Accidental Gallbladder Perforation During Laparoscopic Cholecystectomy: Does It Have an Effect on the Clinical Outcomes?

Abstract

Background:

Accidental gallbladder perforation during laparoscopic cholecystectomy (LC) is on the rise because of increased attempts at minimally invasive surgery. There have been a number of studies attempting to determine the influence of gallbladder perforation on the clinical outcomes, but the results are still conflicting. Therefore, we investigated the clinical outcomes and the risk factors in patients who sustained a gallbladder perforation during LC.

Methods:

We evaluated 198 patients who underwent LC between April 2009 and March 2010. Data were collected from a prospectively maintained database.

Results:

Thirty-three patients sustained a gallbladder perforation (16.7%) and it primarily occurred during dissection of the hepatic fossa in 21 patients (63.6%). The mean operative time and duration of postoperative hospitalization were longer in the perforated group (P=.015 and P=.001). Visual analog scale scores on the first and second postoperative days were higher in the perforated group (P=.009 and P=.034). Complications such as ileus and trocar site infection developed more frequently in patients with a gallbladder perforation (P=.001 and P=.004). There was no significant factor related to gallbladder perforation except for male gender (P=.017).

Conclusion:

Accidental gallbladder perforation can cause more postoperative pain, ileus, and trocar site infection, which consequently increases the total duration of hospitalization, undermining the advantages of LC. Based on these interesting results, surgeons should make every effort to prevent gallbladder perforation by performing meticulous dissection during the operation.

Introduction

Laparoscopic cholecystectomy (LC) has become the procedure of choice in surgical treatment of gallbladder disease. Perforation of the gall bladder and spread of the bile juice and gallstones into the peritoneal cavity during LC is common, with an incidence of 13%–40%.¹ Moreover, gallbladder perforation is increasing in frequency because of increased efforts to perform minimally invasive surgery, which has limited the visual field and mobility of the surgical instruments. A number of studies have demonstrated the effect of intraperitoneal contamination with spillage of bile juice and gallstones. The majority of surgeons believe that gallstone spillage during LC is a benign complication and it does not justify conversion to laparotomy, even if a large number of gallstones remain in the abdomen.^2–5 However, there are also some reports that have demonstrated the complications of gallstone spillage, such as intraperitoneal abscesses, adhesions, small bowel obstruction, cutaneous fistulas, and septicemia.^6,7 Hence, we compared the clinical outcomes in patients who sustained a gallbladder perforation and those who did not sustain a gallbladder perforation during LC and also investigated the risk factors for gallbladder perforation.

Patients and Methods

The study was conducted in 198 patients who underwent LC during a 12-month period between April 2009 and March 2010. It was a retrospective study in which data from a prospectively maintained database was used. Patients <20 or >70 years of age or patients with gallbladder neoplasms or coexisting stones within the common or hepatic duct were excluded from the study. Gallbladder diseases were diagnosed and classified postoperatively with pathologic confirmation.

Clinical outcomes, such as operative time, duration of hospital stay after surgery, severity of pain using a visual analog scale (VAS), laboratory results, and postoperative complications, were assessed. Wound infection was diagnosed based on clinical findings such as increased redness and pain around the wound with pus discharge.

The following data were collected in all patients to determine the risk factors for gallbladder perforation during LC: demographics, the physical status classification of the American Society of Anesthesiologists (ASA) risk, physical examination, vital signs, preoperative laboratory results, and operative findings (septations within the gallbladder, pericholecystic adhesions, obliteration of the Calot's triangle (impaired anatomical structure), nonvisualization of the common duct, and whether or not the stone was impacted within the neck of the gallbladder or cystic duct). All patients underwent ultrasonography and abdominopelvic computed tomography for evaluation of wall thickness, gallbladder size, and pericholecystic fluid collection.

