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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 4  |  Issue : 1  |  Page : 14-17

Laparoscopic management of symptomatic gallbladder stump calculi


1 Department of Surgery, DH Budgam, Health Services, Government Medical College and Associated Hospitals, Srinagar, Jammu and Kashmir, India
2 Department of Surgery, DH Budgam, Health Services; Department of Surgery, Government Medical College and Associated Hospitals, Srinagar, Jammu and Kashmir, India

Date of Submission12-Jun-2019
Date of Acceptance14-Jul-2019
Date of Web Publication26-Sep-2019

Correspondence Address:
Dr. Arshad Rashid
G22, Green Lane, Shah Anwar Colony, Hyderpora, Srinagar - 190 014, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/SJL.SJL_11_19

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  Abstract 

Aim: The aim of the present study was to evaluate the safety of laparoscopic completion cholecystectomy in patients with symptomatic gallbladder stump calculi.
Materials and Methods: Ours was a prospective study conducted in three peripheral hospitals over a period of 6 years. All the patients undergoing elective laparoscopic cholecystectomy during this period were enrolled in the study. The outcomes of laparoscopic completion cholecystectomy in patients with gallbladder stump calculi were compared to those undergoing primary laparoscopic cholecystectomy with regards to perioperative morbidity and mortality.
Results: A total of 3127 laparoscopic cholecystectomies were performed. Out of them, laparoscopic completion cholecystectomy was done in 36 (1.15%) patients. There were 21 males and 15 females in these 36 patients. The operative time and hospital stay were significantly increased in the completion group. None of our patients in the completion group required conversion. Perioperative complications were seen more often in the patients posted for completion cholecystectomy (6 [6.67%] vs. 207 [6.69%]; P = 0.0026). Bleeding was the most frequent intraoperative complication seen in the patients undergoing completion cholecystectomy.
Conclusion: Laparoscopic completion cholecystectomy, though technically demanding, can be safely done even in a peripheral health setup with acceptable morbidity rate.

Keywords: Calculi, cholecystectomy, completion, laparoscopic, stump


How to cite this article:
Ganai A, Rashid A, Junaid S, Mushtaque M. Laparoscopic management of symptomatic gallbladder stump calculi. Saudi J Laparosc 2019;4:14-7

How to cite this URL:
Ganai A, Rashid A, Junaid S, Mushtaque M. Laparoscopic management of symptomatic gallbladder stump calculi. Saudi J Laparosc [serial online] 2019 [cited 2019 Nov 21];4:14-7. Available from: http://www.saudijl.org/text.asp?2019/4/1/14/267855


  Introduction Top


Postcholecystectomy syndrome, which was first described by Womack and Crider in 1947, refers to persistence or new appearance of symptoms similar to gallstone disease after varying amount of time from cholecystectomy and is seen in 7%–15% of patients.[1] The gallbladder remnant or cystic duct stump calculus is one of the causes of postcholecystectomy syndrome. The incidence of residual gallstones following cholecystectomy is 2.5%.[2] The condition may arise because of inadequate dissection of cystic duct-gallbladder junction or subtotal cholecystectomy in the setting of difficult intraoperative anatomy.

Laparoscopic cholecystectomy is the gold standard procedure for symptomatic gallstones.[3] Despite its many advantages over open cholecystectomy, surgeons have been circumspect in offering it to patients undergoing completion cholecystectomy. In fact, certain authorities consider it as a relative contraindication to laparoscopic cholecystectomy.[4] With the ever-increasing experience of surgeons with laparoscopy, many tertiary care centers reported on the successful outcome of laparoscopic completion cholecystectomy in patients with gallbladder stump calculi.[5],[6],[7] However, to the best of our knowledge, no paper has reported on this outcome from district or subdistrict hospitals. The current paper presents our experience of laparoscopic completion cholecystectomy in gallbladder stump calculi in a peripheral health-care setup.


  Materials and Methods Top


Ours was a prospective study conducted in three hospitals (two district-level and one subdistrict-level) of the Department of Health Services, Kashmir, over a period of 6 years from February 2013 to February 2019. All the patients undergoing elective laparoscopic cholecystectomy during this period were enrolled in the study. Routine blood and urine investigations, including liver function test, chest X-ray, and ultrasonography abdomen, were done in all the patients. In addition, magnetic resonance cholangiopancreatography was performed for all the patients of laparoscopic completion cholecystectomy.

