

METHODOLOGY

Retrospective analysis of patients admitted with GBP between April 2014 and December 2018 was included in the study. We describe the clinical presentation, preoperative imaging, surgical procedure, operative findings and the outcomes in these patients.

The diagnosis of GBP was made if breach of the gallbladder wall was noted intraoperatively.

Preoperative characters included in the analysis were demographic details, clinical findings, haematological and biochemical parameters. Sepsis was divided into four grades according to the 2001 International Sepsis Definition Conference:[11] Grade 1: systemic inflammatory response syndrome (SIRS); Grade 2: sepsis; Grade 3: severe sepsis and Grade 4: septic shock.

Preoperative cross-sectional imaging (computed tomography and magnetic resonance imaging, whichever available) details regarding the status of gallbladder wall and stone burden was noted. The detection of rent in the gallbladder wall was recorded. In the presence of intraabdominal collection, the location of peritoneal contamination was noted.

All laparoscopic surgeries in our institute are recorded and stored. Intraoperative findings noted from the records were corroborated with the video recordings of the surgery. Parameters such as gallbladder status, adhesions, location and nature of peritoneal contamination were noted. Niemeier classification was used for determining the type of GBP.[12] The site and size of the perforation was also analysed.

Technique of laparoscopic cholecystectomy

After the placement of four ports at conventional position, assessment was done. Peritoneal contamination, if present, was addressed by suctioning and sample obtained for culture. Adhesions of omentum to the parietal wall and liver taken down by combination blunt and sharp dissection. In case of gallbladder completely obscured by adhesions, omentum was dissected from the liver till the gallbladder visualised. Dissection was further carried out till the neck staying closing to the gallbladder predominately by blunt dissection. Attempts were made to visualise the critical view of safety. In case of dense adhesions and further dissection was deemed to increase the risk of bile duct injury by the surgeon, retroinfundibular approach[13] was performed [Figure 1]. The gallbladder was opened at the infundibulum and contents aspirated. Then, circumferential dissection was carried out to delineate cystic duct and managed appropriately (clipping, suturing, endoloop application and external drainage) [Figure 2]. The fundus of gallbladder remnant retained as a hood adherent to the gallbladder fossa was used for retraction. In the event of perforation involving the neck, the dissection was started at the neck and refashioned later to reduce the remnant gallbladder to the minimum as possible. A 14-French drain was placed in the subhepatic space and brought out through the right lumbar port.

Figure 1

Retroinfundibular technique – (a): Frozen Calot's Triangle. (b): Gallbladder divided at the neck using Harmonic scalpel; (c): Thick-walled gallbladder remnant after the division of the neck

Figure 2

Management of cystic duct stump/gallbladder remnant – (a): Endoloop application after circumferential dissection of cystic duct; (b): Laparoscopic subtotal cholecystectomy completed by suturing of the gallbladder remnant

Patients with suspected GBP received injection cefoperazone/sulbactam (3 g intravenously BD). Orals were started after 6 h and increased based on the tolerability of the patient. The criteria for drain removal included the absence of fever, absence of abdominal signs and serous drain output <30 ml over 24 h. The patients were discharged if they were afebrile for 24 h after parenteral antibiotic cessation and tolerating orals adequately. Drains were retained if the output was high at the time discharge and subsequently removed at the time of review.

RESULTS

Fifteen patients were treated for GBP during the study period. Table 1 depicts the clinicodemographic features. Eleven patients were male, and the mean age was 61 years. The most common presentation was abdominal pain followed by fever. Fourteen patients (93.3%) had associated co-morbidities with diabetes present in 12 (80%) patients. Four patients had more than two co-morbidities. At the time of presentation, SIRS was present in 8 (53.3%) and 3 (20%) had organ failure.

