JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES
Volume 12, Number 3, 2002
© Mary Ann Liebert, Inc.
Effect of Timing of Surgery, Type of Inflammation,
and Sex on Outcome of Laparoscopic Cholecystectomy
for Acute Cholecystitis
KAMAL I.A. GHARAIBEH, FRCS (Glasg),1GAZI R. QASAIMEH, FRCS (Edinb),1
HUSSEIN AL-HEISS, FRCS (Edinb),1FOUAD AMMARI, FRCS (Edinb),1
KAMAL BANI-HANI, FRCS (Glasg),1TAREQ M. AL-JABERI, FRCSI,1
and SAID AL-NATOUR, FRCS (Glasg), FACS2
Background and Purpose: Studies have shown the safety and effectiveness of laparoscopic cholecys-
tectomy (LC) for acute cholecystitis (AC). Our aim was to establish the outcome of LC in patients
with AC on the basis of duration of the attack before surgery took place, the type of gallbladder in-
flammation, and patient sex.
Patients and Methods: All 204 patients at Princess Basma Teaching Hospital who underwent LC
for AC by the authors between September 1994 and June 1999, were retrospectively reviewed. They
were categorized into Group I, where surgery took place within 72 hours of the acute attack (N 5
78; 54 women and 24 men), and Group II, if later than that (N 5 126; 70 women and 56 men). Gall-
bladder pathology was classified as gangrenous, empyema, edematous, mucocele, or AC along with
contracted fibrosed gallbladder.
Results: Conversion to open cholecystectomy was needed in 12% of the total series. In Group I,
3.8% of the patients needed conversion compared with 16.7% in Group II patients (P 5 0.01). Also,
4% of the female patients needed conversion compared with 24% of the male patients (P 5 0.000).
There was an association between the pathological type of AC and the likelihood of conversion (P 5
0.002), conversion being least common in those with mucocele and most common in those with
empyema and gangrene. The median operation time was 75 6 36 minutes, but the operation time
for Group II patients was significantly longer (P 5 0.001) than in Group I patients. Operation time
in the male patients was significantly longer than in the female patients (P 5 0.000). There was no
statistically significant difference in the duration of hospital stay in the two groups or in men and
women. There were no deaths or main bile duct injuries in the series. In successful LC, missed stones
occurred in 3.3% of the patients. Bile collection, which was treated by open surgery, developed in
one female patient.
Conclusion: Laparoscopic cholecystectomy is a reliable and safe modality for the management of
AC. It was not associated with an increased incidence of bile duct injury in this series. It should be
the first choice before resorting to open surgery. Factors associated with increased conversion in-
clude delay in surgery of more than 3 days from the acute attack and certain pathology, with con-
version being more likely in empyema. Conversion also was more likely in male patients.
1Department of General Surgery, Princess Basma Teaching Hospital, University of Science and Technology, Irbid, Jordan.
2Department of Surgery, Islamic Hospital, Amman, Jordan.
194 GHARAIBEH ET AL.
superior to open cholecystectomy (OC), with less mor-
tality and morbidity,3and it has become the treatment of
choice for chronic cholecystitis (CC).4,5Acute cholecys-
titis (AC) was initially considered a relative contraindi-
cation to LC,6,7but subsequently, many reports have doc-
umented the safety of LC in AC.8–29
In this report, we review our experience with LC for
AC and evaluate the effect of timing of surgery, type of
gallbladder inflammation, and patient sex on the out-
INCE THE EARLY REPORTS of laparoscopic cholecys-
tectomy (LC),1,2the procedure has been found to be
PATIENTS AND METHODS
Retrospective evaluation of all 204 patients who un-
derwent LC for AC by the authors between September
1994 and June 1999 was carried out. The patient ages
ranged from 20 to 73 years with a median of 38 years.
Data collected using a specially designed form were pre-
operative, operative, and postoperative details, including
the histology report of the gallbladder where documented.
Acute cholecystitis was diagnosed when an acute attack
of biliary pain was present. The diagnosis was confirmed
by ultrasonography, operative findings, and histologic
analysis. During LC, AC was classified as either edema-
tous, with pericholecystic edema; mucocele, with mucus
noted on gallbladder aspiration; empyema, with pus on
aspiration; AC associated with contracted fibrosed gall-
bladder (CGB); or gangrenous cholecystitis. Patients with
AC were categorized as Group I if LC was carried out
within 72 hours of the acute attack (N 5 78; 54 women,
24 men) and Group II if later than that (N 5 126; 70
women, 56 men).
