A study on the outcome of laproscopic cholecystectomy in acute cholecystitis

Outcome of laproscopic cholecystectomy in acute cholecystitis Page 1
A STUDY ON THE OUTCOME OF LAPROSCOPIC
CHOLECYSTECTOMY IN ACUTE CHOLECYSTITIS
A PROJECT REPORT
UNDER THE GUIDANCE OF
Mrs. SWATI MANOJ BRAMHE
SUBMITTED BY
AKSHAYA K.C
ROLL NO:1305018977
IN A PARTIAL FULFILLMENT OF THE REQUIRMENT FOR THE AWARD
OF THE DEGREE OF MBA IN HEALTHCARE SERVICES
S M U
Sikkim Manipal University
Directorate of Distance Education
JULY 2015

Declaration
I hereby declare that the study titled “A study on the outcome of
laproscopic cholecystectomy in acute cholecystitis” submitted for the
partial fulfillment of the requirement for the award of the degree of Masters
in Business Administration in Healthcare Services, is my original work and
the dissertation has not formed the basis for the award of any degree,
association fellowship any other similar titles.
Signature of the student:
Place:
Date:

Bonafide Certificate
Certified that this project titled “A STUDY ON THE OUTCOME OF
LAPROSCOPIC CHOLECYSTECTOMYIN ACUTE CHOLECYSTITIS” is
the bonafide work of Miss.AKSHAYAK.C who carried out the projectwork
under my supervision.
Signature
Mrs.SWATIMANOJ BRAMHE
Co-ordinator
Megavision Diagnostic Center
Shubham Galleria,
Near Kohinoor Tower, Pimpri,
Pune-411018

A PROJECT REPORT
“A STUDY ON THE OUTCOME OF LAPROSCOPIC
CHOLECYSTECTOMYIN ACUTE CHOLECYSTITIS”
UNDER THE GUIDANCE OF
Mrs.SWATI MANOJ BRAMHE
CO-ORDINATOR
MEGAVISIONDIAGNOSTIC CENTER
SUBMITTED BY:
Miss.AKSHAYAK.C
ROLL NO.1305018977
MBA IN HEALTHCARE SERVICES
SUBMITTED TO:
SIKKIM MANIPAL UNIVERSITY
DIRECTORATE OF DISTANCE EDUCATION
INDIAN INSTITUTEOF BUSINESS MANAGEMENT,PUNE.

INTRODUCTION
Gall stones and cholecystitis have been known to mankind as far as
written history goes. Acute cholecystitis is the inflammation of the gall
bladder wall usually secondary to cystic duct obstruction. In 90% of
patients, it is due to gall stone known as acute calculous cholecystitis.
With the advent of 21st
century, the only constant factor in surgery, as
in all faculties of science,is ‘Change’. 'The Lesser,the Better' is guiding the
approach to surgeries in the recent millenium. Laparoscopy is the answer
to the question to 'Minimize Tissue Damage & Maximize Goal
Achievement'.
A variety of treatments have been offered from time to time for gall
bladder diseases. Cholecystectomy has stayed as one of the best & most
accepted treatment modalities for GB diseases. Every year, about 500,000
people all over the planet have their gall bladders removed. Prof Dr. Erich
Muhe of Boblingen, Germany, performed the first laparoscopic
cholecystectomy on September 12, 1985.
Acute cholecystitis was traditionally treated with antibiotics and
supportive treatment and cholecystectomy was performed after 6 weeks of
the acute episode. The potential hazard of severe complications, if surgery
is performed in an area of distorted anatomy caused by acute inflammation
was the major concern.

Till date Laparoscopic Cholecystectomy is considered the 'Gold
Standard' in the treatment of Cholelithiasis / Cholecystitis and highlights all
the advantages of Laparoscopy as minimally invasive surgical aid.
Initially laparoscopic cholecystectomy used to be done in selected
cases. But with advances in instrumentation, better visualisation because
of new generation cameras and optics, increasing knowledge about the
anatomy of the hepato-biliary tree and the surrounding structures and
improving surgical skills, surgeons started performing laparoscopic
cholecystectomy even in acute cholecystitis, which was initially considered
a relative contraindication. It is now the procedure of choice for patient
presenting with acute cholecystitis unless it is contraindicated for technical
reason or safety.
We undertake the present series of patients to evaluate the outcome
and assess the feasibility, efficacyand postoperative complications in acute
cholecystitis in our hospital.

AIMS & OBJECTIVES
A prospective study was undertaken to evaluate outcome of
laparoscopic cholecystectomy as a treatment modality for acute
cholecystitis.
Considering the-
1. Feasibility and Safety of Procedure
2. Time of Intervention (within 3 days (72 hrs) of admission or later)
3. Duration of Operation
4. Difficulty during laparoscopic surgery
5. Complicationrate (intra-operative haemorrhage, post operative biliary
leak)
6. Sepsis
7. Conversion Rate
8. Length of hospital Stay
9. Return to normal activity/work
The study was planned by selecting Patients with strict criteria.