Table 1

Clinicodemographic profile of patients included in the study

Character	n (%)
Age (years), mean±SD	61±13.2
Sex (male/female)	11/4
Presenting complaint
Abdominal pain	14 (93.3)
Vomiting	5 (33.3)
Fever	7 (46.7)
Breathlessness	3 (20)
Co-morbidity	14 (93.3)
DM	12 (80)
HT	9 (60)
IHD	5 (33.3)
ASA
2	6 (40.0)
3	8 (53.3)
4	1 (6.7)
BMI (kg/m2), mean±SD	25.4±2.8
Grade of sepsis
SIRS	3 (20)
Sepsis	3 (20)
Severe sepsis	6 (40)
Septic shock	3 (20)
Deranged liver function test	4 (26.7)
Evidence of organ failure	3 (20)

DM: Diabetes mellitus, HT: Hypertension, IHD: Ischaemic heart disease, ASA: American Society of Anaesthetiologists, BMI: Body mass index, SIRS: Systemic inflammatory response syndrome, SD: Standard deviation

Preoperatively, GBP was detected by cross-sectional imaging in 93.3% (n = 14) patients. The location of the collection was gallbladder fossa, pericholecystic, subhepatic and diffuse abdomen in 5, 5, 3 and 1 patients, respectively [Figure 3]. Stone of size >1 cm was present in 8 (53.3%) patients [Table 2].

Figure 3

Type I gallbladder perforation – (a): Diffuse biliary peritonitis; (b): Right paracolic gutter showing bilious contamination (black arrow); (c): Gangrenous gallbladder wall involving the fundus and body (*)

Table 2

Cross-sectional imaging of the acute gallbladder perforations

Character	n (%)
Gallbladder distension	15 (100)
Wall thickness (mm)	14 (93.3)
Size of largest stone (mm)
<3	2 (13.3)
4-10	5 (33.3)
>10	8 (53.3)
Number of stones
Single	2 (13.3)
Multiple	13 (86.7)
Type of GBP
Type 1	3 (20)
Type 2	12 (80)
Location of collection
Gallbladder fossa	3 (20)
Pericholecystic	5 (33.3)
Subhepatic	4 (26.7)
Diffuse	3 (20)
Detection of rent	14 (93.3)

GBP: Gallbladder perforation

Laparoscopy was attempted in all patients [Table 3]. The nature of intraabdominal collection was bile and pus in 6 (40%) and 9 (60%) patients, respectively. All patients had omentum adherent to the gallbladder followed by the duodenum and colon in 4 patients each. Thirteen patients were detected to have perforation at the fundus of the gallbladder. Multiple perforations were seen in 8 (53.3%) patients. The conventional laparoscopic cholecystectomy was feasible in 3 patients during which the cystic duct and artery was clipped and divided. Twelve patients had retroinfundibular approach.

Table 3

Peri-operative outcomes of early laparoscopic cholecystectomy in acute gallbladder perforation

	n (%)
Procedure
Laparoscopic cholecystectomy	12 (80)
Laparoscopic subtotal cholecystectomy	2 (13.3)
Conversion to open	1 (6.7)
Location of collection
Gallbladder fossa	3 (20)
Pericholecystic	5 (33.3)
Subhepatic	4 (26.7)
Diffuse	3 (20)
Nature of collection (bile/pus)	6/9
GBP (single/multiple)	7/8
Site of perforation (hepatic/peritoneal)	8/7
Location of perforation (fundus/body/neck)	13/1/1
Organs adhered (colon/omentum/duodenum)	4/14/4
Calot’s triangle
Dense adhesions	13 (86.7)
Flimsy adhesions	2 (13.3)
Stone impacted at the neck (yes/no)	7/8
Yes	7 (46.7)
No	8 (53.3)
Management of cystic duct
Clipped	7 (46.7)
Endoloop	2 (13.3)
Sutured	5 (33.3)
External drainage	1 (6.7)
Complications	3 (20)
Post-operative ERC requirement	2 (13.3)
Day of drain removal, median (range)	3 (1-6)
Postoperative hospital stay, median (range)	3 (1-19)

ERC: Endoscopic retrograde cholangiogram, GBP: Gallbladder perforation

Cystic duct stump was managed with clip, endoloop, suturing and external drainage in 7, 2, 5 and 1 patient, respectively. Laparoscopic cholecystectomy was completed in 12 (80%) patients. Laparoscopic subtotal cholecystectomy and conversion to open were performed in 2 and 1 patient, respectively. Dense adhesion with colon was the reason for conversion.

