Surg Endosc (1995) 9:977-980

_Surgical Endoscopy © Springer-VerlagNew YorkInc. 1995

The influence of intraoperative gallbladder perforation on long-term outcome after iaparoscopic cholecystectomy D. B. Jones, D. L. Dunnegan, N. J. Soper Department of Surgery, Washington University Medical School, One Barnes Plaza, Suite 6108, St. Louis, MO 63110, USA Received: 3 March 1995/Accepted: 4 April 1995

Abstract. During laparoscopic cholecystectomy, gallbladder perforation with leakage of bile and/or gallstones into the abdominal cavity occurs frequently. When this occurs, our practice has been to lavage the operative field and retrieve as many gallstones as possible. We were concerned, however, that complications secondary to infection or adhesions might develop. To address this issue, our first 250 consecutive patients undergoing laparoscopic cholecystectomy were surveyed by postal questionnaire. In the 35-48 months (mean, 41 months) since operation, six patients (2.6%) died of nonbiliary causes. Of the 225 patients (90%) who completed the questionnaire, 73 (33%) suffered intraoperative gallbladder perforation. There were no late wound or intraabdominal infectious complications and no patient has required reoperation for intraabdominal sepsis or bowel obstruction. In the entire group, gastrointestinal symptoms were prevalent and included flatulence (40%), loose stools or fecal urgency (35%), belching (23%), and nausea (4%). The prevalence of these complaints was similar in patients with and without gallbladder perforation. Intraoperative gallbladder perforation during laparoscopic cholecystectomy, therefore, does not cause adverse long-term complications when accompanied by operative lavage and stone removal. Key words: Laparoscopy - - Cholecystectomy - - Perforation - - Bile - - Gallstone - - Complications

Laparoscopic cholecystectomy has rapidly become the "gold standard" treatment for symptomatic cholelithiasis [17]. Patients experience less postoperative

Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Orlando, Florida, USA, 11-14 March 1995 Correspondence to: N. J. Soper

pain, earlier hospital discharge, and more rapid return to full activity with the minimally invasive procedure than with its open counterpart [1, 11]. Since the outcome (gallbladder removal) is similar with both laparoscopic and open cholecystectomy, the advantages to the patient from laparoscopy have been attributed to the small incisions. However, technical details of the laparoscopic operation deviate from the traditional operation in ways which may cause long-term problems. One area of concern is the increased rate of gallbladder perforation that occurs during laparoscopic cholecystectomy and the potential effects of spilled bile and stones. Conventional wisdom cautions that perforation of the gallbladder during cholecystectomy risks wound infection, intraabdominal abscess formation, or adhesions with subsequent intestinal obstruction. Theoretically, gallstones are a nidus for infection, especially pigment stones that may harbor bacteria [5, 18]. Furthermore, intraabdominal bile may cause peritonitis and subsequent adhesions. These occurrences may lead to delayed reoperation for intraabdominal infection or intestinal obstruction secondary to adhesions. In the era of minimally invasive surgery, rupture of the gallbladder with leakage of bile and/or gallstones occurs in a significant proportion of laparoscopic cholecystectomies. We previously showed that about one-third of gallbladders were ruptured during the procedure [16]. Nevertheless, in our early experience, patients did surprisingly well after rupture of the gallbladder. While laparoscopic cholecystectomy was prolonged about 10 min for stone retrieval and lavage of the abdominal cavity, there was no evidence of perioperative morbidity related to gallbladder perforation [16]. More recently, several anecdotal case reports have implicated spilled bile and lost stones during laparoscopic cholecystectomy as the cause of delayed complications [5, 7-10, 14]. If true, a change in technique may be necessary. Conversely, in two animal models intraabdominal implantation of sterile gallstones did

978 Table 1. Management of intraoperative gallbladder perforation

Our practice 1) Retrieve lost stones (when possible) 2) Irrigate abdominal cavity 3) Close defect in gallbladder wall 4) Complete laparoscopic cholecystectomy 5) Perioperative intravenous antibiotics Not done 1) Convert to open cholecystectomy 2) Drain in fight upper quadrant 3) Long course of antibiotics 4) Delay hospital discharge

not cause adhesions, fistulas, perforation, or obstruction over a relatively brief study interval [3, 21]. Therefore, the purpose of this study was to determine whether intraoperative leakage of bile and/or stones during laparoscopic cholecystectomy leads to subsequent infection, adhesions, intestinal obstruction, or abdominal symptoms over prolonged follow-up.