Surgical technique and perioperative management

All operations were performed with the patient under general anesthesia. The umbilical port using an 11-mm trocar was introduced and CO₂ gas was insufflated to establish a pneumoperitoneum with an intraperitoneal pressure of 12–15 mmHg. Under visual confirmation, an epigastric port was inserted into the right border of the falciform ligament with a 5- or 11-mm trocar and one or two 5-mm trocars were also inserted in the sequence. Most cases were operated using a three-port technique, but if the visualization of the operative field was inadequate after the traction of gallbladder, more ports were also introduced. The operating table was placed in the reverse Trendelenburg position tilted to the left. A flexible laparoscope for visualization, a blunt dissector, and monopolar cautery scissors were used. In case of perforation of the gallbladder, prompt aspiration of bile spillage and retrieval of residual stones were done with abundant irrigation. No more ports were applied because of the gallbladder perforation. Surgical drain was inserted only in case of spillage of the infected bile.

All patients received first-generation cephalosporin intravenously in the immediate preoperative period for prophylaxis (single dose) and twice daily for 3 days postoperatively. The surgeons assessed the suitability for discharge, considering the clinical symptoms and laboratory results of the patients.

Statistical analysis

Analysis of data was carried out using SPSS 12.0 (SPSS, Inc., Chicago, IL). Categorical variables were analyzed using a chi-square test. Descriptive statistics for continuous variables were calculated by Student's t-test and the mean standard deviation was also expressed. Variables found to be significant (P<.1) on univariate analysis were selected for a multivariate logistic regression model to examine the relationship between these variables and gallbladder perforation. A P value of <.05 was taken as statistically significant for all tests.

Results

Chronic calculous cholecystitis was the most common diagnosis in both groups (Table 1). Of the 198 LCs performed, 33 patients sustained a gallbladder perforation during LC (16.7%). Gallbladder perforation primarily occurred during dissection of the hepatic fossa in 21 patients (63.6%). There was also a case of bile spillage during extraction of the gallbladder through a small port site (Table 2).

Table 1.

Operative Diagnosis of 198 Patients Who Underwent Laparoscopic Cholecystectomy With or Without Accidental Gallbladder Perforation

	Number of patients (%)
	Nonperforated	Perforated	P value
Acute calcalous cholecystitis	15 (9.1)	2 (6.1)
Chronic calcalous cholecystitis	135 (81.8)	26 (78.8)
Gallbladder empyema	15 (9.1)	5 (15.1)
Total	165	33	.674

Table 2.

Causes of Accidental Gallbladder Perforation

	Number of patients (%)
Dissection of hepatic fossa	21 (63.6)
Traction or grasping of gallbladder	6 (18.2)
Extraction of GB through a port site	1 (3.0)
Dissection of cystic duct	5 (15.2)
Total	33

GB, gallbladder.

Table 3 shows a comparison of the clinical outcomes between the perforated and nonperforated groups. The mean operative time and the duration of the postoperative hospital stay were significantly longer in the perforated group (P=.015 and .001). All patients used the same components of patient-controlled analgesia in proportion to body weight, but the VAS scores on the first and second days after surgery were higher in patients with a gallbladder perforation (P=.009 and .034). There was no statistically significant difference in the postoperative laboratory results between groups.

Table 3.

Clinical Outcomes and Postoperative Complications

	Nonperforated	Perforated	P value
Clinical outcomes
Operative time (min±SD)	50.04±28.24	69.83±40.14	.015
Postoperative hospital stay (day±SD)	3.50±2.14	5.58±3.09	.001
Postoperative pain (VAS±SD)
First POD	2.56±1.74	3.50±2.16	.009
Second POD	1.88±2.16	2.50±1.85	.034
Postoperative laboratory results
Leukocytosis	40 (27.6%)	8 (27.6%)	1.000
Bilirubin elevation	14 (9.7%)	0 (0.0%)	.081
LFT elevation	32 (22.1%)	10.3 (3.0%)	.150
Postoperative complications
Headache	12 (7.3%)	2 (6.1%)	.798
Fever	21 (12.8%)	1 (3.0%)	.104
Nausea (including vomiting)	25 (15.2%)	5 (15.2%)	.989
Diarrhea	4 (2.4%)	0 (0.0%)	.365
Ileus	26 (15.9%)	14 (42.4%)	.001
Trocar site infection	5 (3.0%)	5 (15.2%)	.004
Voiding difficulty	22 (13.4%)	6 (18.2%)	.474

