Overall operative outcomes of Laparoscopic Cholecystectomy and our experience in Statistics

Background: The laparoscopic surgery technique has rapidly spread because of its several advantages over conventional open surgery. The diminishment of postoperative pain provided positive human impact, and the reduction of length of hospital stay as well as the earlier return to work generated a positive socioeconomic impact. However, despite being minimal invasive this surgical method, postoperative complication cannot be disregarded. Objective: To evaluate the complications of laparoscopic cholecystectomy in symptomatic and asymptomatic cholelithiasis. Methodology: 364 & 387 patients of laparoscopic cholecystectomy in BIRDEM General Hospital, Dhaka, Bangladesh and Khulna Medical College Hospital, Bangladesh were included in this prospective study on the basis of convenient purposive sampling from a period of 30.06.14 to 30.09.16 & 01.01.11 to 30.09.16 respectively. Result: Results of this study suggests that among the patients of BIRDEM, 25.5% cases were male and 74.5% patients were female. Mean±SD of age were 43±1.4 and 42±1.7 respectively. On the other hand, among the KMCH patients, 26.1% were male and 73.9% were female. Mean±SD of age were 46±1.3 and 43±1.9 respectively. Among the total 364 cases in BIRDEM, in case of 277 (76.1% approximately), laparoscopic cholecystectomy was done due to chronic cholecystitis whereas in case of KMCH it was 83.2%. Post cholecystectomy syndrome was found to be the most frequent complications which was recorded 4.7% in BIRDEM and 7.5% in KMCH followed by port site bleeding, 3.8% and 4.4% respectively. The prevalence rates of vascular, hepatic bed haemorrhage were 2.5% & 2.5% respectively in BIRDEM and 2.8% & 3.4% in KMCH. Open conversion rates were 5.2% in BIRDEM and in 7.0% in KMCH. The overall mortality was approximately 1.1% & 2.3% respectively. The prevalence of spilled stone, biliary leakage, bowel injury, port site infection, surgical emphysema were 1.6%, 1.9%, 1.1%, 3.0% & 0.8% respectively in BIRDEM and 1.8%, 2.3%, 1.8%, 4.9% & 0.5% respectively in KMCH. Conclusion: Laparoscopic cholecystectomy is a safe and effective procedure in almost all patients with cholelithiasis. Proper preoperative work up, awareness of possible complications and adequate training makes this operation a safe procedure with favorable result and lesser complications. Research Article Overall operative outcomes of Laparoscopic Cholecystectomy and our experience in Statistics Faruquzzaman1* and Hossain SM2 1Faruquzzaman, MS Part 3 (Thesis) Course Student, BIRDEM General Hospital, Dhaka, Bangladesh 2Syed Mozammel Hossain, Associate Professor, Department of Surgery, Khulna Medical College Hospital, Bangladesh Dates: Received: 14 February, 2017; Accepted: 19 May, 2017; Published: 22 May, 2017 *Corresponding author: Faruquzzaman, MS Part 3 (Thesis) Course Student, BIRDEM General Hospital, Dhaka, Bangladesh, E-mail:


Introduction
Laparoscopic cholecystectomy (LC) has replaced open surgery in the treatment of cholelithiasis. It is now considered the fi rst option and has become the "gold standard" in treating benign gallbladder disease [1,2]. The risk of intraoperative injury during laparoscopic cholecystectomy is higher than in open cholecystectomy [3,4]. It has been anticipated that this will diminish with increasing surgeon experience in the use of LC. 3 In USA approximately one million patients are newly diagnosed annually with gall disease and approximately 600,000 operations are performed a year more than 75% of them by laparoscopy [5]. represents our experience of laparoscopic cholecystectomy with the aim to evaluate the complications of laparoscopic cholecystectomy in cholelithiasis, both in symptomatic and asymptomatic patients.

