Since the use of laparoscopic technique has been applied to general surgical procedures numerous reports have been published describing vast array of complications. The most common complications reported with laparoscopic cholecystectomy are perforation of gall bladder & bile duct injury. The perforation of gall bladder may occur during laparoscopic cholecystectomy, while mobilizing gall bladder from gall bladder bed. It may also occur in laparoscopic cholecystectomy during removal of gall bladder through the abdominal wall [1].

The perforation of gall bladder may or may not be associated with late complications if prophylactic antibiotic therapy is administered and stones are retrieved, as much as possible. Clinically significant, intraperitoneal gall stone spillage may cause infection, inflammation, fibrosis, adhesions, cutaneous sinuses or intraabdominal abscesses. Hence is subject of study and evaluation [2]. With this background, the present study was done to evaluate theIncidence of perforation of gall bladder during laparoscopic cholecystectomy and its associated factors. 

Aims and Objectives

To evaluate the Incidence of perforation of gall bladder during laparoscopic cholecystectomy and its associated factors

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 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 and 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, gall bladder retrieval problems, technical problems or instrument failure and drain put in or not. 

The patients were discharged if after assessment they had adequate pain control, were self-ambulatory and had post-operative voiding of urine and oral intake without vomiting. Patients not meeting the criteria were kept admitted and discharged when suitable. 

Note was made of pain and analgesia requirement. Post-operative complications like nausea, vomiting, fever, pain, abdominal discomfort, ileus, bleeding from port site, post-operative bile leak, wound hematoma and chest infections were noted. 

Patients were followed up at 7 days when stitches were removed. Note was made of any wound infection or any other complaint. Patients were again followed up at 4 weeks, note were made of any persistent pain, jaundice or any other complaint. Patients were enquired about time; taken to return routine activity i.e., the duration of convalescence and overall status after surgery. Patients were asked of symptomatic improvement. 

This prospective study was conducted to study the socio-demographic and 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. In the present study majority of patients were females (86%) and males were only 14%.

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 and was included in the study.

 In the present study, perforation occurred in 5 out of 13 male patients (38.46%) and 22 out of 84 females (26.19%) The percentage of perforation was more in the age group of 61-70 (60%) and 51-60 (42.85%) (Table 1). In the present study, perforation occurred in 11 out of 34 patients (32.35%) with BMI between 25.1 – 30 kg/m² and in 11 patients out of 32 patients (34.38%) with BMI more than 30 kg/m^2. (Table 1).

Table 1: Gender, Age and BMI Distribution Among Patients with Gall Bladder Perforation 

In the present study, perforation occurred in 22 patients out of 72 (30.55%) patients with multiple stones on preoperative ultrasound and in 5 out of 25 patients (20%) with single stone. Depending upon the size of the largest stone on ultrasound perforation occurred in 13 out of 65 patients (20%) when size of stone was up to 10mm, 12 out of 27 patients (44.44%) when size was 11 to 20 mm, 1 out of 4 patients when size was 21-30 mm and 1out of one patient when the size was >30mm (Table 2).

Table 2: Gall Bladder Perforation and Ultrasound Findings

In the patients with gall bladder wall thickness up to 2mm, 13 out of 27 (48.14%) showed perforation, out of total 6 patients with gall bladder wall thickness between 4.1 – 5 mm, 3 patients (50%) had perforation. Perforation was more common in patients with thin gall bladder wall (<2mm) and in patients with inflamed and oedematous wall (> 4mm) (Table 2). In 22 patients with adhesions with omentum perforation occurred in 9 out of 22 patients (40.91%), out of 8 partly intrahepatic gallbladders perforation occurred in 4 patients (50%), out of 8 mucocele gallbladder no perforation occurred (as intra-operative aspiration of gallbladder was done in all mucocele), in 1 case of empyema, perforation occurred with spillage of pus and out of 5 fibrosed gallbladders perforation occurred in 1 case (Table 3).

Table 3: Anatomy of Gall Bladder and Perforation

The most common mode of perforation during laparoscopic cholecystectomy in 12 cases (44.44%) out of 27 perforations occurred during grasping, in 10 cases (37.04 %) perforation occurred during dissection from liver bed and in 5 cases (18.52%) perforation occurred during dissection in Calot’striangle. Table 4 shows the mode of perforation of gall bladder.

