Laparoscopic cholecystectomy and cirrhosis

Gad EH, et al. Laparoscopic cholecystectomy in patients with liver cirrhosis: 8 years experience in a tertiary center. A retrospective cohort study. Ann Med Surg (Lond). 2020 Jan 15;51:1-10. Free full-text.

Results: The most frequent Child-Turcotte-Pugh (CTP) score was A, The most frequent cause of cirrhosis was hepatitis C virus (HCV), while biliary colic was the most frequent presentation. The harmonic device was used in 39.9% of patients, with a significant correlation between it and lower operative bleeding, lower blood and plasma transfusion rates, higher operative adhesions rates, lower conversion to open surgery and 30-day complication rates, shorter operative time and post-operative hospital stays where operative adhesions and times were independently correlated. The 30-day morbidity and mortality were 22.1% and 2.3% respectively while overall survival was 91.5%, higher CTP, and model for end-stage liver disease (MELD) scores, higher mean international normalization ratio (INR) value, lower mean platelet count, higher operative bleeding, higher blood, and plasma transfusion rates, longer mean operative time and postoperative hospital stays were significantly correlated with all conversion to open surgery, 30-day morbidities and mortalities.

Conclusion: LC can be safely performed in cirrhotic patients. However, higher CTP and MELD scores, operative bleeding, more blood and plasma transfusion units, longer operative time, lower platelet count, and higher INR values are predictors of poor outcome that can be improved by proper patient selection and meticulous peri-operative care and by using Harmonic scalpel shears.

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2020 WSES updated guidelines for the diagnosis and treatment of acute calculus cholecystitis

Pisano M, Allievi N, Gurusamy K, et al. 2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis. World J Emerg Surg. 2020 Nov 5;15(1):61. Free full-text.

Conclusions, knowledge gaps and research recommendations: “ELC has a central role in the management of patients with ACC. The value of surgical treatment for high-risk patients should lead to a distinction between high-risk patients and patients who are not suitable for surgery. Further evidence on the role of clinical judgement and the use of clinical scores as adjunctive tools to guide treatment of high-risk patients and patients who are not suitable for surgery is required. The development of local policies for safe laparoscopic cholecystectomy is recommended.”

2020 WSES Flowchart for the management of patients with acute calcolus cholecystitis.
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Post-Cholecystectomy Biliary Complications

Pesce A, et al. Iatrogenic bile duct injury: impact and management challenges. Clin Exp Gastroenterol. 2019 Mar 6;12:121-128. Free full-text.

“Iatrogenic BDIs represent a serious complication which can be brought on by cholecystectomy. The errors leading to laparoscopic bile duct lesions stem principally from misperception of the biliary anatomy. Any effort toward the reduction of the risk profile of everyday cholecystectomy is appreciated. The key points to successful treatment are characterized by early recognition, control of any intra-abdominal fluid collection and infection, nutritional balance, multidisciplinary approach, and surgical repair by an experienced surgeon in biliary reconstruction.”


Pekolj J, et al. Intraoperative management and repair of bile duct injuries sustained during 10,123 laparoscopic cholecystectomies in a high-volume referral center. J Am Coll Surg. 2013 May;216(5):894-901. Full-text for Emory users.

Results: Among 10,123 LC performed during the study period, 19 patients had a BDI sustained during the procedure. Intraoperative cholangiography was routinely used. Bile duct injury was diagnosed intraoperatively in 17 patients (89.4%). Mean age was 56.4 years (range 18 to 81 years) and 15 patients were women (88%). According to the Strasberg classification of BDI, there were 3 type C lesions, 12 type D lesions, and 2 type E2 lesions. There were no associated vascular injuries. Twelve cases (71%) were converted to open surgery. The repairs included 10 primary biliary closures, 4 Roux-en-Y hepaticojejunostomies, 2 end to end anastomosis, and 1 laparoscopic transpapillary drainage. Postoperative complications occurred in 5 patients (29.4%). During the follow-up period, early biliary strictures developed in 2 patients (11.7%) and were treated by percutaneous dilation and a Roux-en-Y hepaticojejunostomy with satisfactory long-term results.

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What is the utility of routine intraoperative cholangiography during laparoscopic cholecystectomy?

SAGES still recommends that practicing general surgeons learn how to do IOC (though once a surgeon is past their learning curve, it is not necessarily routinely recommended that it be done ‘routinely’).


Hope WW, et al. SAGES clinical spotlight review: intraoperative cholangiography. Surg Endosc. 2017 May;31(5): 2007-2016. Full-text for Emory users.

“The following clinical spotlight review regarding the intraoperative cholangiogram is intended for physicians who manage and treat gallbladder/biliary pathology and perform laparoscopic cholecystectomy. It is meant to critically review the technique of intraoperative cholangiography, alternatives for intraoperative biliary imaging, and the available evidence supporting their safety and efficacy.”

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Laparoscopic Cholecystectomy Versus Percutaneous Catheter Drainage for Acute Cholecystitis in High Risk Patients (CHOCOLATE): Multicentre Randomised Clinical Trial

Loozen CS, et al. Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (CHOCOLATE): multicentre randomised clinical trial. BMJ. 2018 Oct 8; 363:k3965.

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what this study adds

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