LAPAROSCOPIC ANATOMY OF BILIARY TREE
A thorough knowledge of the anatomy of the gall bladder, the extra
hepatic biliary tree and its frequent anatomical variations, is essential for
the performance of a safe Laparoscopic Cholecystectomy.
The gallbladder lies under the right lobe of liver to which it may be
attached directly or by a mesentery; it may be completely embedded in the
liver substance. The fundus of the gall bladder may extend out to the liver
edge. Medially the gall bladder usually narrows lightly to form Hartmann's
pouch, from which cystic duct arises. The cystic duct then joins the
common bile duct opening into the right edge of the duct above the
duodenum. The hepatic artery usually lies posterior to the common bile
duct and after bifurcation; the right hepatic branch runs parallel to the cystic
duct. The cystic artery classically arises from the right hepatic artery and is
divided into anterior and posterior branch to supply gall bladder wall. The
cystic lymph node (of Lund) lies over the anterior cystic artery where it
crosses cystic duct.
Calot Triangle: It is anatomical triangular region bounded by common
hepatic duct medially, the cystic duct laterally and the cystic artery
superiorly.
Hepatobiliary triangle/Hepatocystic triangle: Superior border by inferior
margin of liver, the common hepatic duct medially & cystic duct laterally It
contains the right hepatic artery, the cystic artery and sometimes an
abberent bile duct.

Further in acute cholecystitis the inflammation distorts the anatomy
more.
Hepatocystic Triangle

SURGICAL PHYSIOLOGY& FUNCTIONS OF THE GALL BLADDER
Bile, as it leaves the liver, is composed of 97% water, 1-2% bile salts
and 1% pigments, cholesterol and fatty acids. The liver excretes bile at the
rate estimated to be approximately 40 ml/hr. The rate of bile secretion is
controlled by cholecystokinin, which is released from the duodenal mucosa.
With feeding there is increased production of bile.
The gall bladder is a reservoir for the bile. During fasting, resistance to
flow through the sphincter is high, and bile excreted by the liver is diverted
to the gall bladder. After feeding, the resistance to flow through the
sphincter of Oddi is reduced, the gall bladder contracts and the bile enters
the duodenum. These motor responses of the biliary tract are in part
affected by the hormone cholecystokinin.
The second main function of the gall bladderis concentration of bile by
active absorptionof water, sodium chloride and bicarbonate by the mucous
membrane of the gall bladder. The hepatic bile which enters the gall
bladderbecomesconcentrated 5-10 times with a corresponding increase in
the proportion of bile salts, bile pigments, cholesterol and calcium.
The third function of the gall bladder is the secretion of mucus -
approximately 20ml is produced perday. With total obstruction of the cystic
duct in a healthy gall bladder, a mucocele develops on account of this
function of the mucosa of the gall bladder.

ANATOMY & PATHOPHYSIOLOGYIN ACUTE CHOLECYSTITIS
Acute cholecystitis is related to gall stones in majority of cases.
Obstruction of the cystic duct leading to biliary colic is the initial event in
acute cholecystitis. If the cystic duct remains obstructed, the gall bladder
remains distended, and the gall bladder wall becomes inflammed and
oedematous.
Initially, acute cholecystitis is an inflammatory process with a thickened
and reddish wall with subserosal haemorrhage. The mucosa may show
hyperaemia and patchy area of necrosis.In the most commonscenario, the
gallstone dislodges and the inflammation will gradually resolve. In the most
severe cases, this process can lead to ischemia and necrosis of the gall
bladder wall (5-10%).
Acute gangrenous cholecystitis results in formation of an abscess or
empyemawithin the gall bladder.When the gas-forming organisms are part
of the secondary bacterial infection, gas may be seen in the gall bladder
lumen and in the wall of the gall bladder on imaging resulting in
emphysematous cholecystitis.
Clinical features:
Symptoms: Right upper quadrant pain, fever, nausea, vomiting.
Signs: Right upper quadrant guarding and tenderness, Murphy’s sign
(Inspiratory arrest with deep palpation in right upper quadrant), icterus.

TREATMENT MODALITIES FOR GALL STONES
A. NON-INVASIVE
B. MINIMALLY INVASIVE
C. NEWER SURGICAL TECHNIQUES
D. NEW & INVESTIGATIONAL TECHNIQUES TO PERFORM
CHOLECYSTECTOMY.
A) NON-INVASIVE TREATMENT OF GALLSTONES
 Oral Dissolution therapy (Chenodeoxycholic acid and
Ursodeoxycholicacid)
 Extra Corporeal Shock Wave Lithotripsy
B) MINIMALLY INVASIVE GALLBLADDER PROCEDURES
 Direct percutaneous puncture of gallbladder
 Contact Dissolution Therapy
 Percutaneous Cholecystectomy
 Endoscopic cholecystolithotomy
 Mini Cholecystectomy
C) NEWER SURGICAL TECHNIQUES
 Laparoscopic cholecystectomy
D) NEW & INVESTIGATIONAL TECHNIQUES TO PERFORM
CHOLECYSTECTOMY.
 Single port laparoscopic surgery
 Natural orifice transluminal endoscopic surgery (NOTES).

NEW & INVESTIGATIONAL TECHNIQUES TO PERFORM
CHOLECYSTECTOMY
The advent of laparoscopic cholecystectomy provided a dramatic
benefit to patients who previously underwent laparotomy for gall bladder
disease.While laparoscopic has already set a high bar for cholecystectomy
with regards to perioperative and intraoperative outcomes, there are areas
of surgical research examining ways that could potentially make the
procedure even less invasive.
Single port laparoscopic surgery
Single port laparoscopic surgery is a recent development in
laparoscopic surgery that involves introducing all operative instruments and
images through a single skin incision, usually at the umbilicus.
The proposed benefit of single port laparoscopic cholecystectomy
over traditional laparoscopic cholecystectomy is by reducing the overall
number of abdominal incisions from three or four to one, there will be less
perioperative pain and fewer resulting incisional complications. From a
technical standpoint, single port surgery leads to all of the instruments
entering the operative field in line with the optics. Triangulation and traction
or counter traction are made more difficult,but new instrumentation is being
developed to overcome these limitations. There are currently no
established standard techniques for performing this procedure and
postoperative results are just emerging.

