Clinical Efficacy of Laparoscopic Cholecystectomy via Cystic Plate Approach for Gallstone Patients with Chronic Cholecystitis

Abstract

Introduction:

Chronic cholecystitis has evolved into one of the digestive system diseases that negatively affect the quality of life of patients. This study was conducted to explore the clinical efficacy of laparoscopic cholecystectomy via cystic plate approach for the treatment of gallstones with chronic cholecystitis.

Materials and Methods:

Totally 184 gallstone patients with chronic cholecystitis who underwent laparoscopic cholecystectomy in The First People's Hospital of Wuhu from January 2021 to October 2022 were randomly divided into a control group (n = 92) and an observation group (n = 92). In the observation group and control group, the gallbladder was removed using the cystic plate approach and traditional approach, respectively. Surgical indicators and complications of patients were compared. Serum levels of interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and C-reactive protein (CRP) were measured by enzyme-linked immunosorbent assay. The quality of life of patients was assessed using the SF-36 scale.

Results:

The recovery time of gastrointestinal function, intraoperative blood loss, and postoperative drainage volume in the observation group were significantly lower than those in the control group (P < .05). At 24 hours after surgery, the serum levels of IL-6, TNF-α, and CRP in the observation group were much lower than those in the control group (P < .05). Three months after surgery, the observation group showed a much higher quality of life score than the control group (P < .05).

Conclusion:

Laparoscopic cholecystectomy via cystic plate approach can effectively treat chronic gallstones with chronic cholecystitis. It shortened the recovery time of gastrointestinal function, reduced postoperative inflammation, and improved the quality of life.

Introduction

Chronic cholecystitis has evolved into one of the digestive system diseases that negatively impacts the quality of life as a result of the accelerated pace of life and the development of dietary habits.¹ The incidence of chronic cholecystitis, especially at a younger age, is increasing every year.² Chronic cholecystitis is generally caused by gallstones. Concretely speaking, gallstones leak out from the gallbladder and block the normal flow of bile, resulting in inflammation and infection of the gallbladder.³ If left untreated, it is easy to induce severe infection, sepsis, and multiple organ dysfunction.⁴ At present, laparoscopic and open cholecystectomy are the two most common procedures for the treatment of chronic cholecystitis in clinical practice. Among them, laparoscopic cholecystectomy has emerged as a common surgical approach for the treatment of cholecystitis owing to its advantages, including mild pain, minimal trauma, and better recovery.⁵

However, laparoscopic cholecystectomy is prone to surgical complications such as bile duct injury.⁶ Some researchers have attempted to reduce the incidence of surgical complications by adopting other surgical approaches and equipment, such as the use of trocars with smaller diameter, single-incision laparoscopic cholecystectomy, and natural orifice translumenal endoscopic surgery.^7,8 However, it is challenging to generalize these procedures. Therefore, some studies have attempted to reduce iatrogenic injuries resulting from laparoscopic cholecystectomy by altering the surgical approach.⁹

The selection of surgical approach throughout the procedure has a significant impact on the stress response, pain level, and prognosis of patients. In laparoscopic cholecystectomy, the choice of surgical approach mainly depends on the operating experience of the surgeon.¹⁰ At present, numerous methods have been developed, including antegrade or retrograde approaches, lateral approach, and anterior or posterior cholecystal triangle approaches.^11–13 Unfortunately, these surgical approaches both have some limitations. For the antegrade or retrograde dissection in cholecystectomy, the deep gallbladder neck is first dissected during gallbladder dissection, which violates the therapeutic principle of minimally invasive surgery from shallow to deep through a laparoscope. Under this condition, the anatomical space cannot be clearly detected. Severe adhesions in the neck of the gallbladder are also difficult to manage.¹²