Four well-experienced laparoscopic surgeons (the authors) operated the patients. Laparoscopic cholecystectomy was performed by using Image One® high-definition camera supplied by Karl Storz, Germany, mounted on a Hopkins II 30 laparoscope. The video was visualized on a high-definition widescreen monitor (Karl Storz, Germany). The pneumoperitoneum was created by open method by a subumbilical incision using the umbilical cicatrix tube.[8] In case of a previous infraumbilical surgical incision, a supraumbilical incision was used to create the pneumoperitoneum.[9] A standard four-port cholecystectomy was done with subtle modifications, as mentioned in the discussion part. A tube drain was kept in every patient. All the patients were followed up on an outpatient basis every week for a minimum of three visits. Drains were removed when output was <20 mL in a 24 h period.

The outcomes of laparoscopic completion cholecystectomy were evaluated with regards to perioperative morbidity and mortality and compared to primary laparoscopic cholecystectomy. An approval from the institutional review board was obtained for the purpose of this study (DHSK/Acad/2013-02). Written informed consent was obtained from the patient for publication of this article. A copy of the written consent is available for review by the Editors-in-Chief of this journal. The data thus collected were compiled and analyzed using SPSS version 22 for Mac (IBM Corporation, New York, USA, 2012). To calculate the P value, Fisher's exact test and Pearson's Chi-square test were applied to compare the frequencies for categorical parameters, and the unpaired t-test was used to compare the means (two-tailed) among continuous variables. The results were calculated on 95% confidence interval. P < 0.05 was considered statistically significant.


  Results Top


During the study period, a total of 3127 laparoscopic cholecystectomies were performed. Out of them, laparoscopic completion cholecystectomy was done in 36 (1.15%) patients. There were 21 male and 15 female in these 36 patients. Previous operative records were available in 22 of these patients. The patients posted for completion cholecystectomy were significantly older than those posted for primary cholecystectomy (57.36 8.61 vs. 46.13 14.35 years, P < 0.0001) and women predominated in the latter group. Patients planned for completion cholecystectomy were more likely to have associated comorbidities such as hypertension, diabetes mellitus type II, and steatohepatitis [Table 1].
Table 1: Demographic profile of the patients

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As expected, the operative time was significantly increased in the completion cholecystectomy group [Table 2]. None of our patients in the completion cholecystectomy group required conversion to open surgery. However, perioperative complications were seen more often in the patients posted for completion cholecystectomy (6 [16.67%] vs. 207 [6.69%]; P = 0.0026). Although morbidity was significantly more in this group, it did not translate into any mortality. We did not encounter any biliary injury in the patients posted for laparoscopic completion cholecystectomy. The perioperative complications encountered are given in [Table 3].
Table 2: Intraoperative and postoperative outcomes

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Table 3: Intraoperative and postoperative complications (morbidity)

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  Discussion Top


The dynamics of surgery are constantly evolving. The contraindication of yesterday becomes an indication today. Same is the case with laparoscopic cholecystectomy in case of patients posted for completion cholecystectomy. Once considered as a contraindication, the safety of laparoscopic completion cholecystectomy has been well documented in many retrospective studies and case reports, ever since Gurel et al. reported it first in 1995.[5],[6],[7],[10],[11],[12],[13],[14],[15] All of these studies have reported outcomes from the university-based centers and tertiary care hospitals. To the best of our knowledge, this is the first prospective study documenting the feasibility of laparoscopic completion cholecystectomy for symptomatic gallbladder stump calculi in a peripheral health setup and comparing its outcomes with primary laparoscopic cholecystectomy.