Natural orifice transluminal endoscopic surgery
Natural orifice transluminal endoscopic surgery (NOTES) is an
investigational procedure that aims to reduce and eventually eliminate all
abdominal incisions by accessing the peritoneum through natural orifice
routes including transoral or transgastric, transvaginal, and transanal or
transcolonic.
By eliminating abdominal incision, the hypothesis is that there will be
less pain, fewer complications and decreased morbidity associated with
abdominal incisions. These benefits are proposed to include decreased
incisional hernias, wound infections, and postoperative pain, while
improving cosmesis. Given the current state of technology and lack of
appropriate instrumentation, few pure NOTES cholecystectomy have been
performed worldwide. NOTES hybrid procedures, where a laparoscopic
instrument is used in conjunction with the natural orifice devices,have been
performed in greater numbers, though only in a relatively few specialized
centres. Results from these procedures are also just being reported and
large sets of data are not yet available to evaluate the proposed benefits of
NOTES.

REVIEW OF LITERATURE
Gallstones have been known for centuries. They were observed in
the Mummy of Priestess of Arnan in the 21st
Egyptian dynasty 1500 BC.
Gallstones are one of the most common problems affecting the
digestive tract. Autopsy reports have shown a prevalence of gallstones
from 11-36 %.
Women are 3 times more likely to develop gallstones than men and
1st
degree relatives of patient with gallstones have two fold greater
prevalence.
Cholecystectomy is one of the most common surgical procedure
performed. There has been an increase in the rate of cholecystectomies
subsequent to the introduction of laparoscopic cholecystectomy
accompanied by evidence of lower clinical threshold for operative therapy
of gall bladder disease.
Currently it is estimated that over 80% of cholecystectomies are
performed using the laparoscopic approach.
Open cholecystectomy, first performed by Carl Langenbuch in 1882
through right upper quadrant incision, has been the primary treatment for
gall bladder disease through early 1990’s.
For over 100 years, open cholecystectomy had remained the
standard treatment for gallbladderstones. It has proved its safety (mortality
rate <1%) and efficacy. However, morbidity of open cholecystectomy was
found to be very high. The hospitalization used to be from 6 to 10 days and
about 2/3rd
of patients spent more than 6 weeks off work. Post-

cholecystectomy symptoms like upper abdominal pain, nausea, vomiting
and wound pain were complained by 27-59% patients.
Fear of operation, lengthy recovery period and a large ugly scar
made many patients demand non-operative treatment. In response to these
arguments, over the past two decades many new therapies for gall stones
have been pioneered.
In the late 1980's a combination of new technologies and aggressive
scientific experimentations gave birth to laparoscopic cholecystectomy,
which has radically changed the way the medical fraternity think about
gallstones. Laparoscopic cholecystectomy has been accepted as the
procedure of choice for treatment of symptomatic gallstones and chronic
cholecystitis.
HISTORY OF LAPAROSCOPIC CHOLECYSTECTOMY
In 1985,the 1st
endoscopiccholecystectomy was performed by Erich
Muhe of Boblingen, Germany.
Shortly thereafter, pioneers in France & the United States coupled a
CCD video camera with a laparoscope to allow the entire surgical team to
view the operative field & performed cholecystectomies with laparoscopic
equipments. Since then, laparoscopic cholecystectomy has been adopted
around the world & subsequentlybeen recognized as the gold standard for
the treatment of gall stone disease.
Credit of performing the first cholecystectomy in India goes to Dr.
Tehemton Udwadia from Mumbai. He started doing laparoscopic
cholecystectomy in 1990 and is now a pioneer in the field.

In 1992, the National Institute of Health consensus development
conference stated that laparoscopic cholecystectomy provides a safe and
effective treatment for most patients with symptomatic gallstones.
Many Studies and Clinical trial have been done worldwide performing
laparoscopic cholecystectomy for acute cholecystitis. Results are
favourable & encouraging. Trials with high risk of bias indicate that early
laparoscopic cholecystectomy during acute cholecystitis seems safe and
may shorten the total hospital stay.
The advantages of laparoscopic over open cholecystectomy have
been well documented. These advantages includes earlier return to bowel
function, less post operative pain, improved cosmesis, shorter hospital
stay, earlier return to full activity & decrease overall cost.
Laparoscopic cholecystectomy performed by experienced surgeons
is a safe technique for treatment of acute cholecystitis. Patients treated
within 48 hours of onsetof symptoms experience a lower conversion rate to
an open procedure, shorter operative time and reduced hospitalization.
Both early and delayed laparoscopic cholecystectomy is safe and
effective in the treatment of acute cholecystitis.
However, an early operation offers definite treatment during the same
admission with a reduction of total hospital stay.