Because of various circumstances (such as edema and adhesion in the Calot triangle), cholecystectomy via the anterior cholecystal triangle approach presents a risk of accidental injury to the cystic artery and bile duct, resulting in an increased incidence of complications.¹⁴ Recently, it has been reported that gallbladder resection via the cystic plate approach in the treatment of acute cholecystitis significantly lowers the risk of biliary tract injury, intraoperative blood loss, and total postoperative drainage.¹⁵ However, the effect of laparoscopic cholecystectomy via cystic plate approach in the treatment of gallstones with chronic cholecystitis is unknown. In this study, laparoscopic cholecystectomy via cystic plate approach was used to treat gallstone patients with chronic cholecystitis and compared with conventional laparoscopic cholecystectomy. The study hoped to establish a foundation for the clinical treatment of gallstone patients with chronic cholecystitis.

Materials and Methods

Study objects

A total of 184 patients diagnosed with gallstones combined with chronic cholecystitis in The First People's Hospital of Wuhu from January 2021 to October 2022 were included in this study. Patients were divided into a control group (n = 92) and an observation group (n = 92) based on the principle of randomized double-blind trial. This study has been approved by the Ethics Committee of The First People's Hospital of Wuhu (2023-01). All procedures were performed in accordance with the ethical requirements of the Declaration of Helsinki. All participants and their families were informed about the study and voluntarily signed an informed consent form.

Inclusion criteria were as follows: (1) aged 18–85 years; (2) with symptoms of chronic cholecystitis; and (3) with images of gallstones. Ultrasonography showed gallbladder wall thickening (≥3 mm), roughness, fibrosis, and hyperechogenicity and posterior shadowing, which met the diagnostic criteria for gallstones; (4) meeting laparoscopic cholecystectomy indications.¹⁶

Exclusion criteria were as follows: (1) combined with jaundice, choledocholithiasis, and intrahepatic bile duct stones; (2) with a history of biliary pancreatitis; (3) with laparoscopic surgery contraindications; (4) with systemic malignancies; (5) underwent administration of immunosuppressive agents in the past month; (6) with cognitive disorder or mental retardation, and disability to cooperate with the successful completion of the study.

General data collection

The clinical data of the patients were collected, including age, gender, duration of gallstones with chronic cholecystitis, diameter of gallstones, number of stones, and adhesion of the Calot triangle.

Treatment regimen

Patients in the observation group underwent cholecystectomy via the cystic plate approach. Following general intravenous anesthesia, patients were kept in reverse Trendelenberg position with a left lateral tilt. A 10 mm observation hole was established beside the umbilicus; a 12 mm main operation hole at the angle between the xiphoid process and the right rib, which should facilitate the right-hand device to lift up the quadrate lobe of the liver; a 5 mm auxiliary hole at 3 cm below the projection position of the abdominal wall of the gallbladder fundus, which should facilitate the low gallbladder drainage. The gallbladder infundibulum was pulled by left-hand instrument to the lower right, and the quadrate lobe of the liver was lifted up by the electric hook in the right hand.

Subsequently, the triangular region of the gallbladder was exposed, and the lymph nodes of cystic duct and the “fat window” of the Calot triangle were identified. Using an electric hook near the gallbladder side, the gallbladder serosa was opened along the anterior margin of the gallbladder bed. Later, the gallbladder infundibulum was pulled by the left-hand instrument, the posterior Calot triangle was exposed, and the serosa was opened as much as possible along the posterior margin of the gallbladder bed. The gallbladder infundibulum was tracted with the left-hand instrument to the lower right. After estimating the course of the cystic artery, a small amount of tissue was hooked using an electric hook; the gallbladder triangle region was opened layer by layer close to the gallbladder, the duct structure was exposed, the cystic artery was identified, and the cystic artery was clamped with a biological clip and later disconnected.