SD, standard deviation; VAS, visual analog scale; POD, postoperative day; LFT, liver function test.

The postoperative symptoms, such as fever, nausea, vomiting, and diarrhea, were not different between groups. However, postoperative complications, such as ileus (the patient complains of abdominal discomfort with symptoms of constipation) and trocar site infection, were significantly more common in the perforated group (P=.001 and P=.004).

On univariate analysis, there were no differences in the demographics, medical and operative history, or ASA score between the perforated and nonperforated groups, except that the rate of gallbladder perforation in men was 73.63%, whereas the rate of gallbladder perforation in women was 8.41% (P=.001). Clinical factors, for example, vital signs such as heart rate and temperature, Murphy's sign, and preoperative laboratory results, did not reach statistical significance in predicting gallbladder perforation during LC. Among the radiologic findings, the mean size of the gallbladder (longitudinal length×width, 241.46±228.04 versus 99.37±123.88 π cm²) was meaningfully increased in the perforated group compared with the nonperforated group and pericholecystic fluid collection also reached statistical significance (Table 4). Intraoperative findings, such as pericholecystic adhesions, obliteration of the Calot's triangle, and nonvisualization of the common duct, had an effect on the incidence of gallbladder perforation (P=.025, P=.001, and P=.004). The number or maximum size of gallstones was not different between the two groups (Table 5). There was no difference in the incidence of gallbladder perforation between the three- and four-port technique (44.7% versus 57.1%, P=.522). From the variables relevant to gallbladder perforation, an independent risk model of a multivariate analysis was investigated. The only significant predictor of accidental gallbladder perforation was male gender (odds ratio: 4.44, confidence limits: 1.301–15.214, P=.017; Table 6).

Table 4.

Preoperative Clinical Characteristics According to the Presence of Accidental Gallbladder Perforation

	Nonperforated	Perforated	P value
Age (years±SD)	49.69±15.03	55.15±16.85	.063
Gender
Male	67 (40.6%)	24 (72.7%)
Female	98 (59.4%)	9 (27.3%)	.001
BMI (kg/m²±SD)	24.50±2.95	25.81±3.75	.028
Comorbidity
Diabetes	17 (10.3%)	5 (15.2%)	.418
Hypertension	37 (22.4%)	12 (36.4%)	.090
Liver cirrhosis	2 (1.2%)	2 (6.1%)	.071
Operation history	77 (46.7%)	15 (45.5%)	.899
ASA risk
I/II	90 (55.9%)	22 (66.7%)
III/IV	71 (44.1%)	11 (33.3%)	.254
Preoperative findings
Heart rate (bpm±SD)	76.14±7.46	75.94±5.99	.884
Temperature (°C±SD)	36.51±0.42	36.47±0.33	.614
Murphy sign	24 (14.7%)	10 (31.3%)	.024
Radiology
Pericholecystic fluid collection	8 (12.1%)	9 (36.0%)	.009
GB wall thickness (mm±SD)	6.65±2.23	6.85±2.32	.745
GB size, longitudinal (cm±SD)	99.37±123.88	241.46±228.04	.001
Laboratory result
Leukocytosis	48 (29.1%)	14 (42.4%)	.132
Jaundice	18 (10.9%)	1 (3.0%)	.161
LFT elevation	27 (16.4%)	7 (21.2%)	.500
Amylase elevation	11 (6.7%)	3 (9.1%)	.620

ASA, American Society of Anesthesiologists; BMI, body mass index; LFT, liver function test.