MATERIALS & METHODS
Materials:-
This Study includes all patients presenting to Poona Hospital and
Research Centre with clinical & sonographic evidence of acute
cholecystitis.
Inclusion criteria:-
Patients presenting with pain in right hypo-chondrium or with USG
evidence of acute cholecystitis.
Exclusion criteria:-
 Patients with coagulopathy
 Patients with severe COPD
 Patients with end stage liver disease
 Patients with CCF
 Patients with obstructive jaundice
 Pregnant females
Methods:-
Laparoscopic cholecystectomy by standard 4-port technique
Sample size: 50 cases.
Duration of study:-1 year starting from May 2014

WORKING PRINCIPLES:
"Acute cholecystitis is defined as acute inflammation of GB, either due to
infection or due to other factors, in the presence or absence of gall bladder
calculi. In our study, the following criteria are used to define acute
cholecystitis -
 Clinical:
 Right upper quadrant pain and Tenderness (Murphy's sign)
 Fever
 Sonological:
 Cholelithiasis (GB Calculi, single /multiple/sludge)
 Thickened GB wall (>3 mm)
 Sonographic Murphy's Sign
 Peri-cholecystic collection
 Laparoscopic: Appearance of GB - inflammation, swelling.
 Confirmation of diagnosis of acute cholecystitis on histopathology report
of gall bladder:
SELECTION CRITERIA FOR DIAGNOSIS:-
"Clinical + sonological = acute cholecystitis”

HISTORY AND EXAMINATION:-
Initially, a thorough history was taken with particular stress on
symptoms like dyspepsia, backache, pain in right hypochondrium, fever,
vomiting, loss of appetite, loss of weight & jaundice.
Special notice was also taken of symptoms, suggestive of cardio-
respiratory problems, diabetes, bleeding disorders, nature and site of
previous surgery.
Physical examination was used to correlate and confirm the diagnosis
and assess the patient for operation.
INVESTIGATIONS:-
As directed by hospital policy, the routine investigations in all cases
included blood counts, BSL, creatinine, LFT, clotting screen, chest x-ray,
electrocardiogram, HIV & Hbsag.
IMAGING:-
Routine ultrasound was done in all patients.
CT-scan in selected cases

CONSENT:-
In all cases the disease and the proposed operation with the
technique was explained to the patient and his/her relatives with all-risks
attached and an informed consent of laparoscopic with SOS open
cholecystectomy was taken.
PREOPERATIVE PREPRATION:-
All patients were prepared as for routine abdominal surgery with
fasting for 6 hours. The patient was shaved as for a laparotomy. Peri-
operative antibiotic within 1 hour of incision was given. Patient was asked
to empty the bladder before induction.
ANAESTHESIA:-
We have used general anaesthesia in all cases. The vital functions
were watched with the help of cardiac monitor. Ryle’s tube was passed to
deflate the stomach in cases where stomach was distended.
OT LAYOUT:-
The anaesthetist was at the patient’s head with the Boyle’s machine
to his/her right. Intravenous drip was started on left upper limb.
We did all the operations with the surgeon and the camera operator
on left side and the first assistant on the right side of the table.

LAPARASCOPIC INSTRUMENTS
Our department owns a laparoscopic set for performing laparoscopic
cholecystectomy.
We use a set comprising of,
1. Medical video camera ( 3chip HD camera)
2. Video telescope (0,30 Degree)
3. Xenon 300 W cold light source
4. Light cable
5. CO2 insufflator
6. CO2 cylinder
7. Gas tubing
8. Medical monitor
9. Voltage stabilizer
10.Veress needle
11.Trocar - cannula 10mm, 5mm
12.Blunt trocar
13.Reducer 10mm to 5mm
14.Maryland's forceps
15.Dissecting forceps
16.Plain grasping forceps
17.Toothed grasping forceps
18.Babcock laparoscopic forceps
19.Right angle forceps
20.Scissors
21.Bipolar cautery with cable

22.Mono-polar cautery cable
23.Harmonic knife
24.Clip applicator
25.Liga-clips (LT 300)
26.Hook
27.Spatula
28.Suction-Irrigation Cannula
29.Suction tubing
30.Gall bladder extraction forceps
31.Liver/fan retractor
32.Electro cautery unit

SURGICAL TECHNIQUE:
Before any surgery was commenced, all the instruments and
equipment were tested including the insufflators circuit, video camera and
monitor.
1. INSERTION OF THE CAMERA PORT:
The Sub-umbilical port of 10mm is made after creating
pneumoperitoneum with the help of Veress needle. Then a trocar is
inserted using a rotator movement and the entry in the peritoneal cavity
was confirmed. The pressure of the CO2 in the abdomen was allowed to
rise up to 14 mm of Hg. The telescope was inserted, camera was
connected to it and the initial diagnostic laparoscopy was carried out
visualizing the gall bladder.
2. INSERTION OF THE OTHER OPERATIVE PORTS:
Second port was placed in the epigastrium. This port is a 10mm cannula
inserted under direct vision just below the xiphi-sternum. This port was
used for dissection of Calot's triangle, application of various clips,
suction / irrigation and for extraction of gall bladder at the end.
Third port of 5mm was inserted through a right Sub-costal incision. The
gall bladder was visualized and port placed near it, slightly lateral to the
fundus of gall bladder. This port is used to pass a grasper to hold gall
bladder for dissection of Calot’s triangle.

