Role of laparoscopic cholecystectomy in the management of gangrenous cholecystitis

Background: Laparoscopic cholecystectomy is increasingly being employed as the initial surgical approach in patients with acute cholecystitis. Gangren ous cholecystitis will be unexpectedly encountered in a proportion of these patients. The applicability of laparoscopic techniques and its outcome in this group of patients remain poorly defined. This paper presents our exper ience with laparoscopic cholecystectomy in the treatment of patients with g angrenous cholecystitis. Methods: From January 1994 to March 1999, 281 patients underwent laparoscop ic cholecystectomy for acute cholecystitis. Operative and histopathologic d ata were obtained and the subgroup with gangrenous cholecystitis identified (53 of 281, 18.8%). Laparoscopic cholecystectomy was the initial surgical approach in 44 (83%) and was successfully completed in 30 of 44 (68%) patie nts. Conversion to an open cholecystectomy became necessary in 14 of 44 (32 %). A retrospective review comparing these two groups of patients was perfo rmed. Results: Of the 44 patients, there were 25 males and 19 females, with a mea n age of 64.6 years. Mean duration of symptoms prior to presentation was 2. 3 and 2.9 days in the laparoscopic and conversion groups, respectively. Cli nical presentation included the presence of right upper quadrant pain (98%) , leukocytosis (91%), fever (16.3%), and jaundice (9%). Liver function test abnormalities included elevations of alkaline phosphatase (25%), aspartate aminotransferase (20.4%), alanine aminotransferase (22.7%), and total bili rubin (18.1%). Ultrasonography revealed the presence of gallstones (88.6%), gallbladder wall thickening (52.3%), and pericholecystic fluid (20.5%). Ai r in the gallbladder wall and intraluminal membranes were present in 2 pati ents and 1 patient, respectively. Nuclear scans performed in 29 patients re vealed cystic duct obstruction in all 29. The rim sign was present in 1 pat ient. A laparoscopic cholecystectomy was attempted in 44 of 53 patients and was successfully completed in 30 (68%). Conversion to an open procedure be came necessary in 14 of 44 (32%). No difference in preoperative factors was noted among the two groups. The mean duration of surgery in patients under going a successful laparoscopic cholecystectomy was 107 minutes versus 110 minutes when conversion was necessary. There were no deaths in the study po pulation. Morbidity occurred in 40% of the laparoscopic group and 71% of th e conversion group. No patient in the laparoscopic group required admission to the intensive care unit. In contrast, 4 of 14 patients in the conversio n group required a mean of 2.6 days in the intensive care unit. Postoperati ve hospital stay was 3.3 versus 5.5 days in the two groups, respectively. Conclusions: Preoperative factors did not predict conversion in patients un dergoing laparoscopic cholecystectomy for presumed acute cholecystitis who are found to have gangrenous cholecystitis. Duration of surgery is not sign ificantly prolonged and outcome in terms of morbidity, admission to the int ensive care unit, and hospital stay are significantly better in patients in whom laparoscopic cholecystectomy is successful. (C) 2001 Excerpta Medica, Inc. All rights reserved.