Table 4: Mode of Perforation of Gall Bladder

Incidence of gall bladder perforation as reported in various studies includes Cuschieri A et al 16%, Soper NJ et al 30%, Manukyan MN et al 17 % [2-5]. Fitzgibbons RJ et al⁵ studied the gall bladder and gall stones removal. They mentioned 24% of gall bladder perforations as reported by Ovaska and 30% gall bladder perforations as reported at Creighton University.

Gartier P. et al. [6] reported 13.9% rupture of gall bladder. Gartiez D. et al. [7] reported 13.9 % of rupture of gall bladder. B. Aytac, S. Cakar observed perforation in 14% patients. [8] J. Diez, C. et al. conducted a study of 3686 laparoscopic cholecystectomies and found gall bladder perforation occurred in 17% of patients [9]. In the present study gall bladder perforation occurred in 27 out of 97 (27.83%) patients. The most common cause of spillage was due to perforation of gall bladder in 27 out of 40 patients (67.5%) other causes of spillage included intra-operative aspiration of gall bladder done in 10 patients (25%) and spillage during retrieval of gall bladder in three patients (7.5%). Rice DC, Memor MA, Jamison RL et al in their studies reported male gender, older age and increased weight to be risk factors for gall bladder perforation [10]. In our studies perforation occurred in 5 out of 14 male patients (35.7%) and in 22 out 86 female patients (25.58%). Most common age group of patients with perforation was 61-70 years in which perforation was noticed in 3 out of 5 patients (60%). Gall bladder perforation was common in patients with body mass index of more than 30 kg/m².

Significant risk factors for perforation and complications due to peritoneal gallstones include acute cholecystic with infected bile, spillage of pigment stones, multiple stones >15, stone size >1.5 cm and elderly patients [11]. In the present studies as per the pre-operative ultrasonography the rate of gall bladder perforation was higher in the patients with multiple gall stones (30.55%). Depending upon the size of stone higher rate of perforation was seen in patients with size of largest stone between 11-20 mm (44.44%). Only one patient was having stone of more than 30mm on preoperative ultrasound and this patient had perforation of gall bladder intra-operatively. In case of wall thickness most of the perforations occurred in a group with thickness between 4.1 – 5mm (50%) and with gall bladder wall thickness of up to 2mm (48.14%).

Rice DC, Memor MA, Jamison RL et al. [10] in their studies found perforation of gallbladder to be more common in patients with omental adhesion. In the present study perforation occurred more commonly in patients with adhesions present between gall bladder and omentum (9 out of 22 patients) and in patients where gall bladder was partly intra-hepatic (4 out of 8 patients). In all the patients with mucocele intra-operative aspiration of gall bladder was done as there was difficulty in grasping the gall bladder. In 1 case of empyema perforation occurred with spillage of pus.

According to B. Aytac and S. Cakarperforation occurred during traction and grasping in 75% patients, dissection of gall bladder in 15% patient, removal of gall bladder in 8 % patients [8].

Gartiez D, Guzman G, Alonso V. et al. reported 13.9 % of rupture of gall bladder. They found that rupture is most frequent during the separation of gall bladder from the hepatic bed or during forced extraction through one of the trocar sites [7].

The common mechanisms of gallbladder perforation during laparoscopic cholecystectomy are injury to the gall bladder during diathermy dissection from the hepatic fossa and traction injury to Hartmann’s pouch [11,12]. Less frequent causes include slippage of the endoclips and tearing of gallbladder as it is removed through the port site [13].

Woodfield JC et al studied the risk factors for perforation of the gall bladder. The principal mechanisms of gallbladder perforation during LCs are injury to the gallbladder during diathermy dissection from the hepatic fossa and traction injury to Hartmann’s pouch [14].

In the present studies perforation occurred most commonly during grasping of gall bladder 12 out of 27 patients (44%) and during dissection of gall bladder from liver bed 10 out of 27 patients (37.04%). There was no spillage due to slippage of endoclips and in 3 cases spillage occurred due to tearing of gallbladder while removing stones during retrieval of gallbladder through port site.

Stones left in the peritoneal cavity were initially considered harmless but presently there is strong recommendation that spilled gallstones should be removed and every attempt should be taken to prevent the spread of bile and calculi if gall bladder is accidently perforated [4,15,16]. 

Gallbladder perforation is common intra-operative phenomenon, more common in males & in older age group. Perforation is more common in gallbladder with adhesion with omentum and if gallbladder is partly intra-hepatic. 

In case of perforation, if thorough irrigation is done with normal saline and retrieval of spilled gall stones, as many as possible, the chances of post-operative complications is very less.

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