Fourth port, another 5mm cannula was placed laterally in anterior
axillary line under direct vision. This port is directed towards the fundus
of gall bladder and it is used for retraction of gall bladder fundus.
3. RETRACTION OF THE GALLBLADDER:
A grasper holds gall bladder fundus and the fundus pushed upward and
laterally towards the patients right shoulder i.e., superolaterally. This
displays the Calot's triangle. Many times adhesions were noted between
gall bladder and surrounding structures, they were separated or divided
after cauterization.
4. EXPOSURE OF CALOT’S TRIANGLE:
After fundus of the gall bladder was pushed up and to the right over the
liver using a grasping forceps,further retraction was done by the second
grasper holding the gall bladder neck exposing the Calot's triangle.
5. DISSECTION IN CALOT'S TRIANGLE:
Once the adhesions from neighbouring structures were separated from
the gall bladder, attention was directed to the cystic duct. This was
dissected by straight and curved blunt dissector (Maryland's) cauterizing
the strands on and around it. After the duct was well skeletanized, two
clips were applied on the cystic duct towards the common bile duct and
one towards the gall bladder, the cystic duct was divided. Cystic artery
was defined, dissected by a curve blunt dissector, doubly clipped and
divided similarly.
6. DISSECTION OF GALLBLADDER BED:

Once the cystic duct and cystic artery were divided, gall bladder was
lifted from its bed, exposing the connective tissue between it and liver.
Using the grasper the gall bladder was held close to the area to be
dissected and traction was maintained to expose the fibrous tissue,
which was then dissected by diathermy hook. Occasionally hepatic vein
were encountered in this area, which could be cauterized, the
gallbladder was gradually dissected until completely freed. Coagulating
small vessels and keeping pressure by pushing gall bladder in the liver
bed, secured haemostasis.
7. DRAIN:
We kept a No. 14 or 16 Ryle’s tube as a drain in gall bladder fossa in
some patient’s (diabetic patient, gangrenous G.B, emphysematous or
perforated G.B). This is placed through fourth port.
8. HAEMOSTASIS:
Before removing the gallbladder and instruments, a thorough check was
made of the abdominal cavity for bleeding, including the following:
1. Gallbladder bed
2. Porta hepatis
3. Adhesiolysed bowel
4. Elsewhere in abdomen
Any area with clots was thoroughly washed, bleeding point picked up
and cauterized.
9. EXTRACTION OF GALLBLADDER:

We have extracted Gall Bladder through the Epi-gastric port. The gall
bladder was manoeuvred into position just below the liver. The grasping
forceps was passed through the port and the neck of the gall bladder
was grasped in the region of previously applied cystic duct clips. The
neck of the gall bladder was then gently manoeuvred into the port and
the port slowly extracted from the abdomen. The gall bladder was then
opened externally, a sucker inserted and the bile emptied. The gall
bladderwas then gradually removed.In some cases, the exit port had to
be enlarged. In cases of gangrenous / perforated gall bladder endo bag
was used for removal of gall bladder.
10. CLOSURE:
Closure of the 10mm ports with 1-0 / 2-0 vicryl and skin closure with 2-
0 / 3-0 ethilon was done.

POST-OPERATIVE MANAGEMENT:
After one hour in the recovery room, the patient was shifted to the
ward. Pain relief was obtained by Diclofenac or paracetamol injection.
Antibiotics continued parenteral for 48-72 hours. The Ryle's tube was
removed after 12 hours (if inserted) and oral clear liquids commenced on
the evening of surgery if there is no nausea or vomiting. The drainage tube
(if placed) was removed after 24 hours if there is no significant drain.
Patients were made ambulatory on the next day and discharged on 3rd
-
4th
postoperative day in mostof the cases. They were called for review after
1week; sutures were removed accordingly and were given dietary advice
regarding small frequent meals with avoidance of fatty and spicy food.

SCOPE OF THE STUDY
Data Collection and Follow Up
The patients were evaluated daily during their stay in the hospital. On
discharge, they were requested to attend the OPD on day 7, one month
and three months. At each assessment, the patients were evaluated in
detail and the data was collected in individual proformaforms (appended at
the end). At the end of the study the entire data was collected and
analysed.
Statistical Methods
Mean, Standard deviation and percentage of data collected were
used to analyse individual variables in the study.
MEAN(65): To obtain the mean the individual observations are first added
together, then divided by the number of observation. Although easy to
calculate and understand, the mean may be unduly influenced by abnormal
values in the distribution.
STANDARD DEVIATION:It is defined as root mean square deviation and it
is denoted by S.D or sigma (σ).
We have used Fisher’s exact test, Chi square test and two independent
sample t-test in our study.
We have used SPSS software for our statistics.

Ethical Issues
All surgeries were performed after obtaining informed consent. The
patients right to privacy and information was given due respect throughout
the study. The study was self-sponsored. There was no animal study
involved. The study was approved by the ethics committee of our institute.
Limitation of the Study
Every attempt was made to adhere to the standard steps of the
surgical procedure as described, some degree of deviation was inevitable
in certain cases.
The study was conducted on limited patient population of fifty.

OBSERVATION
From May 2014 to May 2015,
 Laparoscopic cholecystectomy was performed on 50 patients,
 All this 50 patients were confirmed as acute cases on histo-pathology
report.
 The mean age of patients was 42 yrs.
 64% of patients were female and 36 % were male.
 They were followed up on day 7, 1 month and 3 month.