Material and Methods
This prospective study was carried out in Surgery Unit 1 of BIRDEM General Hospital, Dhaka, Bangladesh from 30.06.14 to 30.09. 16  Preoperative prophylactic antibiotics were given to all patients. Mainly 4-ports entry procedure was adopted. The average operation time was 40 minutes. Single doses of injectable antibiotics was given till the next morning. Patients were mobilized on the same evening while they were discharged home the next morning or the second day with advice for follow up visit 10 days after surgery.

Results
The age and sex distribution of the study population of BIRDEM General Hospital, Dhaka is presented in table 1 which suggest that majority of the patients were female (74.5%). Mean±SD of age was 43±1.4 and 42±1.7 in case of male and female patients respectively (Table 1). On the other hand, the demographic distribution of the study population of KMCH, Khulna is presented in table 2 which suggest that majority of the patients were female (73.9%). Mean±SD of age was 46±1.3 and 43±1.9 in case of male and female patients respectively.
Majority of the patients of laparoscopic cholecystectomy in BIRDEM were due to chronic cholecystitis (76.1%) followed by 17.0% due to acute cholecystitis. In case of KMCH, these were 83.2% & 9.6% respectively ( Table 3). Table 4 suggests the overall complications of laparoscopic cholecystectomy in both BIRDEM and KMCH which refl ects that the overall open conversion rates are 5.2% and 7.0% respectively and the prevalence rates of mortality are 1.1% in BIRDEM and 2.3 in KMCH.

Discussion
Laparoscopic cholecystectomy (LC) has virtually replaced conventional open cholecystectomy as the gold standard for symptomatic cholelithiasis and chronic cholecystitis [6,7].
In acute cholecystitis the reports are scanty and confl icting 7 .
The application of laparoscopic technique for cholecystectomy is expanding very rapidly and now performed in almost all major cities and tertiary level hospitals in our country. The laparoscopic approach brings numerous advantages at the expense of higher complication rate especially in training facilities [6].
In this study among the patients of BIRDEM, 25.5% cases were male (out of total 364 patients) and 74.5% patients were female. In male group, most of the patients (11.8%) were in 41-50 years of age group followed by 6.3% were in 51-60 years age group, whereas among the female patients it was 40.4% and 19.0% respectively. Mean±SD of age were 43±1. 4 Table 4).
The reported incidence of injuries from trocars or verses needle is up to 0.2%.5 Bile duct injury is a severe and potentially life threatening complication of LC and several studies report 0.5% to 1.4% incidence bile duct injuries [10][11][12]. Cystic duct leak is an infrequent but potentially serious complication of LC and can be reduced by using locking clips instead of simple clips [13]. In another series, bile duct injury was minimum and biliary leak occurred in only 14 (3.98%) cases [8].  [14].
Spillage of gallstones into the peritoneal cavity during LC occurs frequently due to gallbladder perforation and may be associated with complications, and every effort should be made to remove spilled gallstones but conversion is not mandatory [15][16][17]. Incidence is estimated between 10% and 30% [5]. In a retrospective study from Switzerland, only 1.4% of patients with spillage of gallstones during LC developed serious postoperative complications [5].
Signifi cant reduction in the postoperative infection is one of the main benefi ts of minimally invasive surgery as the rates of surgical site infection is 2% versus 8% in open surgery [18]. In another study it is reported as 1.4% in laparoscopic surgeries versus 14.8% in open cases [19]. Bowel injuries incidence in LC is 0.07-0.7% and most probably occur during the insertion of the trocars, seldom during operations [20,21].

Conclusions
Laparoscopic cholecystectomy is one of the most frequently performed laparoscopic operations. It has a low rate of mortality and morbidity. It is a safe and effective procedure in almost all patients presenting with cholelithiasis. Most of the complications are due to lack of experience or knowledge of typical error.
A rational selection of patients and proper preoperative work up as well as knowledge of possible complications, initial assessment of anatomy of that intended site prior to operation, proper time of conversion, in combination with adequate training are required. This assessment of correct judgment requires optimal experience of laparoscopy under proper supervision, makes this operation a safe procedure with favorable results.