Gall Bladder disease mainly, the presence of stones in gall bladder i.e., cholelithiasis is of common occurrence. The high occurrence of gall stones has become apparent since introduction of ultrasonography [1].

The prevalence is higher in women, more with multiple pregnancies, obesity as well as in older patients. Epidemiological studies have clearly demonstrated a linear relationship between increasing age and prevalence of cholelithiasis. As a cause of hospitalization gall stones are the most common and most costly digestive disease with an annual estimated overall cost more than $5 million. Of these 20% are symptomatic at the time of diagnosis while as many as 80% may remain asymptomatic during individuals' life time. Of these asymptomatic patients, 1-4% per year will develop symptoms. During the last several centuries, numerous techniques have been introduced in an effort to manage patients with symptomatic gall stone disease [2,3].

Cholecystectomy is the commonest operation of biliary tract and second most common operative procedure performed today. Laparoscopic cholecystectomy has gained wide acceptance as treatment of choice for gall stone disease and cholecystitis. While the most common complication reported with laparoscopic cholecystectomy is bile duct injury, bile and gall stone spillage, other commonly described complications include vascular injury, haemorrhage, bowel and other visceral injury and retained common duct stones [3-5].

Hence keeping these factors in mind this study was undertaken and conducted in the department of surgery, Indira Gandhi Medical College, Shimla, to evaluate the Socio-demographic & clinical profile of patients having gall bladder perforation and spillage of bile & gall stones during laparoscopic cholecystectomy.

AIMS AND OBJECTIVES

To evaluate the socio-demographic & clinical profile of patients having gall bladder perforation and spillage of bile & gall stones during laparoscopic cholecystectomy

This prospective study was conducted in the Department of General Surgery, Indira Gandhi Medical College and Associated Hospitals. One hundred consecutive patients of symptomatic gallstones satisfying the selection and exclusion criteria and with the documented gallstones on ultrasonography and undergoing laparoscopic cholecystectomy were included in the study. 

Selection Criteria

• Patients of symptomatic gall stone disease with gall stones documented on ultrasonography. 

• No clinical, biochemical or ultrasonographic evidence of common bile duct stone or gall bladder mass.

• Patients of both sexes between 16-75 years of age.

Exclusion Criteria 

• Any illness which makes patient unfit for anesthesia.

• Presence of jaundice

• Acute pancreatitis. 

• Pregnancy.

• Presence of stones in common bile duct. 

• Gall bladder mass and carcinoma. 

• Severe coagulopathy. 

• Conversion to open cholecystectomy. 

Patients were thoroughly worked up starting from the outdoor patient's department and were subjected to detailed history and clinical examination, abdominal ultrasonography, routine haematological investigations, liver function tests & pre-anaesthetic check-up.

All the patients were operated under general anaesthesia. All patients were operated using three/ four port techniques. During the procedure careful note was made of operative time and technique. The intra-operative difficulties and complications related to gall bladder perforation were analysed as anatomical problems, gall bladder perforation, spillage of bile/ pus/ mucous, spillage of stones, retrieval of stones completely or loss of stones in peritoneal cavity and gall bladder retrieval problems.

Statistical Analysis

Data was entered in MS Excel and analysed using Epi Info Software V7. Qualitative variables were expressed as frequency and percentages while quantitative variables were expressed as mean and standard deviation. Appropriate statistical tests were applied to find the association. P value<0.05 was taken as statistically significant.

OBSERVATION AND ANALYSIS

This prospective study was conducted to study the socio-demographic & clinical profile of patients having gall bladder perforation and spillage of bile and gall stones during laparoscopic cholecystectomy. The study was conducted on 100 patients admitted to Indira Gandhi Medical College and Hospital. One hundred patients of symptomatic gall stones satisfying the selection and exclusion criteria underwent laparoscopic cholecystectomy during the period from July 2011 to March 2012. The observations thus made were analyzed and recorded as follows in Table 1. 

Table 1: Age and Gender Distribution of Study Participants

In the present study majority of patients were females (86%) and males were only 14%. Most of the female patients were in the age group of 31- 40 years (30.23%). Majority of male patients were in the age group of 41-60.

The youngest patient in this study was a 19-year-old female and the oldest was 75-year-old female. Mean age of the females was 40.15±10.97 years and in the male patients it was 47.64 years. The overall mean age was 41.20±12.29 years. (Table 1) 

In the present study majority of the patients presented with symptoms of pain right upper abdomen (96%), dyspepsia (37%), vomiting (37%). No patient had fever at the time of presentation. In the present study, most of the patients had symptoms for a period of 1-6 months (37%). The range of duration of symptom was 1-60 months with mean of 10.95±15.45 months. (Table 2)

Table 2: Presenting Symptoms and Its Duration among Study Participants

There was no patient with upper abdominal surgery. There were 16 patients with previous lower abdominal surgery. Among these 16 patients who had history of lower abdominal surgery, 3 had history of hysterectomy,11 had history of tubectomy and 2 had history of caesarean section (Table 3)

Table 3: Previous Abdominal Surgery

Among the total, 4% of the patients had multiple stones on ultrasound whereas 26% had single stone on ultrasound. 68% of the patients had gallbladder stone up to 1cm in size and one patient had stone greater than 3 cm. The gallbladder wall thickness in 29% of patients was up to 2mm, in48% patients was between 2.1 -3 mm; 15% patients had wall thickness 3.1 – 4 mm; 7% patients had wall thickness of 4.1 – 5mm and 1% patient had wall thickness more than 5 mm. Impacted stone at Hartman's pouch was present in 1% patients. No pericholecystic fluid was present on USG in any of the patients. All the patients had their biochemical tests (RBS, LFT, and RFT) within normal range before surgery. (Table 4)

