Morbidity, Mortality and Major Bile Duct Injury in 2296 Patients Undergoing Laparoscopic Cholecystectomy-Review of Literature

Phillippe Mouret performed the first videoscopic laparoscopic cholecystectomy on a human patient in 1987 [1]. Since then, this new advancement in the history of general surgery has gained wide acceptance and entered daily practice for general surgeons throughout the world [2-8]. With a few exceptional randomized controlled studies [6], most efficacy and safety studies for laparoscopic cholecystectomy were observational and retrospective case controlled studies [9]. Therefore, this study aims at the safety of laparoscopic cholecystectomy as compared among those of reports in the literature and the author’s personal series. Safety of open cholecystectomy was also compared. Materials and Methods Patients


Introduction
Phillippe Mouret performed the first videoscopic laparoscopic cholecystectomy on a human patient in 1987 [1]. Since then, this new advancement in the history of general surgery has gained wide acceptance and entered daily practice for general surgeons throughout the world [2][3][4][5][6][7][8]. With a few exceptional randomized controlled studies [6], most efficacy and safety studies for laparoscopic cholecystectomy were observational and retrospective case controlled studies [9]. Therefore, this study aims at the safety of laparoscopic cholecystectomy as compared among those of reports in the literature and the author's personal series. Safety of open cholecystectomy was also compared.

Materials and Methods
Juniper Online Journal of Case Studies 002 cholecystitis. In acute cholecystitis patients, male predominant was found whereas female predominant was found in chronic cholecystitis patients (P < 0.0001). The average age for patients with symptomatic gallstones, chronic cholecystitis and acute cholecystitis are 54±15, 53±15 and 57±17 years old.
The patient complicated with hypoxic encephalopathy was a 76-year-old male diagnosed with gallstone with acute cholecystitis. Preoperative electrocardiogram did not reveal any cardiac arrhythmia. The operative procedure was uneventful except that it was a relatively long procedure. The operation time was 121 minutes. An episode of bradycardia developed which was followed by a cardiac arrest.
After resuscitation, the patient's heartbeat and respiration returned. However, the consciousness did not return. Glasgow coma scale was 4 (E1V1M2). The patient did not recover from the hypoxic encephalopathy and finally succumbed to consequent pneumonia. This is the only mortality in this series. The patient complicated with spontaneous pneumothorax was a 65-year-old male associated with chronic obstructive pulmonary disease. Intra-operatively, the anesthesiologist noted a drop of oxygen saturation from 98% to 90% at 50% alveolar oxygen concentration. Auscultation revealed decreased breathing sound over right lung field. Emergent insertion of a pigtail drain into right pleural cavity revealed a jet of air emitting out. The operation was completed smoothly. The pigtail was removed 3 days postoperatively and was discharged on 4th postoperative day.
There were 32 surgical infections associated with laparoscopic cholecystectomy in this series (1.39%), including 3 (0.13%) right peri-hepatic abscesses and 29 (1.26%) wound abscesses. The former tended to suffer from spiking fever and right upper abdominal pain 2 weeks after laparoscopic cholecystectomy.
Ultrasonography revealed sonolucent fluid collections around peri-hepatic spaces were detected. Ultrasound-guided insertion of pigtail drains and intravenous antibiotics were all that were needed to resolve these conditions. The patients were discharged around 7 days later. The latter were managed by incisional drainage and open wound dressings successfully.
There was one patient who had undergone previous abdominal surgery. This 56-year-old male patient underwent laparoscopic cholecystectomy for gallbladder stone with open laparoscopic technique. A severe small intestinal loop adhesion directly under the umbilicus was found. The procedure was completely. However, on the 3rd postoperative day, profuse yellowish small intestinal contents flew out from the infraumbilicus trocar wound. The patient underwent immediate reoperation and a 6 cm transverse extension of the infra-umbilicus wound was performed. A small 0.3 cm perforation hole was found at a mid-jejunum loop located immediately below the umbilicus. Primary repair with peritoneal cavity lavage was performed and the wound was closed. The postoperative course was uneventful and the patient was discharged 7 days later.
Three patients suffered from urinary tract infections. They received Foley catheter insertion after general anesthesia because longer operation was expected. Among them, two were from the contracted gallbladder group. Antibiotics and sulfa drugs were all that were needed to resolve the condition (Table  1).
Major bile duct injury patients required more sophisticated repairing procedures, such as hepato-jejunostomy or choledochojejunostomy (patient 1 and patient 8). Their prognosis needs longer periods of follow-up to make sure they are not inflicted with recurrent cholangitis like biliary cripples, as patients 1 and 8 were devoid of these episodes for 6 -7 years.

Juniper Online Journal of Case Studies
Minor bile duct injury patients required only simpler managements, such as, primary repair with T-tube splinting or simple T-tube insertion would suffice in patients 5, 6 and 7. The prognosis was usually good.
Patients with delayed bile leakage also required only simple management, such as, T-tube insertion, which solved the problem in patients 2, 3, 4 and 9. Their prognosis was uniformly good within 7 days (Table 2).

Discussion
Undoubtedly, laparoscopic cholecystectomy is the greatest arena for laparoscopic surgery. There is a pattern of the incidence of major bile duct injury requiring biliary reconstruction corresponding to the case number of the surgeon. Major bile duct injury is high or none in the surgeon's learning curve period (the first 100 cases to less than 500 cases, Table 3), also as in case 1 of Table  2 in this series. Not with standing the experienced surgeon has past the learning curve period, the incidence of major bile duct Juniper Online Journal of Case Studies injury did not fall [10,11]. It looks as if when surgeon passed his first 500 and less than 1,000 cases, he begins handling more complicated cases and major bile duct injury incidence tends to re-appear, i.e., 0.79-1.4%, as case 9 of Table 2 in this series. With further experiences gained with increasing case number beyond 1,000 the surgeon's laparoscopic cholecystectomy-associated incidence begins to descend and level off, i.e., 0.1-0.6% [8,[12][13].
In turn, for morbidity rate, the order of lowest rate was: the average of open cholecystectomy in the literature 0.13% (7,608/59,332, Table 4), our series 2.18% (50/2,296) and then laparoscopic cholecystectomy in the literature5.2% (8,072/155,622, Table 3). For mortality rate, the order of lowest rate was: our series 0.04% (1/2,296), the average of open cholecystectomy in the literature 0.27% (158/59,332, Table 4) and then the average of laparoscopic cholecystectomy in the literature 0.46% (27,635/6,040,632, Table 3). For major bile duct injury rate, the order of lowest rate was: our series 0.08 (2/2,296), the average of laparoscopic cholecystectomy in the literature0.22% (16,382/7,559,461, Table 3 Table 4). a operation related mortality b non-operation related mortality c major bile duct injuryd author's (SMH) personal series, e 3minor bile duct injuries in which no biliary reconstruction was required were not included, fBile duct reconstructions were associated with 4.4% mortality.

Conclusion
In conclusion, an observational study was conducted on 2296 patients with gallbladder disease undergoing laparoscopic cholecystectomy. It was found our morbidity, mortality and major bile duct injury rates were lower than those of laparoscopic cholecystectomy reported in the literature. The mortality and major bile duct injury rates were also lower than those of open cholecystectomy reported in the literature. However morbidity rate of our series was higher than that of open cholecystectomy.

Authors Contribution
A. Study concept and design: Huang SM, Huang NL, Huang SD and Pan H. Acquisition of data: Huang SM and Huang SD. Analysis and interpretation of data: Huang SM, Huang SD, Huang NL, and Pan H.

B.
Drafting of the manuscript: Huang SM, Huang NL, Huang SD, and Pan H.