OUTCOME OF RECOMMENCEMENT OF LAPAROSCOPIC CHOLECYSTECTOMY

SERVICE AFTER A LONG HIATUS IN A NON HEPATOBILIARY CENTER

Rahim Samad, Syaza Faizul, Ibrahim Yahaya, Alif Yunus, Wan Emizam, Yap Lee Ming
General Surgery Department, Hospital Melaka
INTRODUCTION & BACKGROUND
Laparoscopic cholecystectomy is now widely practiced as the gold standard in the treatment of gallstone disease, in replacement
of the traditional method of open cholecystectomy. It has become part of formal surgical training and thus is a skill that all surgeons
are expected to possess. Due to the emergence of the COVID pandemic, laparoscopic procedures have been limited. With this
mind, we have conducted a retrospective analysis of laparoscopic cholecystectomy (LC) procedures performed at Hospital
Melaka following the departure of the consultant hepatobiliary surgeon and a long hiatus owing to the current COVID-19 pandemic
which forced surgical operating theaters to limit cases to emergency cases or elective oncological cases.

Hospital Melaka is the only government-run tertiary hospital in the state of Melaka. Up till June 2019, it had a hepatobiliary surgeon
who would perform both elective and emergency LC. Following his departure, a drop in the number of LC was seen, and more
open cholecystectomies were performed instead. Shortly after, in early 2020, the COVID pandemic made it difficult to plan for
elective cholecystectomies altogether. Knowing that there are numerous well documented literatures regarding the advantages of
laparoscopic versus open cholecystectomy in terms of good clinical outcomes, we owe it to our patients to recommence
laparoscopic procedures for treatment of symptomatic gallstone disease. This analysis was done retrospectively to review the
outcomes of performing regular LC in Hospital Melaka towards the patients despite being a non-hepatobiliary center.

METHODOLOGY & RESULTS

METHOD

For the purpose of this observational retrospective study, we collected data from a total of 42 patients that underwent laparoscopic
cholecystectomy from July 2020 to April 2021 in Hospital Melaka through patient records. The data collected includes details
regarding the patient demographics and surgical outcomes.
DIAGNOSIS
RESULTS

From the data gathered, among the 42 patients included, 9 (21.4%) of them were male
12%
and 33 (78.6%) were female. The diagnosis of biliary colic and cholecystitis gives an 7%
equal number of 17 patients (40.5%) each. 3 of them (7%) were diagnosed with gall
bladder empyema, and the remaining 5 patients (12%) had gallstone pancreatitis. 18 40.5%
patients (43%) were operated by general surgeons, 20 (47.6%) by general surgery
consultants and the remaining 4 (9.6%) by the visiting HPB consultant. Mean length of
Prednisolone
40.5% Cyclophosphamide
MMF

surgery was found to be 2.15 hours. It was found that 3 cases (7.1%) were complicated Prednisolone
Cyclophosphamide

with bile leak diagnosed intraoperatively and by ultrasonography postoperatively, all of

which were managed conservatively. Out of 42 surgeries performed, 7 (16.6%) were
biliary colic cholecystitis
converted to open surgeries due to facing difficulties intraoperatively. In our study, only
1 patient required intraoperative cholangiography, while no readmissions and no
Day
gall bladder empyema gallstone pancratitis
Figure 1: Platelet trend corresponded to medication during admission Figure 2: Platelet trend after discharge
mortalities
* PEX=Plasmawere recorded.
exchange, M=Methyprednisolone, D=Dexamethasone, P=Prednisolone, IV=Intravenous, T=Tablet
Chart 1.0: diagnosis of patient prior to surgery

DISCUSSION
Following the departure of the hepatobiliary consultant, it was found that gall stone diseases in Hospital Melaka were often
managed either very selectively for LC or being referred to the other HPB center, whilst in non-urgent cases, elective surgery was
delayed. Compounding on this was the emergence of the COVID-19 outbreak which resulted in reduced number of elective cases.
In an effort to restart the service of LC, several strategies were deployed including getting a visiting HPB consultant to perform
potentially complicated LC and for general surgeons to overcome the learning curve by starting off with simple biliary colic or acute
cholecystitis cases. Throughout the process, the use of the Nassar score was employed to document the grade of difficulty using a
fixed scale which will hopefully allow for better identification of difficult LC in the future. This study has helped highlight the rates of
complications experienced and it is found that a 16.6% laparoscopic-to-open cholecystectomy conversion rate is comparable to
tertiary centres similar to that of Hospital Melaka which had a rate of 16.8%, and thus far there have been no readmissions or
mortalities associated with this period of recommencement of the service of laparoscopic cholecystectomy.

CONCLUSION
Recommencement of laparoscopic cholecystectomy services may carry quite a significant impact towards the patients in the sense
that it provides better post-operative outcomes compared to the open technique. However, the challenge in a non-HPB center is
that laparoscopic cholecystectomy requires continuous training and guidance. With the data obtained through this study, we aim
for it to be a steppingstone towards conducting a study that can outline a system to predict difficult laparoscopic
cholecystectomies and further improve patient outcomes.

REFERENCES
1.Campanile, Fabio Cesare, Mauro Podda, Alberto Arezzo, Emanuele Botteri, Alberto Sartori, Mario Guerrieri, Elisa Cassinotti et al.
"Acute cholecystitis during COVID-19 pandemic: a multisocietary position statement." World Journal of Emergency Surgery 15, no. 1
(2020): 1-5.https://www.researchgate.net/publication/342023042_Acute_cholecystitis_during_COVID-
19_pandemic_A_multisocietary_position_statement
2.Lai, Elaine, Jin-Jiun Mah, and Jitt Aun Chuah. "Laparoscopic Cholecystectomy Audit in Queen Elizabeth Hospital, Sabah,
Malaysia." HPB 21 (2019): S457. https://www.hpbonline.org/article/S1365-182X(19)32988-0/fulltext