We adopted the American surgical technique1but used
diathermy for coagulation instead of a laser. Nasogastric
tubes, urinary catheters, and intraoperative cholangiog-
raphy were not used routinely. If the gallbladder was
found to be tense, it was punctured at the fundus and
evacuated by a suction aspiration needle. The epigastric
port was used to extract the gallbladder and was extended
if necessary. Preoperative antibiotics of the cephalosporin
group were used from the time of admission until the time
of surgery if there was leukocytosis or fever. All patients
were given peroperative antibiotics of the cephalosporin
group. In cases of perforation and leak of bile or stones
or in cases of empyema or gangrene of the gallbladder,
antibiotics were continued for 1 to 3 days. The operation
time (in minutes) was calculated from the time of inci-
sion for the Veress needle to the completion of the last
suture. Postoperative stay was calculated as the number
of nights spent in the hospital after surgery.
Statistical significance was assessed using the Yates
corrected chi-square and the two-sample t-test for com-
parison of two means. A P value was considered signif-
icant if less than 0.05.
Conversion to OC
Conversion was carried out in 24 patients (12%), 3
(3.8%) in Group I and 21 (16.7%) in Group II (P 5 0.01)
(Table 1). Five female patients (4%) and 19 male patients
(24%) underwent conversion (P 5 0.000). There was a
significant difference in the conversion rate between dif-
ferent pathologic types (P 5 0.002), the rate being high-
est in gangrenous cholecystitis and empyema and lowest
in the mucocele variety (Table 2).
There was statistically significant difference in the op-
eration time between the patients in Group I and Group
II before (P 5 0.001) and after (P 5 0.012) excluding the
converted cases (Table 3). There also was a significant
difference between the male and female patients before
(P 5 0.000) and after (P 5 0.002) excluding the con-
verted cases in both sexes.
There was no mortality or bile duct injury (BDI) in the
series. In the patients who underwent successful LC, gall-
bladder perforation occurred in 31.1% (35 females, 21
males), spilled stones in 12.2% (14 females, 9 males),
and lost stones in 3.3% (2 females, 4 males) (Table 4).
There was no significant difference in the perforation rate
between the patients in Group I and Group II (P 5 0.3)
or between the female and male patients (P 5 0.6). No
problems related to missed stones have been reported in
the patients. Veress needle-induced omento-pneumato-
cele occurred in one patient and was punctured laparo-
scopically. Early in the study, a 10-mm trocar-induced
aortic injury underwent immediate open repair and OC.
During a Hasson open technique, the sigmoid colon was
TABLE 1. REASONS FOR CONVERSION TO LAPAROTOMY
Suspected duodenal injury
Suspected colonic injury
Trocar-induced aortic injury
Difficult dissection and obscured anatomy
Bleeding from the cystic artery
6 (2 F, 4 M)
2 (1 F, 1 M)
11 (2 F, 9 M)
24 (5 F, 19 M)
CHOLECYSTECTOMY FOR ACUTE CHOLECYSTITIS195
injured while opening the posterior rectus sheath. The
small tear was repaired immediately by widening the um-
bilical incision followed by LC. An epigastric port inci-
sional hernia occurred in one patient where the fascia of
the 10-mm incision was not closed. Superior epigastric
vessel bleeding occurred intraperitonealy and was treated
conservatively by blood transfusion. Shoulder pain was
reported in 51% (93/180) of the patients.
The postoperative stay ranged from 0.5 to 10 days
(mean 1.9 6 1.34 days). After excluding the converted
cases and the female patient with the bile collection, the
range was 0.5 to 6 days (mean 1.66 6 1.1 days). There
was no statistically significant difference between Group
I and Group II or between male and female patients be-
fore and after exclusion.
