Abstract
Background
Adhesions in acute cholecystitis tax even the more experienced operator during laparoscopic cholecystectomy. Blunt and sharp dissection, electrocautery, laser, hydrodissection, and ultrasonic dissection may all have their limitations. Thus there is a need for an alternative and more effective method.
Method
Laparoscopic cholecystectomy was carried out in 281 patients with acute cholecystitis. Separation of the gallbladder from the adherent structures was carried out in 13 patients, using the forefinger of the left hand introduced through the right hypochondrial port. In two patients a second finger was introduced through the epigastric port.
Results
The mean time required for the dissection was 7.9 minutes. Finger dissection failed in three patients because of dense adhesions on a high subcostal position of the gallbladder.
Discussion
Finger dissection is easy, fast, and limits injury because of the direct vision and tactile sensation, which are missing in other methods of laparoscopic dissection.
Keywords: acute cholecystitis, finger port
Introduction
The conventionally preferred interval cholecystectomy, whether laparoscopic or otherwise, is gradually giving way to early cholecystectomy for patients with acute cholecystitis.
The hindrance to early surgical intervention had been the adhesions around the gallbladder, but with the numerous methods for dissection now available laparoscopic cholecystectomy (LC) in acute cholecystitis is becoming easier. The routine blunt and sharp dissection as well as electrocautery 1,2, laser 1,2,3, hydrodissection 4, and ultrasonic dissection 5,6 can all be used to assist the dissection. However, all these procedures are either cost-inhibitive or potentially damaging and may not be successful in every patient. Thus there is a need for an alternative procedure in a small number of patients in whom the above methods are either not available or have failed.
Methods
A total of 1530 patients underwent LC over a period of 4.5 years, starting in October 1994. Of these, 281 patients with acute cholecystitis were assigned to one of three groups according to the interval between the onset of acute attack and the time of presentation, as follows: <3 days, 3–7 days and >7 days.
The diagnosis of acute cholecystitis was based on (1) a contributory clinical picture of acute right upper abdominal pain lasting >8 hours, tenderness, temperature >37.5°C, with or without mild jaundice and leucocytosis (white blood cell count > 10×109/L) supplemented by (2) ultrasonographic evidence of a distended gallbladder with an edematous wall and a positive ultrasonographic Murphy's sign with or without a pericholecystic phlegmon and/or fluid in Morrison's pouch.
Routine LC with three or four ports was carried out, and dissection was performed with a harmonic scalpel and occasionally with electrocautery. In those patients in whom there was tense empyema or mucocele, aspiration with a Veress needle was carried out to enable adequate grasper function. In 15 patients in the >7 days group, LC had to be modified using the finger dissection method when electrocautery and the harmonic scalpel did not help. Postoperative histopathology was carried out on every gallbladder removed. Patients were excluded from the study if they had a serious medical illness that rendered them unfit for laparoscopic surgery.
Operative technique
The LC is started with a routine 10-mm umbilical port plus 5-mm epigastric and 5-mm right hypochondrial ports. When the separation of adhesions from the gallbladder becomes difficult with blunt/sharp dissection or electrocautery or the harmonic scalpel, the 5-mm hypochondrial port is enlarged to either 10 or 12 mm or slightly larger (depending on the thickness of the surgeon's forefinger) and the forefinger of the left hand is introduced inside the abdomen. The gallbladder is separated from the omentum and duodenum and transverse colon if adherent. The dissection from the liver bed is usually accomplished with the harmonic scalped under direct vision. By reducing the pneumoperitoneal pressure to 6–8 mmHg, the abdominal wall becomes less tense, the finger can be negotiated deeper, and the adhesions can easily be separated right up to the neck of the gallbladder. The epigastric port dissector assists in this dissection. Often the dissector will not effectively stabilise the gallbladder and the liver during this dissection, and in such patients the forefinger of the other hand is introduced through the epigastric port (enlarged in a similar way) to help the dissection. Subsequently LC proceeds by placing a 10- or 12-mm trocar at these finger port sites. Occasionally when the finger port incision is loose around the 12-mm trocar, a stitch at the trocar site narrows the aperture to prevent gas leakage. The LC is completed using these three or an additional fourth port (5 mm in the right anterior axillary line).
Results
In all, 198 of the 281 patients (71%) with acute cholecystitis were women, mostly in the age group 31–40 years, the youngest patient being a boy of 8 years. A total of 219 patients (78%) presented with an interval period of either <3 days or 3–7 days (groups 1 and 2) (Table 1). Ten patients had acalculous cholecystitis (Table 2). Empyema of the gallbladder was seen in 195 patients, phlegmon in 71 and patchy gangrene in 5 patients (Table 2). Jaundice (bilirubin >55 µmol/L)was present in 36 patients and acute pancreatitis was associated in 8. Most of the patients with a gallbladder phlegmon had Zuhlke 7 type 1 or 2 omental adhesions (Table 3).