Next, the instrument was extended upward along the anterior margin of the gallbladder bed and downward around the cystic duct to separate the space between the gallbladder plate and the common hepatic duct. The left-hand instrument pulled the gallbladder infundibulum to the right front. As a result, the gallbladder infundibulum was rotated to the lower right front. Afterward, anatomy was performed clinging to the cystic plate. The pipe structure (including left and right hepatic, cystic ducts) exceeding 3 mm (including 3 mm) was clamped with a biological clip and then disconnected. Attention was paid to the posterior branch of the cystic artery and the reflux vein of the gallbladder bed; a complete separation of the cystic plate from the hepatic hilar plate close to the cystic duct was carried out from the “elephant trunk” (junction of gallbladder infundibulum and cystic duct) toward the common bile duct.

Following that, the cystic duct was clipped and divided using a biological clamp 0.5 cm from the common bile duct, the gallbladder was completely dissected from the gallbladder bed, and the gallbladder bed was treated with an electrocautery rod. Finally, a plicated negative pressure drainage tube (Gauge 16) was indwelled in the gallbladder bed.

Patients in the control group underwent conventional laparoscopic cholecystectomy. The gallbladder was dissected antegrade or retrograde, and the neck of the gallbladder was grasped. The antegrade dissection of the gallbladder was completed from top to bottom using an electric hook. When the adhesion in the neck of the gallbladder is severe, retrograde dissection or the combination of antegrade and retrograde dissection was adopted for the dissection of the gallbladder from the gallbladder bed. Using a specimen retrieval bag, the dissected gallbladder was removed intact. Subsequently, the surgical field was explored, and the abdominal cavity was irrigated. For bleeding, spray coagulation or dressing was performed to stop bleeding. When there was oozing from the wound, an indwelling drainage tube was given. Ultimately, the incision was sutured, and the surgery was finished. The liquid diet was administered 6 hours after surgery, followed by a semi-liquid diet and a general diet. After discharge, the patient returned to the hospital regularly.

Outcome measures

Surgical indicators were collected, including operation time, recovery time of gastrointestinal function, intraoperative blood loss, total postoperative drainage volume, and postoperative hospital stay, as well as adverse reactions and complications during hospitalization, including biliary fistula, bleeding, and bile duct injury.

Before and 24 hours after surgery, 5 mL of venous blood was collected from the left elbow of patients and centrifuged at 2000 rpm/minutes for 10 minutes. Supernatant (serum) was collected and stored in a −80°C freezer. Serum levels of interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and serum C-reactive protein (CRP) were measured by enzyme-linked immunosorbent assay kits (mlbio, China).

Before and 3 months after surgery, the quality of life of patients was assessed using the SF-36 scale. The SF-36 scale consists of eight dimensions: physical functioning, physical, bodily pain, general health, emotional, vitality, mental health, and social functioning. Higher scores represent a better quality of life.¹⁷

Statistical analysis

Statistical analysis was performed using SPSS 22.0 statistical software. Measurement data were expressed as mean ± standard deviation, independent t-test was used for comparison between groups, and paired t-test was used for comparison between preoperative and postoperative within groups. Count data were displayed as n (%), and chi-square test (α = 0.05) or Fisher exact test was used for comparison between groups. P < .05 was considered to indicate a statistically significant difference.

Results

Comparison of general data between the two groups

A total of 184 gallstone patients with chronic cholecystitis were enrolled in this study, including 68 men and 116 women. They were 17–82 years of age (mean: 50.79 ± 14.30 years), a duration of 3–19 years (mean: 8.64 ± 3.35 years), and a stone diameter of 0.2–3.2 cm (mean: 2.10 ± 0.49 cm). Besides, there were 103 cases without adhesion and 81 cases with adhesion of gallbladder triangle. The patients were randomly divided into a control group and an observation group. There was no statistical difference in age, gender, course of disease, and other general data between the two groups (P > .05; Table 1), with comparability.

Table 1.