 Age group of the patients:
Age of Patients Number of Patients
21-30 10
31-40 14
41-50 12
51-60 8
>60 6
Mean age of the patients was around 42 yrs.
0
2
4
6
8
10
12
14
16
21-30 31-40 41-50 51-60 >60
NumberofPatients
Age Range
Age group of Patients

 Sex distribution:
Male Female
18(36%) 32(64%)
18 males and 32 females were there out of 50 acute cholecystitis patients.
36%
64%
Sex Distribution
Male
Female

 Time of surgery:
Early Delayed
30(60%) 20(40%)
We had ascribed operation within 72 hrs of presentation as ‘early’ surgery
& anywhere thereafter up to 6 weeks as ‘delayed’.
60%
40%
Time of Surgery
Early
Delayed

 Mean duration of Surgery:
Minutes Number of Patients
<50 2
51-60 16
61-70 3
71-80 4
81-90 5
91-100 7
101-110 6
111-120 5
>120 2
Mean duration of surgery was recorded as 85 min +/- 30 min
0
2
4
6
8
10
12
14
16
18
<50 51-60 61-70 71-80 81-90 91-100 101-110 111-120 >120
NumberofPatients
Minutes
Duration of Surgery

(2 S.D) with significant lesser time for early laparoscopic cholecystectomy
with mean of 69 min compared to delayed laparoscopic cholecystectomy
with mean of 108.5 min.
For AGE and SEX to be comparable in early and delayed group
For AGE
Early/ Delayed
Surgery
Number Mean Standard
Deviation
Early 30 44.23 11.428
Delayed 20 39.50 11.682
p-value is 0.165
2 independent sample t-test is used.
For SEX
Gender Early Delayed Total
Female 20 12 32
Male 10 8 18
total 30 20 50
p- value is 0.765
Chi-square test is used.
Hence, both the group early and delayed are comparable, with respect to
age and sex.
Presentation
Number of
patients
Duration of surgery
(min) P-value
Mean SD
Early 30 69.33 15.30
< 0.001
Delayed 20 108.50 16.94
Conclusion: -By using 2 independent sample t-test

P-value< 0.05 therefore there is significant difference between early and
delayed presentation with respect to duration of surgery (min.).
 Occurrence of complications:
None
Wound
Infection
Bile
Leak
Sub-hepatic
Collection
Bowel Herniation
in Port Site
44(88%) 2(4%) 2(4%) 1(2%) 1(2%)
Out of 50 laparoscopic cholecystectomies for acute cases, 6 cases were
complicated (12%). Two patient had minor bile leak managed
endoscopically, 2 patient had wound infection managed with antibiotics &
88%
4%
4%
2% 2%
Complications
None
Wound Infection
Bile Leak
Sub-hepatic Collection

dressing, 1 patient had sub-hepatic collection managed conservatively, 1
obese patient had bowel herniation at port site diagnosed on x-ray
abdomen as obstruction & on USG as bowel herniation through the port
site, explored locally through laparotomy under GA on next day, findings
were inflamed but viable bowel which was reduced. Patient improved and
was discharged on day 10 without any complaint. Majority of these
complications were found in delayed cases.
Complication
Presentation
Total P-value
Early Delayed
Yes 1 5 6
0.032
No 29 15 44
Total 30 20 50
Conclusion: - By using Fisher’s exact test
P-value< 0.05 therefore there is significant association between early and
delayed presentation with respect to occurrence of complication.
 No patient developed sepsis.
As none of our patient postoperatively developed fever, tachycardia or
increased in WBC count and majority of our patient got discharged on day
6(mean). We say that none of our patient developed sepsis.

 Rate of conversionto open surgery
Laparoscopic Converted
45(90%) 5(10%)
Five out of 50 cases of laparoscopic cholecystectomy in acute cholecystitis
needed to be converted to open surgery. All occurred while doing delayed
surgery i.e. after 72 hours of presentation. Conversion occurred in three
cases due to dense adhesion & in two cases due to bleeding.
90%
10%
Conversionin Acute Cases
Laparoscopic
Converted

Conversion
Presentation
Total P-value
Early Delayed
YES 0 5 5
0.007
No 30 15 45
Total 30 20 50
Conclusion: - By using Fisher’s exact test
P-value< 0.05 therefore there is significant association between early and
delayed presentation with respect to occurrence of complication.

 Totalhospitalstay:
Days Number of Patient
3 1
4 22
5 3
6 9
7 2
8 3
9 4
10 5
>10 1
0
5
10
15
20
25
3 4 5 6 7 8 9 10 >10
NumberofPatients
Days
Total Hospital Stay

Presentation
Number of
patients
Hospital stay
P-value
Mean SD
Early 30 4.93 2.12
< 0.001
Delayed 20 7.40 1.82
delayed surgery with respect to hospital stay (days).
Mean total hospital stay was recorded as 6 days (3-12 days). Wound
infection, other complications & associated medical disorders contribute to
increased hospital stay. Significant shorter hospital stay was recorded in
early laparoscopic cholecystectomycases with mean of 4.9 days compared
to delayed laparoscopic cholecystectomy with mean of 7.4 days.

 Time required to return to full activity/work:
Number of Days Number of Patients
10-14 28
15-19 17
>20 5
Mean time of return to full home activity or productive work efficacy was 14
days (10-20 days). Early laparoscopic cholecystectomy patients had
significantly earlier return to full activity/work with mean of 12.5 days
56%34%
10%
Return to Full Activity
14-10
19-15
>20
Days

compared to delayed laparoscopic cholecystectomy with mean of 16.3
days.
Presentation
Number of
patients
Return to full activity
P-value
Mean SD
Early 30 12.57 3.28
< 0.001
Delayed 20 16.30 2.39
delayed presentation with respect to mean days require to return full
activity (days).