In the early years of laparoscopic cholecystectomy, AC
was considered a relative contraindication, especially in
severe attacks or if the gallbladder wall thickness was
more than 4 mm.6,7Since then, many reports worldwide
documented the safety of the procedure in AC,8–29and
the operation is recommended now as the treatment of
choice for AC.28It is well recognized, however, that in
AC there is a higher rate of conversion than in
CC,15,22,25,29,30and in our series, conversion was needed
in 11.8% of the patients. Conversion should not be looked
at as a complication,5however, but as a safety net.29Con-
verted cases run a course similar to that following OC.11
Operative mortality in LC for AC was reported in 0 to
0.9% of the cases.9,21,24,28In our series, there were no
deaths. Bile duct injury (BDI) is reported more frequently
in LC than in OC, and some consider AC a risk factor.25
An incidence of 0.4% (1/221) was reported.24Others re-
ported no such risk.23,28,31We had no clinically detected
cases of BDI. We feel that AC may protect from
diathermy injury because the associated swelling and
edema decrease the conduction of diathermy to the duct
system. There is also the fact that LC for AC is usually
performed by the more experienced surgeons, and the sur-
geon is usually more careful and slower in the dissection
of the Calot triangle area. Gallbladder perforation in AC
with spillage of bile, stones, or both may occur in as many
as 58% of the patients.28Stones may be lost in as many
as 40% of the patients,32but only about 0.08% develop
stone-related clinical problems.33We have had no prob-
lems related to the 3.3% rate of missed stones. During
LC, most surgeons do not consider lost stones a cause
During the prelaparoscopic era, the recommended
management of AC was early OC, within 72 hours of the
acute attack.37With the introduction of LC, the timing is
still not firmly established. In one study, it was found that
the converted cases were operated on 5 days from the
acute attack, whereas the successful ones had the LC
within a mean of 0.6 days from the attack.16A conver-
sion rate of 7.7% was reported when surgery was carried
TABLE 2. DETAILS OF CONVERTED CASES IN GROUP I AND GROUP II IN RELATION TO TYPE OF INFLAMMATION
Pathology typeNo. Group I Group II% Conversion
TABLE 3. OPERATION TIME IN MALE AND FEMALE PATIENTS AND IN GROUPS I AND II
RangeMean 6 SDRangeMean 6 SD
89 6 40
79 6 38
65 6 30
63 6 27
Group IGroup II
64 6 38
61 6 35
79 6 33
73 6 27
196 GHARAIBEH ET AL.
out within 24 hours,28whereas when it was performed
within 72 hours, a conversion of 13% to 22%18,22was
reported. Another study reported a conversion rate of
1.8% when LC was carried out within the first 4 days
and 31.7% when carried later, without a significant dif-
ference in the operation time or postoperative stay.13
Thus, the results of these studies suggest that the same
rule of early OC applies and that the golden time should
be as early as possible once the diagnosis has been made.
In our series, we had a statistically significant difference
in conversion (P 5 0.01) between Group I, with a rate of
3.8% (3/78), and Group II, 16.7% (21/126).
A prospective study concluded that the duration of the
operation did not affect the risk of complications.38In
our study, the operation time was significantly longer
(P 5 0.001) in Group II than in Group I (81 6 33 and
64 6 38 minutes, respectively). The difference was still
significant (P 5 0.012) after excluding the converted
cases in both groups (3 cases in Group I and 21 cases in
Group II). The difference in the postoperative stay was
not statistically significant (P 5 0.11) in the two groups
(1.6 6 1 nights and 2 6 1.5 nights in Group I and Group
II, respectively). The difference was still not statistically
significant after excluding female patient who developed
a subphrenic collection in addition to the converted cases
in both groups (P 5 0.23).
Examination of the conversion rate according to
pathology has shown a rate of 40% to 50% in the gan-
grene variety,9,12,1512.5% to 83.3% in empyema,9,12,15,23
and 7% in mucocele,15while in the commonest edema-
tous variety, a conversion rate of 21.8% to 29.2% has
been reported.9,15,23The wide range of conversion rates
in empyema is probably caused by the small number of
cases reported in the studies. In our series, we had a con-
version rate of 0 in the 26 examples of the mucocele va-
riety and 10% (15/147), 17% (3/18), 42% (5/12), and
100% (1/1) in the edematous, CGB, empyema, and gan-
grenous varieties, respectively. The difference was sta-
tistically significant (P 5 0.002), being lowest in muco-
cele and highest in empyema and gangrene. These results
are generally in accordance with the groups, because all
patients with empyema and gangrene belonged to Group
II and the majority of the patients with the mucocele va-
riety of AC were in Group I.
Very few reports have discussed the effect of the sex
of the patient on the course of LC in CC and AC. A higher
conversion rate was reported in male patients in both CC
and AC.11,27,39,40Delay in the seeking of medical advice
by men or difference in the disease pattern have been
suggested.40In our study, conversion showed a signifi-
cant difference (P 5 0.000) between the female and male
patients (5/124 v 19/80). The operation time in the male
patients was significantly higher (P 5 0.000) than the fe-
male patients (89 6 40 minutes and 65 6 30 minutes, re-
spectively). The difference was still highly significant af-
ter excluding the converted cases (19 men and 5 women).
Laparoscopic cholecystectomy is a reliable, safe
modality for AC. It is not associated with an increased
incidence of BDI. It should be the first choice before
restoring to open surgery. Factors associated with in-
creased conversion include a delay in surgery of more
than 3 days from the acute attack; type of pathology, con-
version being more common in empyema and gangrene
of the gallbladder; and male sex.
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Address reprint requests to:
Kamal I.A. Gharaibeh, FRCS(Glasg)
P.O. Box 1154
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