Three patients required further intervention. Two required endoscopic retrograde cholangiogram and common bile duct stenting, including the patient who had external drainage due to friable stump. The one other had leak from sutured cystic duct stump. One patient was reexplored for cystic artery bleed secondary to clip dislodgment on the 3rd post-operative day. There were no mortalities. The median duration of post-operative hospital stay and drain removal was 3 (1–19) and 3 (1–6), respectively.

DISCUSSION

Type I and II GBP is a sequela of acute cholecystitis. The septic complications in the background of multiple co-morbidities result in high morbidity and mortality. With a better understanding of pathophysiology of sepsis, antibiotics, fluid resuscitation, organ support and source control are considered the cornerstones of sepsis management.[14] On the same note, the removal of gangrenous gallbladder and drainage of collection are likely to improve the outcome.

In our institute, cross-sectional imaging is performed when complicated acute cholecystitis is suspected. Apart from providing early diagnosis, cross-sectional imaging also gives more accurate information regarding the location of collection and status of the gallbladder.[15] Rent in the gallbladder was detected in 14 of the 15 patients.

The placement of image-guided percutaneous drain has been increasingly used for temporary control of infective foci and resuscitation. After optimisation, cholecystectomy is planned at a later date. However, in the presence of thick pus or multiloculated collection, effective drainage can be challenging. The patient is likely to receive a longer course of antibiotics and has prolonged hospital stay in the event of suboptimal source control.[5]

Laparoscopic cholecystectomy will enable better sepsis control with effective drainage and also the removal of gangrenous gallbladder wall. The improved anaesthesia techniques, broad-spectrum antibiotics and reduced tissue trauma during laparoscopy reduce the negative impact of cytokine storm in comparison to open surgery. We found the median hospital stay and antibiotic course to be low, 3 days, indicating the advantages of such an approach.

Fear of bile duct injury, especially in the acute setting, is the probable reason for not attempting early laparoscopic surgery. The thick-walled turgid gallbladder prevents reliable grasp and liver retraction. We adopted the conventional approach initially but switched to retroinfundibular approach if dissecting the Calot's triangle was considered unsafe. Apart from remnant gallbladder fundus being used for retraction, the division of the gallbladder improves the degree of liver retraction and easier dislodgement of an impacted calculus. This enables the better visualisation of the infundibulum and dissection of the surrounding structure [Figure 4]. Endoloop application and suturing of the stump are also more convenient with the liver adequately retracted. Despite initially considered unsafe to proceed with Calot's dissection, adopting retroinfundibular technique in 12 patients, 9 had total cholecystectomy done. Laparoscopic subtotal cholecystectomy was completed in two other patients.

Figure 4

Intraoperative image showing the fundus (solid black arrow) being used to retract the liver. Gallbladder remnant (solid white arrow) visualised properly enabling further dissection and suturing

Two patients required post-operative biliary stenting, of which one was planned intraoperatively when external drainage was done. The other was performed for leak from sutured stump. In both patients, stent was removed after 1 month, with no long-term sequelae at 1 year of follow-up. Although low in incidence, drainage of subhepatic space and early endoscopic intervention could avoid post-operative collection and its sequelae in case of a leaking stump.

The limitations of the study include the retrospective nature and small study population. The availability of laparoscopic expertise, advanced anaesthesia techniques and endoscopic intervention, if required, limits following the protocol in only high-volume tertiary care centre. The outcomes of early laparoscopic cholecystectomy and percutaneous drainage need to be studied prospectively.

To our knowledge, our study is the first to describe the challenges of early laparoscopic cholecystectomy in acute GBP and also establish its safety. We believe routine cross-sectional imaging in suspected cases of complicated cholecystitis and early laparoscopic cholecystectomy resulted in the improved outcome of GBP in our study.

CONCLUSION

Early laparoscopic cholecystectomy in GBP is feasible and can be safely performed in centres having sufficient expertise. Retroinfundibular technique of laparoscopic cholecystectomy is useful in tackling frozen Calot's triangle in GBP.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.