Table 5.

Operative Findings With or Without Accidental Gallbladder Perforation

	Nonperforated	Perforated	P value
Gallbladder septation	4 (5.9%)	0 (0.0%)	.245
Pericholecystic adhesion	14 (19.7%)	12 (41.4%)	.025
Calot's triangle obliteration	10 (14.1%)	13 (44.8%)	.001
Common duct invisible	9 (11.1%)	11 (34.4%)	.004
Stone impaction	20 (39.2%)	6 (28.6%)	.393
GB stone number (±SD)	7.22±9.63	4.76±4.27	.193
Gall stone maximum size (mm±SD)	9.80±7.56	9.67±8.21	.947

Table 6.

Multivariate Analysis for Risk Factors of Accidental Gallbladder Perforation

	Odds ratio	95% Confidence interval	P value
Age	1.01	0.966–1.048	.076
Sex	4.44	1.301–15.124	.017
BMI	1.03	0.858–1.238	.748
HTN	0.55	0.124–2.409	.425
LC	0.18	0.015–2.040	.165
Murphy sign	0.33	0.071–1.492	.149
Pericholecystic fluid collection	1.00	0.103–2.324	.369
GB size	1.29	0.998–1.005	.331
Pericholecystic adhesion	0.28	0.151–10.941	.817
Calot's triangle obliteration	0.98	0.047–1.709	.169
Common duct invisible	2.82	0.149–6.441	.982

LC, laparoscopic cholecystectomy.

Discussion

During the past decade, LC has become the standard surgical procedure for gallbladder disease. LC offers a variety of advantages, such as decreased postoperative morbidity, shorter hospital stay, quicker return to normal activities and work, and improved cosmesis, compared with traditional cholecystectomy.¹

In our study, the rate of gallbladder perforation was 16.7%, which was similar to the average rate reported by others.^1–4 The wall of the gallbladder may be torn by traction and repetitive grasping, and it may also be inadvertently entered during dissection from the hepatic fossa with cautery, which was the most common cause of gallbladder perforation in the present study.

Many studies have reported that intraperitoneal contamination with bile and calculi does not affect the clinical outcomes.^3,5,8,9 However, there are also many cases of postoperative complications, such as intra-abdominal abscesses and wound infections, and one study reported that complications occur in ∼1.7 per 1000 LCs with gallbladder perforation.^6,10,11

Gallbladder perforation leads to prolongation of the operative time and postoperative hospital stay and, consequently, an increase in the total hospital costs, which reduces the advantages of LC compared with classic laparotomy. The mean operative time was longer in the perforated group, and it was likely to be due to the time required for abundant irrigation to obtain a clear aspiration and retrieve the gallstones. The postoperative hospital stay was also longer in the perforated group, which may be due to increased pain and ileus, including constipation. There are a few studies on the correlation between gallbladder perforation and pain, which may result from irritation of the peritoneum due to the spillage of bile juice and gallstones. The postoperative ileus was more common in the perforated group, which was also likely to be due to irritation of the peritoneum.

There were five cases of significant trocar site infection in the perforated group, but the result could have been affected since we had used prophylactic perioperative antibiotics in all patients. It has been argued that the perioperative use of antibiotics prevents complications of gallbladder perforation because many patients with a bile leak have positive bile cultures, and if the peritoneal cavity is not properly cleansed, the risk of infection remains.⁴ It has also been reported that routine administration of antibiotics is not necessary in gallbladder perforation, but it is recommended in patients with diabetes mellitus, patients >60 years of age, classified as >ASA 3, or when the surgery is anticipated to last >70 minutes.¹²

Late complications associated with gallbladder perforation include intraperitoneal abscess, fistula formation in the abdominal cavity and the wall, small bowel obstruction secondary to adhesions, and detection of gallstones within hernia sacs.¹³ There has been a rare case of a patient presenting with acute appendicitis secondary to retained gallstones as late as 8 years from surgery.¹⁴ Sometimes the spilled gallstones mimic a malignancy, requiring the patient to spend time and money for unnecessary examinations, as well as the psychological trauma associated with the incorrect diagnosis of malignancy in ensuing years.⁷ Therefore, the surgeon should inform the patient about the possible consequences of spillage of bile and gallstones and should not hesitate to record the events.