Table 1. Duration of symptoms in 281 patients with acute cholecystitis.
| Male |
Female |
|||||
|---|---|---|---|---|---|---|
| Group | Duration | Total (%) | No. | % | No. | % |
| 1 | <3 days | 39 (13.9) | 12 | 14.6 | 27 | 13.6 |
| 2 | 3–7 days | 180 (64.0) | 54 | 65.4 | 126 | 63.7 |
| 3 | 7–14 days | 62(22.1) | 17 | 20.0 | 45 | 22.7 |
Table 2. Gallbladder complications among 281 patients with acute cholecystitis.
| Gallbladder complication | Number* | Percentage |
|---|---|---|
| Phlegmon | 71 (10) | 25.3 |
| Empyema/mucocele | 195 (4) | 69.4 |
| Perforation | 15 | 5.3 |
Of the patients with acute cholecystitis, 271 were calculous and 10 were acalculous.
*Numbers in parentheses indicate the number of patients in whom conversion was required.
Table 3. Composition of gallbladder phlegmon in 71 patients.
| Fibrinous adhesions* | Dense | |
|---|---|---|
| Phlegmon adhesions* | (Zuhlke type I/II) | (Zuhlke type III/IV) |
| With omentum | 27 | 21 (3) |
| With omentum + bowel | 14(2) | 5(5) |
| Pericholecystic pus collection | 4 | – |
*Numbers in parentheses indicate the number of patients in whom conversion was required.
More than three ports were used in 54 patients (19.2%). The operating time varied with the time of presentation: group 3 patients had a mean operating time almost three times longer than that of group 1 patients (56.2 vs 18.5 min) (Table 4). There was little difference in the length of hospital stay, but conversion to open operation was required in 14.5% of group 3 patients as opposed to 2.5% for group 1 and 3.5% for elective LC. The major cause was adhesions in the 14 patients who were converted to open cholecystectomy.
Table 4. Operative details according to patient group.
| Group 1 | Group 2 | Group 3 | Elective laparoscopic cholecystectomy | ||
|---|---|---|---|---|---|
| Parameter | Mean | (n=39) | (n= 180) | (n=62) | |
| Operating time | 33.5 min | 18.5 min (16–21) | 32.5 (17–60) | 56.2 (28–90) | 17.5 (10–70) |
| Number of ports >3 | … | 54 (19.2%) | 71 (8.5%) | ||
| Length of hospital stay (days) | 2.4 | 2.4 | 2.4 | 2.4 | 2.4 |
| Conversion rate(%) | 4.2% | 1/39 (2.5) | 4/180 (2.2) | 9/62 (14.5) | 20 (3.5) |
| Complication rate (%) | … | 1/26 (3.8) | 5/120 (4.2) | 3/41 (7.3) | 31 (3.7) |
Single-finger dissection was required in 13 patients, and 2 patients required two-finger dissection. The mean time required for separation of the adhesions was only 7.9 minutes (range 5–17 min), which did not alter the mean operating time for LC for that group (52.2 min). The finger failed to achieve dissection in three patients; in two there were very dense adhesions, and in one the gallbladder was inaccessible because of its high subcostal position (Table 5). Similarly the complication rate tended to be highest among group 3 patients (7.3%), as opposed to 3.8% in group 1 and 3.7% for elective LC; injury to the common bile duct occurred in only one patient (Table 5), who did not belong to the finger dissection group. One of the patients with finger dissection had wound infection. Histopathologically all removed gallbladders showed evidence of acute cholecystitis.
Table 5. Postoperative complications in 281 patients undergoing laparoscopic cholecystectmy for acute cholecystitis (n=14;5.69%).
| Complication | Number |
|---|---|
| Choleperitoneum (localised) | |
| slipped cystic duct clips | 1 |
| accessory cystic duct | 2 |
| Choleperitoneum (generalised) | |
| common bile duct injury | 1 |
| Wound granuloma/infection | 8 |
| Subcutaneous emphysema | 2 |
Discussion
Excessive oedema and friability of the gallbladder wall in patients with acute cholecystitis makes retraction of the fundus difficult or even impossible. In addition, tenacious omental or bowel adhesions can make for a difficult dissection, especially Zuhlke's type 2 or 3 adhesions 7. In such patients conventional blunt and sharp dissection has the potential to cause organ injury, even perforation. The associated use of monopolar cautery may compound the immediate injury and may be responsible for delayed ischemic injuries 8,9. With the use of laser, larger volumes of tissue suffer thermal damage, leading to either immediate (or, more commonly, delayed) complications 1,2,3. Laser is also exorbitantly expensive, is subject to frequent breakdowns, and requires operator expertise 1. Thus the laser is no longer a considered option in our unit.
