Risk Factors and Complications Associated with Difficult Emergency Cholecystectomies: Experience of a Single Urban Center

BACKGROUND

In Ecuador, gallbladder pathology is the leading cause of morbidity among women and the fifth cause among men.¹ While often asymptomatic, gallstones can become symptomatic leading to acute cholecystitis, cholangitis, choledocholithiasis, and acute biliary pancreatitis at a rate of 1–2% per year.² Laparoscopic cholecystectomy is the gold standard for the management of symptomatic gallbladder disease,³ as it is associated with less pain, less morbidity, and earlier recovery.^2,4,5

The level of complexity of a cholecystectomy is hard to predict. Knowledge and surgical expertise are fundamental to be able to safely execute these cases.^4,6,7 There is no accepted scoring system.⁶ There are, however, various classifications describing the severity of acute cholecystitis including the AAST classification (Table 1). There are established preoperative risk factors for difficult cholecystectomy such as the presence of acute cholecystitis, male sex, advanced age, history of recurrent episodes of acute cholecystitis leading to fibrosis and adhesions, obesity, and cirrhosis.^8–10 There are also intraoperative risk factors including the presence of severe fibrosis, scleroatrophic gallbladder, Mirizzi syndrome, gallbladder empyema, dilated and short cystic duct, biliary and vascular anatomical variants,^2,11 total operative time of >90 minutes, as well as dissections of Calot’s triangle lasting >20.³

Our work aims to describe the incidence, the risk factors, and outcomes associated with difficult cholecystectomy in our population in Southern Ecuador.

MATERIALS AND METHODS

Using operative reports, a retrospective study was carried out from January 2016 through March 2017. This study included patients who presented to the acute care surgical service by way of the emergency room with acute cholecystitis, symptomatic cholelithiasis, resolved acute biliary pancreatitis, and/or choledocholithiasis previously resolved by endoscopic retrograde cholangiopancreatography (ERCP). Patients who required common bile duct exploration and who had previously undergone percutaneous cholecystostomy tube placement were excluded. Data were collected from the operative reports of the seven acute care surgeons working at our institution. The following preoperative risk factors were evaluated: age, sex, obesity (BMI ≥30), pregnancy, presence of resolved pancreatitis, presence of choledocholithiasis resolved by ERCP, and surgical wait time. The following intraoperative risk factors were also evaluated: the presence of anatomical variants (biliary and vascular), operative time >90 minutes, and the presence of liver disease (hepatomegaly, nodular liver, cirrhosis). We also evaluated the conversion rate from laparoscopic to open, postoperative complications, and mortality rate.

The primary endpoint for this study was the incidence of difficult cholecystectomy, defined by the operating surgeon in his or her operative report based on the presence of any one of the following criteria: gangrenous cholecystitis, severe adhesions of nearby structures to the gallbladder, suppurative cholecystitis, perivesicular abscess, the presence of severe adhesions, inability to identify the critical view of safety (CVS), scleroatrophic gallbladder, Mirizzi syndrome, and gallbladder perforation with localized or generalized peritonitis.

All patients were operated on by the same group of seven surgeons using the same operative technique which included open Hasson entry into the abdomen, establishment of pneumoperitoneum at 12–14 mm Hg, and dissection of Calot’s triangle using four laparoscopic ports. We quantified the number of patients who underwent a rescue cholecystectomy, which included: retrograde, fenestrative, and reconstituting subtotal and modified Pribram cholecystectomy. The type of cholecystectomy performed depending on the comfort level of the attending surgeon in the case.

RESULTS

DISCUSSION

Hospital Vicente Corral Moscoso is a tertiary care center in Southern Ecuador, with an Acute Care Surgery Service that can immediately care for acute gallbladder pathologies. During the surgical dissection of Calot’s triangle, identifying the CVS is paramount for achieving a safe cholecystectomy.^9,12 However, there are situations wherein Calot’s triangle is distorted by anatomic variants or severe inflammation.¹³ In these cases, several surgical techniques can be used to avoid vascular and bile duct injuries. These include aborting the procedure and placing a cholecystostomy tube, antegrade gallbladder dissection, and rescue cholecystectomy.^14,15 The information gained from our experience in detecting and predicting difficult cholecystectomy can help with both preoperative and intraoperative decision-making among surgeons including the decision to perform a damage control cholecystectomy, help to inform the patient of the possible findings and associated risks of surgery before entering in the operating room, and allow for appropriate equipment and expertise to be available during a difficult case.

We have described a prevalence of difficult cholecystectomy of 37.6%. This rate is higher than described by Randhawa and Pujahari, which quoted an incidence of 21.9% in 228 laparoscopic cholecystectomies.⁶

LIMITATIONS

This was a retrospective study performed at a single institution. Moreover, the definition of “difficult cholecystectomy” is ultimately subjective. What may be considered a difficult cholecystectomy may vary significantly from surgeon to surgeon. Identification of a “difficult cholecystectomy” relied upon the documentation in the operative report and was heavily dependent on the surgeon taking the time to detail the case.

CONCLUSION

The prevalence of difficult cholecystectomy at our institution was high. The statistically significant preoperative factors found to be associated with difficult cholecystectomy included: age older than 65, male sex and the presence of comorbidities. The statistically significant intraoperative factors found to be associated with difficult cholecystectomy included: the presence of anatomical variants, liver disease, and surgical time >90 minutes. At our institution, we describe a low rate of complications and conversion.

DECLARATIONS

The research was carried out with the approval of the Committee of Ethics and Research in Humans of the Vicente Corral Moscoso Hospital. Informed consent was provided before surgical intervention and for the use of their data in the study. The data were used exclusively for research.

The datasets generated during this study are available from the corresponding author on reasonable request. All data generated during this study are included in this published article.

AUTHOR’S CONTRIBUTIONS

DSA: Data collection, statistical analysis, writing of the manuscript; FDAC: Data collection; NFL: Data collection, writing of the manuscript; AH: Translation, writing of the manuscript; JCP: Review of manuscript, translation; JCSM: Review of manuscript.

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