There are a few studies which have focused on gender as a risk factor for gallbladder perforation during LC. The current study showed that male patients were significantly more prone to gallbladder perforation. One study also reported that the surgeon should be aware of an increased risk of gallbladder perforation, but the reason for this admonition was unclear.¹⁵

Many studies have shown that the incidence of gallbladder perforation increased if the gallbladder was acutely inflamed because such a gallbladder is quite fragile and easy to tear under the stress of traction and dissection.^2,10 But our study revealed that radiologic findings, laboratory results and intraoperative findings which were evaluated to detect the extent of inflammation were not different between the perforated and nonperforated groups. It appears that inflammation is not a predictive factor, but if inflammation irritates the peritoneum through any cause, inflammation may be related to gallbladder perforation.

Disease severity, as well as previous abdominal surgery had no effect on the rate of gallbladder perforation in our study. However, there is a report of previous surgical intervention in the causation as the cause of gallbladder perforation.⁴ A gallbladder with septations or impacted stones makes grasping or traction of the gallbladder difficult, but it does not significantly influence the incidence of gallbladder perforation. The number or size of gallstones was not related to gallbladder perforation, and one study showed the type of calculi (pigment stones) contributed to gallbladder perforation.³

However, as with most surgeons,^2,3 our surgeons also did not consider gallbladder perforation to be an important complication, which may have affected the results of the study which shows an elevated rate of gallbladder perforation. It seems that the surgeon's attitude toward the importance of gallbladder perforation may also play a crucial role.

To minimize the risk of gallbladder perforation, some technical modifications and new methods for dissection of the gallbladder from the liver bed have been attempted. However, variations such as diathermy, laser, ultrasonic dissector, and harmonic scalpel instead of standard dissection with monopolar electrocautery have not managed to decrease the elevated intraluminal pressure in the gallbladder during the dissection maneuver, and as a consequence the rate of gallbladder perforation has not reduced.^10,15 One study evaluated the effect of a solution (a combination of adrenaline, lidocaine, and saline) by injection into the gallbladder bed, but there was no improvement in the incidence of gallbladder perforation, bleeding, and postoperative pain.¹⁶ Closing the perforated part of a gallbladder with application of a clip or an Endoloop is a possible solution to prevent spillage after gallbladder perforation, but it is ineffective in many cases because the clip or Endoloop may slip or loosen owing to traction. The rubber band was the newly used technique and it seemed to be an effective method in some cases.¹⁷ There was an experimental study in which surgical adhesions and abscesses related to spilled bile juice and gallstones were prevented with a hyaluronic-acid derivative, thus significantly improving the clinical outcomes.¹⁸

There were some limitations to this study. The sample size was relatively small and some of the observations, though statistically valid might have been affected by the small sample size. The diagnosis of wound infection and patients' suitability for discharge were assessed by surgeons depending on their own clinical experiences that it might lead to bias in the observations.

In conclusion, gallbladder perforation during LC causes postoperative pain, ileus, and trocar site infection, which consequently leads to an increase in the duration of hospitalization, thereby reducing the advantages of a laparoscopic procedure. The only significant predictor of gallbladder perforation was male gender. We should remember the interesting finding that meticulous dissection should be performed during operation to prevent gallbladder perforation. In addition, the surgeons should not hesitate to record the intraoperative events of spillage of bile and gallstones and inform the patient about the possible consequences.

Footnotes

Disclosure Statement

No competing financial interests exist.

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