Comparison of General Data Between the Two Groups

General data	Observation group (n = 92)	Control group (n = 92)	t/χ²	P
Age	52.15 ± 14.01	49.43 ± 14.61	1.288	.200
Gender, n (%)			0.093	.760
Male	33 (35.9)	35 (38.0)
Female	59 (64.1)	57 (62.0)
Course (months)	8.87 ± 3.57	8.40 ± 3.15	0.942	.347
Stone diameter (cm)	2.10 ± 0.50	2.11 ± 0.49	–0.134	.894
Number of stones, n (%)			0.023	.880
≤3	35 (38.0)	36 (39.1)
>3	57 (62.0)	56 (60.9)
Adhesion of gallbladder triangle, n (%)			1.081	.299
Without	55 (59.8)	48 (52.2)
With	37 (40.2)	44 (47.8)

Comparison of surgical indicators between the two groups

The operation time in the observation group was higher than that in the control group (P < .05). However, the gastrointestinal function recovery time (mean 1.90 ± 1.21 days), intraoperative blood loss (mean 11.93 ± 14.15 mL), postoperative drainage fluid volume (15.54 ± 22.62 mL), and postoperative hospital stay (4.53 ± 1.22 days) in the observation group were much less than those in the control group (P < .05; Table 2).

Table 2.

Comparison of Surgical Indicators Between the Two Groups

Group	Operation time (minutes)	Gastrointestinal function recovery time (days)	Intraoperative blood loss (mL)	Postoperative drainage fluid volume (mL)	Postoperative hospital stay (days)
Observation group (n = 92)	47.48 ± 8.23	1.90 ± 1.21	11.93 ± 14.15	15.54 ± 22.62	4.53 ± 1.22
Control group (n = 92)	49.58 ± 4.91	2.25 ± 0.83	16.79 ± 9.00	26.68 ± 35.54	4.96 ± 1.18
t	–2.121	–2.265	–2.779	–2.537	–2.402
P	.035	.025	.006	.012	.017

Comparison of inflammatory factor levels before and after surgery between the two groups

Before surgery, there was no significant difference in the serum levels of IL-6, TNF-α, and CRP between the two groups (P > .05). At 24 hours after surgery, the serum levels of IL-6, TNF-α, and CRP in the two groups were higher than those before surgery; the serum levels of IL-6, TNF-α, and CRP in the observation group were much lower than those in the control group (P < .05; Table 3).

Table 3.

Comparison of Inflammatory Factor Levels Between the Two Groups

Group	IL-6 (ng/L)		TNF-α (ng/L)		CRP (mg/L)
Group	Before surgery	24 hours after surgery	Before surgery	24 hours after surgery	Before surgery	24 hours after surgery
Observation group (n = 92)	8.66 ± 2.04	24.30 ± 5.70^a	13.32 ± 4.16	19.49 ± 4.35^a	4.29 ± 0.99	8.18 ± 1.50^a
Control group (n = 92)	8.31 ± 1.87	27.98 ± 4.36^a	13.41 ± 3.95	23.12 ± 3.59^a	4.04 ± 1.62	11.49 ± 1.67^a
t	1.229	–4.920	–0.145	–6.179	1.252	–14.158
P	.221	<.001	.885	<.001	.212	<.001

P < .05 versus Before surgery.

CRP, C-reactive protein; IL-6, interleukin-6; TNF-α, tumor necrosis factor-α.

Comparison of postoperative complications between the two groups

The main postoperative complications included biliary fistula, bile duct injury and bleeding. In the observation group, 4 patients developed complications, including 1 biliary fistula and 3 bile duct injuries. Of note, patients in the control group had no complications. There was no statistical difference in the incidence of complications between the two groups (P > .05; Table 4).

Table 4.

Comparison of Postoperative Complications Between the Two Groups

Group	Biliary fistula, n (%)	Bile duct injury, n (%)	Bleeding, n (%)	Total, n (%)
Observation group (n = 92)	1 (1.1)	3 (3.3)	0 (0)	4 (4.3)
Control group (n = 92)	0 (0)	0 (0)	0 (0)	0 (0)
χ²	—	1.355	—	2.300
P	1.000	.244	—	.129

— indicates no exact value.