In the face of operative difficulty that precludes a safe dissection of Calot's triangle, resorting to subtotal cholecystectomy is the norm. In about 3%–8% of patients undergoing surgery for gallstone disease, subtotal cholecystectomy is required and has proven to be a safe and effective option in such patients with gallstone disease to avoid iatrogenic complications.[16],[17],[18],[19] Following a subtotal cholecystectomy, the remnant that remains may comprise of a cystic duct with variable amounts of gallbladder and is known as gallbladder stump or residual gallbladder.[20] Although being a safe option, the gallbladder stump remaining after subtotal cholecystectomy carries a significant risk of developing further pathologies including stump calculi with cholecystitis, biliary pancreatitis, or cholecystoenteric fistulae, all leading to postcholecystectomy syndrome.[4]

In our series of 36 completion cholecystectomies, all the primary surgeries were done by laparoscopy. Operative records of primary surgery were available for only 22 (61.12%) cases. As per the operative records, out of 22 cases, subtotal cholecystectomy was done at the index presentation in 16 (72.73%) cases. Despite achieving a proper critical view of safety and doing a total cholecystectomy, gallbladder stump calculi had developed in the remaining six patients. We have previously described “artery to cystic duct” as a consistent branch of the cystic duct.[3] We believe that not taking down this branch leaves a cystic duct stump with a viable blood supply, consequently, resulting in enlargement of the stump with stone formation. It is in place to mention that the length of the cystic duct remaining is longer if this “artery to cystic duct” is not buzzed during cholecystectomy. Although these are still presumptions, studies should be directed to probe them further.

Performing a successful laparoscopic completion cholecystectomy is technically difficult, as there is usually significant scarring and anatomic distortion at the gallbladder bed.[21] One of the main difficulties that we encountered in our series was the cephalad retraction of the gallbladder stump to expose the Calot's triangle. We circumvented this problem by retracting the liver by holding a gauze piece in a nontraumatic grasper introduced through the lumbar port and pushing on to the liver. All these patients were operated by a fundus first method. After the initial peritoneal incision at the fundus of the stump, the peritoneal fold attached to the liver was also used for retraction.

There was a lot of neovascularization observed during relaparoscopy with a single predominant artery to the stump. The magnified view gained in laparoscopy with the current high-definition optics allows the identification of this neovascularization, thereby avoiding injury and bleeding. Bipolar energy and ultrasonic energy devices were used liberally in our series. The use of intraoperative cholangiogram has been recommended in completion cholecystectomy,[4] but we did not do it, as it was not available at our centers. However, we ensured that the cystic duct was clipped only after ensuring a proper critical view of safety, and we routinely identified the cystic duct-common duct junction in all our cases. After applying a distal clip on the cystic duct toward the stump, the cystic duct was partially incised and the contents were milked up from the common duct toward the cystic duct, and only after clear free-flowing bile came out of the cystic duct, the proximal clips were applied and the cystic duct was transected.

As expected, intraoperative bleeding was the most frequent complication seen in the completion cholecystectomy group. However, it was manageable by laparoscopy only and did not require any transfusion. Postoperative ileus and persistent serous drainage was more common in the completion cholecystectomy group as compared to the primary cholecystectomy, probably, because more dissection and bowel handling occurred in the former group. Spironolactone 25 mg QID was used if the serous drainage persisted for >3 days and it helped in controlling it. We did not encounter any major biliary injury in the completion cholecystectomy group, probably reflecting the small sample size and probably because of more meticulous and careful dissection in this group.

One of the limitations of the current study is that it was not a randomized controlled study, but we enrolled all the patients planned for laparoscopic cholecystectomy irrespective of them being posted for completion cholecystectomy or primary cholecystectomy, thus trying to minimize the selection bias. The other strength of our study is that well-experienced surgeons who had completed their learning curve did the cholecystectomies irrespective of the nature of cholecystectomy (whether completion or primary). Ours was a multicentric prospective comparative study adhering to a single robust protocol, thereby adding to the strength of the study.


  Conclusion Top


Patients with residual gallbladder stump calculi undergoing laparoscopic cholecystectomy have a higher incidence of postoperative complications than patients undergoing laparoscopic cholecystectomy in the primary setting. Our study demonstrates that laparoscopic cholecystectomy, though technically demanding in these cases, can be safely done even in a peripheral health setup with acceptable morbidity rate. The technical challenges can be offset by proper instrumentation and expertise. However, appropriate preoperative investigations and meticulous intraoperative techniques are quintessential for safer results.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Womack NA, Crider RL. The persistence of symptoms following cholecystectomy. Ann Surg 1947;126:31-55.  Back to cited text no. 1
    