 Associated medicaldisorders:
None Diabetes Hypertension IHD
40% 18% 24% 18%
Postoperative course was found to be uneventful & similar to cases without
associated medicalproblems.These disorders were found to be marginally
increasing the postoperative stay.
40%
18%
24%
18%
Associated Medical Disorders
None
Diabetes
Hypertension
IHD

DISCUSSION
The last decade has seen Laparoscopic Cholecystectomy clearly
emerging, as a safe & Cost effective treatment for symptomatic gall stone
disease & its use in elective surgery is well accepted.
LaparoscopicCholecystectomyhas become the procedure of choice
for managing symptomatic Cholelithiasis as well as acute cholecystitis.
Early Laparoscopic Cholecystectomy for purely acute Cholecystitis
has been demonstrated to have a significantly lower conversion rate
possibility due to adhesions that have not yet developed so early after the
onset of inflammation. In addition, other advantages are lower costs, owing
to a shorter hospital stay with less morbidity and mortality.
In the present study, we evaluated the application of laparoscopic
cholecystectomy in acute cholecystitis.

A. Duration of Operation:
Author No. of Patients Mean duration
Norrby (1983) 101 110
R.G Wilson (1992) 31 90
A.A.M Bakr, et al (1997) 31 43
Garber, et al (1997) 109 100
P.B.S Lai, et al (1998) 53 123
Madan, et al (2002) 14 73
C H Hsieh (2003) 31 98.2
Present Study (2015) 50 85
Duration in minutes
Average duration for laparoscopic cholecystectomy in Acute
Cholecystitis ranges from 43 min to 123 min in different studies.
AL Qasabi et al. have reported mean duration of surgery of 98 min.
In addition, significant lesser time in early laparoscopic
cholecystectomy versus delay laparoscopic cholecystectomy.
In the present study, we found the mean duration to be 85 min+/-
30min for laparoscopic cholecystectomy in acute cholecystitis.
Comparatively lesser time was taken due to adhesions have not yet
developed so early after the onset of inflammation along with the
Experienced Surgery team.
In cases of early surgery, mean duration was 69.33 min whereas in
cases of delayed surgery mean duration was 108.5 min.

B. Rate or Conversion:
Author Total no.
of LC in
AC(n)
Number of
Cases converted
to open
%
Garber, et al (1997) 194 29 15
LO CM, et al (1998) 99 17 17
Johansson et al (2002) 145 44 30.5
Madan et al (2002) 45 9 20
C H Hsieh (2003) 31 2 6.2
Present Study (2015) 50 5 10
The conversion rate of laparoscopic cholecystectomy for acute
cholecystitis ranges from 6.2 % to 30.5 % in different studies.
Indications for conversion in most studies, including the present one,
were inability to identify the anatomy secondary to inflammatory adhesions
& profuse bleeding.
Most studies found that conversion rates were significantly lower in
early laparoscopic cholecystectomy as compared to delayed laparoscopic
cholecystectomyforacute cholecystitis.In our study, conversion was found
in 5 cases out of 50 cases i.e. 10 % of patients and all were in delayed
cases.

C. ComplicationRates:
Author Total Cases Number of cases
complicated
%
Garber, et al (1997) 194 16 8
Wilsonet al (1992) 31 3 10
LO CM, et al (1998) 86 25 29
Johansson et al (2002) 145 26 18
C H Hsieh (2003) 31 2 6.7
Present Study (2015) 50 6 12
The complication rates ranges from 6.7% to 29% in different studies.
Postoperative wound Infection forms the major part of complications in
most of the studies. Other causes have been postoperative ileus, bile leak,
CBD Stricture, Jaundice (mostly due to undetected CBD calculous tackled
later with ERCP).
Complication rates were found to be lesser in early laparoscopic
cholecystectomy than delayed laparoscopic cholecystectomy in most
studies.
In our study complication was found in 6 cases i.e.,12 % and majority
was in delayed operated cases.

D. Mean Total Hospital Stay:
Author Mean Total Hospital Stay (in days)
Early Delayed Significance
Garber, et al (1997) 5.5 10.8 S
Lai PB, et al (1998) 7.6 11.6 S
Lo CM, et al (1998) 6 11 S
Johansson, et al (2002) 5 8 S
Madan, et al (2002) 2.1 5.4 S
Present Study (2015) 4.9 7.4 S
S= Statistically Significant, NS = Non Significant
It has been well documented by various authors that laparoscopic
cholecystectomysignificantly reduces total hospital stay of patients. Added
benefits were observed in early surgery (within 72 hrs) bringing down the
total hospital stay significantly.
Post-operative Hospital stay had been found to be markedly less for
our patients as well. In the present series, mean stay of 4.9 days for early
laparoscopic cholecystectomy & 7.4 days for delayed laparoscopic
cholecystectomy has been recorded with statistically significant difference.
Our series had an average Hospital Stay ranging 3 – 12 days. Increased
post-op stay was there because of the complications most of which were
managed conservatively. These results are similar to various other series.

E. Return to Normal Activity/Work:
Author Early Delayed Significance
Wilson, et al (1992) 14
Lo CM, et al (1998) 12 19 S
Present Study (2015) 12.5 16.3 S
The time required for return to full home activities or normal work has
been shown to decrease significantly after early laparoscopic
cholecystectomy for acute cholecystitis. Various authors have observed
similar results.
In the present series, operating timing was less, resumption of oral
fluids & diet was significantly early, total hospital stay was short & return to
full home activity / work was significantly early than compared to other
studies.
As the present study was conducted in a Charitable Hospital, cost
analysis could not be done. However, earlier return to work & by complete
cure of disease, laparoscopic cholecystectomy enables the patients
towards earning productive hours & in turn directly saves the cost.
In present series no other significant abdominal / pelvic pathology
was found. In all 50 cases, HPE report yielded diagnosis of acute
cholecystitis.

