LAPAROSCOPIC CHOLECYSTECTOMY FOR ACUTE CHOLECYSTITIS AND THE CONSEQUENCES OF GALLBLADDER PERFORATION, BILE SPILLAGE, AND LOSS OF STONES

Objective: To study the factors associated with accidental perforation of the gallbladder and spillage of bile and stones and to assess the consequences of these mishaps. Design: Prospective study with retrospe ctive bacteriological evaluation. Setting: Teaching hospital, Israel. Subjects: 189 Patients who were treated for clinical acute cholecystit is between January 1994 and August 1996. Interventions: Emergency lapa roscopic cholecystectomy. Main outcome measures. Incidence of accident al perforation of gallbladder and spillage of bile and stones and of c onversion and complications in relation to preoperative and operative findings. Results: Bile was spilt in 65 (34%) and gall-stones were ''l ost'' in 27 (14%), 44 (23%) required conversion to an open approach an d 36 (19%) developed complications. Preoperative duration of symptoms >96 hours and a palpable gallbladder were associated with accidental p erforation of the gallbladder and spillage of bile. A palpable gallbla dder, gangrenous cholecystitis, and WBC > 15 x 10(9)/L were associated with stones ''lost'' in the peritoneum. A history of biliary disease was inversely related to ''lost'' stones. Conversion of laparoscopic t o open cholecystectomy was associated with male sex, age >60 years, a nonpalpable gallbladder, WBC > 15 x 109/L, and a gangrenous gallbladde r. Complications of surgery were more common among men and associated with fever of >38 degrees C. Neither the conversion nor the complicati ons were associated with perforation of the gallbladder or ''lost'' st ones. Conclusion: Perforation of the gallbladder and intraperitoneal s pillage of bile or stones during laparoscopic cholecystectomy for acut e cholecystitis are not associated with undesirable events, are not in dications for conversion, and are not associated with further complica tions. When patients are given appropriate antibiotics perioperatively and the spilt bile is properly aspirated and the peritoneum irrigated , the operative and postoperative courses are similar to those of pati ents with unperforated gallbladder.