Patients and methods As previously reported, laparoscopic cholecystectomy was performed on 250 consecutive patients between November 1989 and December 1990 at Washington University School of Medicine [16]. All patients received a preoperative dose of intravenous antibiotics, usually a second-generation cephalosporin. Forms completed at the time of operation identified significant gallbladder perforation with bile and/or stone leakage in 80 patients (32%). Outcome of the index admission was assessed prospectively and has been detailed previously [16]. Gallbladder perforation was managed similarly in all patients (Table 1). Spilled stones were retrieved whenever possible although it was not easily determined whether such stones were always removed, especially when small and numerous. Free bile was aspirated and the abdominal cavity irrigated until clear. If dissection of the gallbladder from the hepatic fossa had not been completed, the tear in the gallbladder was closed with a loop ligature (Fig. 1). Filling the gallbladder with saline prior to closure seemed to aid in retraction and dissection. The bile was routinely cultured, and patients with gallbladder perforation were given a second dose of intravenous antibiotics postoperatively. No patient was converted to open cholecystectomy due to gallbladder perforation nor were drains placed in the fight upper quadrant, To determine the long-term effects of intraoperative gallbladder perforation, surveys were sent by mail to these same 250 patients. The patients were asked to document their interval medical and surgical history, indicate current abdominal and gastrointestinal symptoms, and state their overall satisfaction with the laparoscopic operation. Data in the two groups (those with and without intraoperative gallbladder perforation) were compared by unpaired Student's t-test and chi-square analysis, and significance was assumed to exist when P < 0.05. Summary data in the text was presented as mean -+ SEM.

Results

Questionnaires were completed and returned by 225 patients (90%). Follow-up was 35--48 months (mean, 41 months) after laparoscopic cholecystectomy. Of the 225 respondents, 52 patients were male (23%) and 173 were female (77%). Mean age was 47 +_ 1 years, ranging from 18 to 82 years. During the initial operation, 152 (67%) had removal of an intact gallbladder without bile leakage while gallbladder perforation occurred in 73 (33%). Long-term outcome was similar in the two

groups (Table 2). There were no late wound complications and no patient required reoperation for abscess or intestinal obstruction. One patient without gallbladder perforation had early postoperative cellulitis at a trocar site treated with oral antibiotics and another patient has a small asymptomatic hernia at the epigastric cannula site. There were no deaths occurring in the early postoperative period (Table 2). Late mortality was unrelated to perforation of the gallbladder during cholecystectomy. All subsequent deaths were either cardiovascular or due to gastric malignancy and occurred on average 18 months after cholecystectomy. Gastrointestinal complaints were common at follow-up, although their prevalence was similar in patients with and without intraoperative gallbladder perforation (Table 3). In the entire group, long-term abdominal or gastrointestinal s y m p t o m s included flatulence (40%), loose stools or fecal urgency (35%), belching (23%), indigestion (21%), nausea (4%), and "typical gallbladder pain" (4%). When surveyed more than 35 months postoperatively, 224/225 patients (99.6%) were satisfied with their operation and "would recommend a laparoscopic cholecystectomy to friends with gallbladder disease."

Discussion

There are several reasons for the increased rate of gallbladder perforation with laparoscopic cholecystectomy. Using the "American" technique, the gallbladder wall is grasped with forceps and used as a retractor to elevate the liver and expose the gallbladder infundibulum and Calot's triangle. As the surgeon divides peritoneal adhesions, a grasping device on the infundibulum gives countertraction. Traction and repetitive grasping may tear the wall. The gallbladder also may be inadvertently entered during dissection of the gallbladder from the hepatic fossa by the cautery probe. Bile leakage and/or gallstone spillage may also occur as the surgeon removes the gallbladder from the abdominal cavity through a small trocar site. Since our initial report, our operative technique has changed from using a spatula to a hook cautery for dissection of the gallbladder from its bed, which more precisely transmits thermal energy for dissection of tissues. Nevertheless, our incidence of gallbladder perforation has not changed, with 34% of our last 100 laparoscopic cholecystectomies resulting in gallbladder rupture. This occurrence likely reflects, in part, the inexperience of junior surgical residents who perform most laparoscopic cholecystectomies at our institution. After intraoperative rupture of the gallbladder, the operative field is lavaged and obvious stones are retrieved. If dissection of the gallbladder from the hepatic fossa is incomplete or there are multiple stones in the gallbladder, the gallbladder can be filled with saline and rents in its wall can be closed with a loop ligature to prevent further spillage. The distended gallbladder simplifies retraction and dissection of the gallbladder from the hepatic fossa. Our practice is to administer an additional dose of antibiotics empirically in patients

979

//

~J

• 1. Simple closure of gallbladder tear. A Place grasping instrument through loop ligature. B Fill gallbladder with saline and approximate sides of tear with grasper, then loop ligate everted tissue. C Excess suture is cut, and the perforation is closed. (Reprinted with permission from Ref. 16)