SUMMARY
OBJECTIVES:
In the present series, a study was undertaken performing
laparoscopic cholecystectomy for patients with acute cholecystitis to
assess the feasibility, efficacy, postoperative complications and to
determine optimal timing.
PATIENTS & METHODS:
50 patients with acute cholecystitis under strict clinical & sonological
criteria underwent laparoscopic cholecystectomy over a period from May
2014 to May 2015.
Histopathology report confirmed 50 cases as acute cholecystitis.
Type of study – Prospective, observational
Duration- 1yr
Mean Age of patients - 42 yrs.
There were 32 (64%) female & 18 (36%) male patients
Out of 50 acute cases on HP report, 60% patient underwent early surgery
<72 hrs and 40 % delayed surgery.
Mean duration of surgery was 85 min, with 69 min for early surgery and
108.5 min for delayed surgery.
Complication rates of 12 %
No patient developed sepsis.

Conversion rates of 10 %.
Mean hospital stay of 6 days, early surgery cases 4.9 days and delayed
surgery 7.4 days.
Return to full activity in 14 days, with early surgery group in 12.5 days
where as delayed surgery group in 16.3 days.
Medical disorders in 60% of patients, out of which 18% patient had DM,
24% patient had HT, 18% patient had IHD
Follow up time was up to 3 months of surgery.

RESULTS
There was no mortality.
Mean Operative Time was 85 min +/- 30 min. Less time was required for
early laparoscopic cholecystectomy as compared with that required for
delayed laparoscopic cholecystectomy.
Complication rate was 12%; a total of 6 patients, 2 involving wound
infection, 2 with bile leak, 1 with sub hepatic collection & 1 with bowel
herniation at port site in obese patient.
None of our patient post-operatively developed fever, tachycardia,
tachypnea, increased in WBC count or any systemic manifestation of
sepsis.
Mean conversionrate for acute cholecystitis was 10% i.e., 5 patients out of
50 laparoscopic cholecystectomy, three due to excess inflammatory
adhesions & the other due to bleeding that could not be controlled
laparoscopically.
Mean total hospital stay was 5.92 days (3-12 days).
Mean return to normal activity was 14 days (12-17 days).
“All Cases of acute cholecystitis with early laparoscopic cholecystectomy
have lesser conversion rates, lesser mean operating time & significantly
lesser total hospital stay” than delayed laparoscopic cholecystectomy.
Marginally more complication rate was found in the present series than
demographic values.

CONCLUSIONS
1. LaparoscopicCholecystectomy is a feasible procedure that is safe &
effective for Acute Cholecystitis accompanied with usual risk of injury
to surrounding structures & considerable benefits.
2. Early the surgery in acute cholecystitis, better is the outcome
3. The duration of surgery is short in acute cholecystitis. (performed
within 3 days of presentation is significantly lesser than that done
after 3 days).
4. Early the surgery performed in acute cholecystitis i.e. within 3 days,
lesser is the adhesion formations and less difficult is the surgery
compared to surgery done after 3 days.
5. Early laparoscopic surgery in acute cholecystitis is associated with
less complication rates.
6. None of our patient developed sepsis, as early surgery removes the
source of infection early.
7. Laparoscopic cholecystectomy in acute cholecystitis is associated
with less conversion rates. Much less are the conversion rates if
surgery is performed early than delayed laparoscopic
cholecystectomy.
8. Laparoscopiccholecystectomyforacute cholecystitis results in lesser
hospital stay and much lesser days in cases of early surgery.
9. Laparoscopic cholecystectomy for acute cholecystitis results in early
return to full activity.
Thus, Laparoscopic Cholecystectomyfor Acute cholecystitis offers quick
relief to the patients with definitive treatment & complete cure during the
same hospital admission.

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PROFORMA
Serial No:
IPD No:
DOA:
DOD:
Name:
Age: Sex:
Occupation:
Address:
Chief Complaints:
History of:
DM: Y/N since
Hypertension: Y/N since
Renal disease: Y/N since
Liver disease: Y/N since
Resp.Disease: Y/N since
Thyroid disease: Y/N since
Coronary disease: Y/N since
IHD: Y/N since
Personal history:
Sleep:
Appetite:
Bowel/Bladder:
Addiction: Smoking Y/N
Alcoholism Y/N
Tobacco Y/N

Significant drug history:
General examination:
Temperature: Weight: Kg.
Pulse:
BP:
RR:
JVP:
Pallor:
Icterus:
Cyanosis:
Clubbing:
Lymphadenopathy:
Oedema:
Systemic examination:
CVS:
RS:
CNS:
P/A:
Local examination:
Murphy’s sign:
Investigations:
Haematological:
Hb:
WBC:
Platelets:
LFT:

Amylase:
Lipase:
BUL:
Sr. Creatinine:
Urine:
USG abdomenand pelvis:
Chest X-ray:
X-ray abdomen:
CT scan of abdomen (if done):
Others:
Final diagnosis:
Time of Operation after Presentation:
Duration of surgery:
Treatment Given:
Condition on Discharge:
Hospital Stay:
HPE (GB):
Follow Up – day 7, 1 month, 3 month

Abbreviation
GB: Gall Bladder
AC: Acute Cholecystitis
LC: Laparoscopic Cholecystectomy
LFT: Liver Function Test
Hb: Haemoglobin
USG: Ultrasonography
HPE: histo pathology examination
DM: Diabetes Mellitus
HT: Hypertension
IHD: Ischemic Heart Disease
NAD: No Abnormality Detected
NOR: Normal

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