Comparison of postoperative quality of life between the two groups

There was no significant difference in preoperative quality of life between the two groups. At 3 months after surgery, the scores of eight dimensions of the SF-36 scale increased significantly in both groups (P < .05). Furthermore, the scores of eight dimensions in the observation group were obviously higher than those in the control group (P < .05; Table 5). The results showed that both the cystic plate approach and the traditional approach could improve the quality of life of patients, but the improvement effect of the cystic plate approach was better than that of the traditional one.

Table 5.

Comparison of Eight Dimensions of SF-36 Scale Between the Two Groups

Group		Observation group (n = 92)	Control group (n = 92)	t	P
Physical functioning	Before surgery	40.78 ± 4.14	41.29 ± 4.45	0.518	.605
Physical functioning	3 months after surgery	80.38 ± 3.02^a	74.60 ± 3.03^a	19.958	<.001
Role physical	Before surgery	35.71 ± 2.97	35.02 ± 2.98	1.561	.120
Role physical	3 months after surgery	80.21 ± 2.83^a	72.43 ± 2.79^a	18.754	<.001
Role emotional	Before surgery	50.02 ± 4.19	50.62 ± 4.07	–0.981	.328
Role emotional	3 months after surgery	86.54 ± 3.62^a	79.71 ± 3.38^a	13.236	<.001
General health	Before surgery	41.64 ± 4.66	41.29 ± 4.45	0.518	.605
General health	3 months after surgery	80.38 ± 3.02^a	74.60 ± 3.03^a	12.971	<.001
Bodily pain	Before surgery	43.71 ± 4.02	43.18 ± 3.67	0.920	.359
Bodily pain	3 months after surgery	83.20 ± 3.33^a	78.17 ± 3.36^a	10.184	<.001
Social functioning	Before surgery	45.40 ± 4.08	44.49 ± 4.38	1.462	.145
Social functioning	3 months after surgery	84.38 ± 3.08^a	79.98 ± 3.43^a	9.169	<.001
Vitality	Before surgery	40.32 ± 2.70	39.99 ± 2.37	0.872	.384
Vitality	3 months after surgery	79.13 ± 2.09^a	70.99 ± 2.08^a	26.479	<.001
Mental health	Before surgery	49.68 ± 3.55	48.96 ± 3.79	1.346	.180
Mental health	3 months after surgery	87.42 ± 3.42^a	79.26 ± 3.29^a	16.496	<.001

P < .05 versus before surgery.

Discussion

Chronic cholecystitis is a common biliary system disease in clinical practice with etiological causes primarily associated with gallstone leakage. Laparoscopic cholecystectomy is widely used for the clinical treatment of chronic cholecystitis. However, hemorrhage and biliary tract injury are risks associated with laparoscopic cholecystectomy.¹⁸ Therefore, there is a critical need to advance surgical techniques to improve the safety of laparoscopic cholecystectomy.

The surgical method chosen has a significant impact on the prognosis of patients. As a part of the hilar plate system, the cystic plate is located in the connective tissue layer in the gallbladder wall. The cystic plate is a continuation of the portal plate covering the surface of the hepatic duct, and the continuation part is a bare area without capsule.¹⁹ An anatomically separable space exists between the cystic plate and the hilar plate, which could be a potential approach for laparoscopic cholecystectomy. In laparoscopic cholecystectomy, the cystic plate approach indicates that the serosa is opened in the region of the Calot triangle, an electric hook was gradually expanded along the cystic plate; the gallbladder infundibulum, cystic duct, and common hepatic duct are separated close to the gallbladder side until the cystic duct is completely separated, so as to remove the gallbladder.