-

// // C

Table 2. Long-term outcome following laparoscopic cholecystectomy a

Wound infection Sepsis/abscess Intestinal obstruction Mortality Biliary related Cardiovascular Gastric cancer

IOP (N = 73)

No IOP (N = 152)

0 0 0

1 0 0

0 1 1

0 2 2

a p = NS for all variables. IOP = intraoperative perforation

Table 3. Gastrointestinal complaintsa

Flatulence Loose stools or fecal urgency Belching Indigestion Nausea Typical "gallbladder pain"

lOP (N = 73)

No lOP (N = 152)

30 (41%) 23 (32%) 19 (26%) 14 (19%) 2 (3%) 3 (4%)

60 56 32 34 8 5

(39%) (37%) (21%) (22%) (5%) (3%)

a p = NS for all comparisons. IOP = intraoperative perforation

whose gallbladder has ruptured. Lost stones are not thought to be an indication for conversion to open cholecystectomy. When gallbladder perforation is managed in this fashion, we previously experienced no untoward perioperative complications [16]. Although not used during our first 250 patients, we have subsequently used an entrapment sac to prevent bile or

stone leakage during extraction of the gallbladder through the abdominal wall in patients with a sizable hole in the gallbladder wall. Long-term follow-up of this cohort similarly did not reveal any delayed complications related to intraoperative gallbladder perforation. Specifically, there was no evidence of sepsis, abscess formation, or intestinal obstruction. The one significant wound infection developed in a patient whose gallbladder was removed intact without bile spillage. These results are consistent with our general experience after having performed more than 1,000 laparoscopic cholecystectomies. Long-term follow-up after laparoscopic cholecystectomy also underscores the frequent occurrence of gastrointestinal symptoms that has previously been noted after open removal of the gallbladder. Following open cholecystectomy, gastrointestinal symptoms have been reported in 10-50% of patients [2]. Symptoms are usually mild, but about one-third of patients experience persistent upper abdominal pain up to 2 years after surgery [2]. Symptoms in these patients may be unrelated to gallbladder disease or the operation, but may rather be due to irritable bowel syndrome, lactose intolerance, or other functional problems. In addition, cholecystectomy removes the reservoir for bile storage and may cause loose stools and fecal urgency. Although enterohepatic cycling of bile acids is increased, unabsorbed bile salts may enter the colon and stimulate colonic motility and secretion of NaCI and water, causing diarrhea [12]. However, the exact pathogenesis of postcholecystectomy diarrhea is not clear and is probably multifactorial [4, 15]. There-

980

fore, our practice has been to inform patients preoperatively that diarrhea may develop after cholecystectomy, but that typical gallbladder pain is uncommon. Despite persistent gastrointestinal complaints, most patients have been highly satisfied with laparoscopic cholecystectomy. The relatively high incidence of gastric carcinoma among patients with gallbladder disease in this study (1.2% or 1,200 per I00,000) may simply reflect the small sample size, but the finding raises several questions. Possibly there is an association between gastric cancer and gallbladder disease [13]. In the United States the age-adjusted mortality of gastric carcinoma is about 7.8 per 100,000 men and 3.7 per 100,000 women [20]. More worrisome is whether these patients had symptoms misdiagnosed as biliary disease. During laparoscopic cholecystectomy, the wall of the stomach is not routinely examined, and early carcinoma may therefore have been missed. In the future, other methods of evaluating the stomach and other intraabdominal organs may be employed to more thoroughly explore the abdomen. Intraoperative laparoscopic ultrasonography accurately evaluates the liver parenchyma and could potentially be used to scan the gastric wall for abnormalities [6]. Upper endoscopy before cholecystectomy may detect gastric malignancy, peptic ulcer, gastric erosions, and esophagitis, but routine evaluation for patients with typical gallstone symptoms is probably not clinically useful or cost-effective [19]. Laparoscopic cholecystectomy has revolutionized the management of symptomatic cholelithiasis. Avoiding laparotomy allows the patient to recuperate sooner. Although the surgical principles are essentially the same in open and laparoscopic cholecystectomy, technical differences exist, and rupture of the gallbladder occurs frequently in the era of laparoscopy. Several anecdotal reports suggest that bile leakage and spilled stones cause formation of abscesses and adhesions [5, 7-10, 14]; however, our findings do not support adverse long-term sequelae of gallbladder perforation during laparoscopic cholecystectomy when managed with stone retrieval, saline lavage, and perioperative antibiotics. Acknowledgment. The authors gratefully acknowledge the Washington University Institute for Minimally Invasive Surgery as funded by a grant from Ethicon-Endosurgery, Inc.

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