Table 4: Ultrasound Findings of study participants

Among the total, 53 patients (53%) had distended gall bladder without any adhesions, 22 patients (22%) had distended gallbladder with adhesions with omentum, 8 patients (8%) had gallbladder which was partly intrahepatic, 8 patients (8%) had mucocele of gallbladder, 1 patient (1%) had empyema gallbladder, 5 patients (5%) had fibrosed shrunken gallbladder and in 3 patients (3%) there were dense adhesions with unclear anatomy. (Table 5)

Table 5: Operative Findings among Study Participants

Among the total, 3% of patients had to be converted to open cholecystectomy. The cause of conversion in all the three cases was unclear anatomy in the Calot’s triangle. In all other 97 patients, cholecystectomy was completed by laparoscopy. (Table 6)

Table 6: Conversion to Open Cholecystectomy:

Gall stones have affected mankind for centuries and are a common problem in the western countries and in our own. The increasing acceptance of surgical therapy for gall stone disease and its consequences over past 100 years is the result of availability of accurate methods of diagnosis, the safety and the ease with which the operations are accomplished and the satisfactory long-term relief of symptoms [6]. Laparoscopic cholecystectomy is a gold standard for elective cholecystectomy [7].

The present study was undertaken in the Department of Surgery, Indira Gandhi Medical College and Hospital, to study the socio-demographic & clinical profile of patients who had gall bladder perforation and spillage of bile and gall stones during laparoscopic cholecystectomy.

In the present study majority of the patients are in age group 31- 40 years within average age of 41.20 years, range being 19-75 years. Mean age reported was 47 years by Bailey RW et al., [8] 43.2 years by Schrimer BD et al., [9] 46.1 years by Peters JH et al., [10]. From above it is clear that in the present study the age of patients is comparable to other series reported earlier.

In present study, there were 86% females and 15% males. In the previous studies the sex wise distribution as reported by Bailey RWet al., [8] was 69%(female) and 31%(male), Schrimer BD et al., [9] 78%(female) and 22%(male) and by Peters JH et al., [10] was 81%(female) and 19%(male).

Duration of symptoms in the present study ranges between 1- 60 months. Most of the patients presented with pain right hypochondrium (96%), vomiting and dyspepsia. In Bailey RW et al., [8] series 90% of the patients had symptoms with 105 having acalculous gall bladder disease.

In the present study all the 16 patients with history of previous surgery were having lower abdominal surgery and in none of the patients, converted to open cholecystectomy, the cause was previous abdominal surgery. The conversion was due to dense adhesions and unclear anatomy in Calot’s triangle.

Jorgensen and Hunt in their analysis of the potential causes of failure of laparoscopic cholecystectomy and requiring conversion to the open operation concluded that the failures were attributable to upper abdominal adhesions, and lower abdominal surgery scar did not seem to pose a problem [11].

Majority of patients in this study were females and were in age group of 31- 40 years. Pain right hypochondrium was the most common symptoms and majority of the patients had multiple stones documented on ultrasonography, the size of largest stone in most of the patients was ≤10 mm and most of the patients had gallbladder thickness ranging between 2.1-3. Conversion was required in 3 patients due to dense adhesion and unclear calot’s triangle anatomy.

1. Shehadi, W.H. The Biliary System Through the Ages. USA, vol. 64, no. 6, 1979, pp. 63–78.

2. “Consensus Conference: Gallstones and Laparoscopic Cholecystectomy.” JAMA, vol. 269, no. 8, 1993, pp. 1018–1024.

3. De, U. “Evolution of Cholecystectomy: A Tribute to Carl August Langenbuch.” Indian Journal of Surgery, vol. 66, no. 2, Mar. 2004, pp. 97–100.

4. Nagy, A.G.et al. “History of Laparoscopic Surgery.” Canadian Journal of Surgery, vol. 35, no. 3, 1992, pp. 271–274.

5. Gunning, J.E. “The History of Laparoscopy.” Journal of Reproductive Medicine, vol. 12, 1974, pp. 222–226.

6. McSherry, C.K. “Cholecystectomy: The Gold Standard.” The American Journal of Surgery, vol. 158, no. 3, Sept. 1989, pp. 174–178.

7. Zacks, S.L.et al. “A Population-Based Cohort Study Comparing Laparoscopic Cholecystectomy and Open Cholecystectomy.” American Journal of Gastroenterology, vol. 97, no. 2, Feb. 2002, pp. 334–340.

8. Bailey, R.W.et al. “Laparoscopic Cholecystectomy: Experience with 375 Consecutive Patients.” Annals of Surgery, vol. 214, no. 4, Oct. 1991, p. 531.

9. Schirmer, B.D.et al. “Laparoscopic Cholecystectomy: Treatment of Choice for Symptomatic Cholelithiasis.” Annals of Surgery, vol. 213, no. 6, June 1991, p. 665.

10. Peters, J.H.et al. “Safety and Efficacy of Laparoscopic Cholecystectomy: A Prospective Analysis of 100 Initial Patients.” Annals of Surgery, vol. 213, no. 1, Jan. 1991, p. 3.

11. Jorgensen, J.O., and D.R. Hunt. “Laparoscopic Cholecystectomy: A Prospective Analysis of the Potential Causes of Failure.” Surgical Laparoscopy & Endoscopy, vol. 3, no. 1, Feb. 1993, pp. 49–53.