2.
Demetriades H, Pramateftakis MG, Kanellos I, Angelopoulos S, Mantzoros I, Betsis D. Retained gallbladder remnant after laparoscopic cholecystectomy. J Laparoendosc Adv Surg Tech A 2008;18:276-9.  Back to cited text no. 2
    
3.
Rashid A, Mushtaque M, Bali RS, Nazir S, Khuroo S, Ishaq S. Artery to cystic duct: A consistent branch of cystic artery seen in laparoscopic cholecystectomy. Anat Res Int 2015;2015:847812.  Back to cited text no. 3
    
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Cawich SO, Mohammed F, Spence R, Naraynsingh V. Laparoscopic removal of a gallbladder remnant in a patient with severe biliary pancreatitis. J Surg Case Rep 2016;2016. pii: rjw163.  Back to cited text no. 4
    
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Palanivelu C, Rangarajan M, Jategaonkar PA, Madankumar MV, Anand NV. Laparoscopic management of remnant cystic duct calculi: A retrospective study. Ann R Coll Surg Engl 2009;91:25-9.  Back to cited text no. 6
    
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Parmar AK, Khandelwal RG, Mathew MJ, Reddy PK. Laparoscopic completion cholecystectomy: A retrospective study of 40 cases. Asian J Endosc Surg 2013;6:96-9.  Back to cited text no. 7
    
8.
Lal P, Sharma R, Chander R, Ramteke VK. A technique for open trocar placement in laparoscopic surgery using the umbilical cicatrix tube. Surg Endosc 2002;16:1366-70.  Back to cited text no. 8
    
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11.
Tantia O, Jain M, Khanna S. Post cholecystectomy syndrome: role of cystic duct stump and re-intervention by laparoscopic surgery. J Minim Access Surg 2008;4:71-5.  Back to cited text no. 11
    
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Chowbey P, Sharma A, Goswami A, Afaque Y, Najma K, Baijal M, et al. Residual gallbladder stones after cholecystectomy: A literature review. J Minim Access Surg 2015;11:223-30.  Back to cited text no. 12
    
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Mageed SA, Omar MA, Redwan AA. Remnant gallbladder and cystic duct stone after cholecystectomy: Tertiary multicenter experience. Int Surg J 2018;5:3478-83.  Back to cited text no. 13
    
14.
Li LB, Cai XJ, Mou YP, Wei Q. Reoperation of biliary tract by laparoscopy: Experiences with 39 cases. World J Gastroenterol 2008;14:3081-4.  Back to cited text no. 14
    
15.
Gurel M, Sare M, Gurer S, Hilmioglu F. Laparoscopic removal of a gallbladder remnant. Surg Laparosc Endosc 1995;5:410-1.  Back to cited text no. 15
    
16.
Palanivelu C, Rajan PS, Jani K, Shetty AR, Sendhilkumar K, Senthilnathan P, et al. Laparoscopic cholecystectomy in cirrhotic patients: The role of subtotal cholecystectomy and its variants. J Am Coll Surg 2006;203:145-51.  Back to cited text no. 16
    
17.
Ibrarullah MD, Kacker LK, Sikora SS, Saxena R, Kapoor VK, Kaushik SP. Partial cholecystectomy – safe and effective. HPB Surg 1993;7:61-5.  Back to cited text no. 17
    
18.
Ji W, Li LT, Li JS. Role of laparoscopic subtotal cholecystectomy in the treatment of complicated cholecystitis. Hepatobiliary Pancreat Dis Int 2006;5:584-9.  Back to cited text no. 18
    
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Beldi G, Glättli A. Laparoscopic subtotal cholecystectomy for severe cholecystitis. Surg Endosc 2003;17:1437-9.  Back to cited text no. 19
    
20.
Singh A, Kapoor A, Singh RK, Prakash A, Behari A, Kumar A, et al. Management of residual gall bladder: A 15-year experience from a North Indian tertiary care centre. Ann Hepatobiliary Pancreat Surg 2018;22:36-41.  Back to cited text no. 20
    
21.
Cawich SO, Wilson C, Simpson LK, Baker AJ. Stump cholecystitis: Laparoscopic completion cholecystectomy with basic laparoscopic equipment in a resource poor setting. Case Rep Med 2014;2014:787631.  Back to cited text no. 21
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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