If the gallbladder was dissected using the conventional approach, the limitation of the visual field necessitates constant adjustments to the laparoscopic angle; on the contrary, it is not easy to control the traction force and anatomical depth of the gallbladder's neck; the intraoperative blood loss is tendentiously increased.²⁰ It is easier to examine the Calot triangle region and immediately confirm the cystic duct using the cystic plate approach.²¹ More importantly, the cystic plate approach has not only the security of the antegrade approach but also the high efficiency of the retrograde approach, which greatly reduces the intraoperative blood loss. Cholecystectomy via the cystic plate approach was chosen for this study. In our study, the recovery time of gastrointestinal function, intraoperative blood loss, and total postoperative drainage volume in the observation group were lower than those in the control group. The results showed that laparoscopic cholecystectomy via cystic plate approach could effectively reduce the intraoperative bleeding and shorten the postoperative recovery time.

IL-6 and TNF-α reflect inflammatory levels in vivo and are tightly correlated with the severity of chronic cholecystitis.²² IL-6 and TNF-α are proinflammatory factors produced by monocytes and macrophages, which can trigger the release of other proinflammatory factors, and encourage the accumulation of leukocytes in the lesion and aggravate the inflammatory response.²² CRP can reflect the degree of systemic inflammatory response.²³ In this study, patients in the observation group had significantly lower levels of inflammatory factors in vivo than those in the control group 24 hours after surgery, suggesting that the cystic plate approach could reduce the postoperative inflammatory response in patients. When using the cystic plate approach, the space between the cystic plate and the hilar plate is opened, the plane of cystic duct disconnection is kept away from the extrahepatic bile duct.

Moreover, the fine anatomy of the Calot triangle allows a clearer identification of the duct structure, which might lessen bodily harm during surgery and the stress response of patients.²⁴ In surgical procedures, the surgical trauma can trigger stress responses in patients, including immune responses mediated by inflammatory factors.²⁵ Therefore, reducing inflammation related to surgery will help improve surgical outcomes and promote postoperative recovery for patients.²⁶ In our study, the low inflammation level in observation group contributed to improve postoperative recovery and quality of life for patients.

It is worth noting that the probability of complications was 4.3% in the observation group, whereas no postoperative complications occurred in the control group. Despite the fact that there was no statistically significant difference in the postoperative complications between the two groups, they nonetheless required attention. Owing to the exploratory nature of the cystic plate approach and the uncertainty of the location of the bile duct, complications like biliary fistulas or bile duct injury are more likely to develop when the surgeon is inexperienced or the laparoscopic technique is too advanced to recognize the anatomy.²⁷ Although some patients had complications, our results still demonstrated that patients treated with the cystic plate approach had a better postoperative quality of life than patients treated with conventional approach.

Limitations

Several limitations, however, remain in this study. First, we did not collect the chronic disease information of patients, including diabetes, hypertension, heart failure, and chronic obstructive pulmonary disease. These chronic diseases may increase the probability of postoperative infection and other complications in patients.^28,29 This defect may affect the results of postoperative complications. Second, the number of patients included in this study was small. It is necessary to consider increasing the sample size to verify the research conclusions in the following research. Furthermore, there are other surgical approaches to laparoscopic cholecystectomy. Limited by the small sample size, we did not analyze and compare the efficacy of other surgical methods. It is to be explored in further study.

Conclusion

Laparoscopic cholecystectomy via cystic plate approach can effectively treat gallstones combined with chronic cholecystitis. In particular, it shortens the recovery time of gastrointestinal function, reduces postoperative inflammation, improves the quality of life of patients after surgery, and has good clinical efficacy.

Footnotes

Authors' Contributions

L.Y.: conceptualization, writing—original draft, and visualization. Y.F.: conceptualization and investigation. Y.P.: resources and data curation. D.W.: formal analysis, resources, data curation. E.S.: validation, supervision. L.W.: formal analysis, projection administration. Q.W.: methodology, writing—review and editing,

Data Availability

All data used during the study are available from the corresponding author by reasonable request.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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