Water dissection is a better alternative than laser, but it requires separate instrumentation 4. However, hydrodissection facilitates both prograde and retrograde gallbladder dissection from adjacent structures and the liver, and it is associated with minimal bleeding and a very low chance of gallbladder injury (which could cause bile leakage and stone spillage) 4. The time required for hydrodissection has been documented to be half that required for routine dissection 4. Ultrasonic energy is perhaps the best of the various methods available, its highly selective tissue destruction minimises tissue injury. Thermal damage is minimal because the temperature achieved is only about 70 °C. There is no generation of smoke, minimal chance of gallbladder injury and a rate of postoperative adhesions in the range of 22%, as compared with 66% for electrosurgery and 77% for laser. All these factors make ultrasonic dissection the best alternative 5,6.
The use of one-finger or two-finger dissection through the finger port(s) gives remarkable results. The dissection is fast and relatively bloodless; damage to the pylorus or transverse colon or any other adjacent structure is almost nonexistent. The surgeon's tactile sensation plays a major part in limiting the injury and hastening the dissection process. In addition, the complications are minimal when compared with the other methods of dissection, while there is no extra expenditure because no new instrumentation is required.
The finger dissection in our series prevented 12 possible conversions without any major deviation from the routinely performed LC, except that the right hypochondrial port becomes a 10-mm port. It may be pointed out that with more patience the other methods may also have succeeded, but at what cost? An excessively prolonged operative time has its own anesthetic and surgical morbidity. The use of a hand port is self-defeating because the gallbladder can just as easily be removed through an open mini-laparotomy incision, which would be smaller than the hand port incision.
In the final analysis this approach differs from an elective LC in the following aspects: (1) the use of a 10-mm instead of a 5-mm port site in the right hypochondrium and (2) the fact that the patient is saved from either conversion to a large incision for conventional open cholecystectomy, or the prolonged operating time of a difficult LC. Does this method have any limitations? In an excessively fat individual the thick abdominal wall would limit the reach of the dissecting finger, and if the adhesions are extremely dense the finger dissection may not be possible, as was seen in two of our conversions. A very high anatomical position of the gallbladder (subcostal) also makes finger dissection impossible. Apart from port site wound infection (as seen in one of our patients) port site hernia can also occur, as at any 10-mm port site.
References
- 1.Bordelon BM, Hobday KA, Hunter JG. Laser vs electrosurgery in laparoscopic cholecystectomy. A prospective randomized trial. Arch Surg. 1993;128:233–6. doi: 10.1001/archsurg.1993.01420140110018. [DOI] [PubMed] [Google Scholar]
- 2.Gelman CL, Barroso EG, Britton CT, Haklin MF, Staren ED. The effect of lasers, electrocautery, and sharp dissection on cutaneous flaps. Plast Reconstr Surg. 1994;94:829–33. doi: 10.1097/00006534-199411000-00012. [DOI] [PubMed] [Google Scholar]
- 3.Brock MB, Kimberly AH, John GH. Laser vs electrosurgery in laparoscopic cholecystectomy – a prospective randomised trial. Arch Surg. 1993;128:233–6. doi: 10.1001/archsurg.1993.01420140110018. [DOI] [PubMed] [Google Scholar]
- 4.Naude GP, Morris E, Bongard FS. Laparoscopic cholecystectomy facilitated by hydrodissection. J Laparoendosc Adv Surg Tech A. 1998;8:215–18. doi: 10.1089/lap.1998.8.215. [DOI] [PubMed] [Google Scholar]
- 5.Amaral JF. Ultrasonic dissection. End Surg. 1994;2:181–5. [PubMed] [Google Scholar]
- 6.Amaral JF, Chrostek CA. Ultrasonically activated scalpel is superior to electrosurgery in porcine laparoscopic cholecystectomy. Surg Endosc. 1993;7:141. [Google Scholar]
- 7.Zuhlke HV, Lorens EMP, Straub EM, Sawas U. Pathophysicologie used classification von adhasionas, longerback. Arch Chir Suppl II Verh Bkch Ges Chir. 1990;345:1009–16. [PubMed] [Google Scholar]
- 8.Reich H, Varicaille T, Soderstroun P. Martin DC, Holtz GL, Levwison CJ, et al. American Association of Gynecologic Laparoscopists; Santa Fe Springs: 1990. Electrical techniques of operative laparoscopy, Manual of Endoscopy; pp. 105–12. [Google Scholar]
- 9.Voyles CR, Tucker RD. Education and engineering solutions for potential problems with laparoscopic monopolar electrosurgery. Am J Surg. 1992;164:57–62. doi: 10.1016/s0002-9610(05)80648-8. [DOI] [PubMed] [Google Scholar]
- 10.Reich H. Baggis M. Elsevier; NewYork: 1990. Aquadissection, Laser Endoscopy, The Clinical Practice of Gynecology Series, vol 2; pp. 159–85. [Google Scholar]
- 11.Reich H, MacGregor TS, Vancaille TG. CO2 laser used through the operating channel of laser laparoscopes: in vitro study of power and power density losses. Obstet Gynecol. 1991;77:40–7. [PubMed] [Google Scholar]
- 12.Hemming H. The Dallas report on laparoscopic complications. Gastrointest Endosc. 1985;31:104–5. doi: 10.1016/s0016-5107(85)72010-x. [DOI] [PubMed] [Google Scholar]