Page 34 - Journal of World Association of Laparoscopic Surgeons

Assessment of Feasibility of Laparoscopic Cholecystectomy at the Time of LSCS
previous cesarean section, transverse lie, twin pregnancy, and requiring frequent admissions and was operated at a referral center
placenta previa. Written informed consent was obtained for for her gallstone disease in her second trimester of pregnancy.
combined procedures at the time of admission. All patients received Other three patients lost their follow-up in their last trimester of
prophylactic intravenous antibiotics. Under general anesthesia, pregnancy. All symptomatic patients were managed conservatively
LSCS was done first by making a Pfannenstiel or lower midline during their pregnancy, including one who developed acute
abdominal incision. Upper abdominal anatomy was assessed via calculous cholecystitis in her first trimester. The indications of LSCS
the cesarean wound after the uterus was closed. A telescope was in our study group were CPD in two, previous LSCS in five, and
also used through the cesarean incision to have a closure look at the placenta previa in one of the patients. All the patients were operated
target site. The lax abdominal wall was easily retracted allowing the at term. Under general anesthesia, LSCS was first done using either
assessment of the upper abdomen. After closing the uterus, the first Pfannenstiel incision (five patients) or lower midline incision (three
10 mm trocar was placed at the umbilicus under direct vision and patients). Anatomy in the upper abdomen was assessed via the
was controlled by surgeons’ left hand, before closing the cesarean cesarean wound after closing the uterus. Direct visual assessment
wound. The abdominal cavity was insufflated with carbon dioxide was somewhat easier via the lower midline incision as compared to
after closing the laparotomy incision and the insufflation pressure Pfannenstiel incision. All the patients had favorable anatomy and
was preset at 12–13 mm Hg. Continuous ETCO monitoring was laparoscopic cholecystectomy was completed in them. A small tube
2
done. Three additional trocars were placed at conventional sites drain was placed via the right flank port site as routine which was
(epigastric 10 mm, right subcostal 5 mm, and right lumbar 5 mm) removed in all patients on the first or the second postoperative day.
under laparoscopic vision (Fig. 1). Laparoscopic cholecystectomy Intraoperative findings included flimsy omental adhesions
was completed in all the patients by the duct first method after in four (50%) patients, and dense adhesions in calots, distended
defining the critical view of safety. The gallbladder was extracted gallbladder, short cystic duct, and mucocele in each (12.5% each)
via the epigastric port. A small 14 Fr tube drain was placed in the of the patients. None of the patients had pericholecystic edema/
subhepatic region in all the patients. Ports were removed under abscess, empyema, or dilated cystic duct. Opened specimen
the vision and port sites closed. All the patients were encouraged revealed gallstones with or without sludge in seven patients, and
to be ambulatory 18 hours after the operation. Data recorded gallstones with clear mucus in one patient.
included age, parity, associated illnesses, biliary symptoms, Surgeries were completed in a mean operating time of
laboratory and radiological investigations, conversion rate, 82 minutes and the mean extra time taken after LSCS, placement
operative findings, intraoperative complications, the time taken for of primary optical supraumbilical trocar, and closure of the cesarean
laparoscopic cholecystectomy after completion of cesarean section, wound was 24 minutes (15–40 minutes). There were no conversions
postoperative complications, length of hospital stay from the day to open cholecystectomy. There were no intraoperative or
of operation, mortality, and pathological findings of gallbladder. postoperative complications except for one woman who developed
postoperative cesarean wound infection (mild) which was treated
results with additional daily dressings. All newborn were healthy with a
The age of the patients ranged between 24 and 37 years (mean 29.7 mean birth weight of 2.9 kg. There were no deaths in our series.
years). All except one patient were multigravida. Ultrasonographic No extra antibiotics or analgesic doses were needed. Patients
findings included multiple gallbladder (GB) calculi in 7 (87.5%) were discharged on the third and the fourth postoperative day.
patients, and a solitary large stone of 30 mm diameter in one (12.5%) Histopathology of the gallbladder specimen revealed features
patient. Clinical presentation included a history of biliary symptoms consistent with chronic cholecystitis in five, acute inflammation
like episodic upper abdominal pain and/or dyspepsia in four (50%) in one, cholesterolosis in one, and a normal gallbladder in one of
and acute cholecystitis in the first trimester in one (12.5%), while the specimens.
three (37.5%) women had silent gallstones. One patient who was
excluded from the study developed recurrent acute biliary colic dIscussIon
Gallstones are more common during pregnancy due to decreased
gallbladder motility and increased cholesterol saturation of bile.
Gallstone disease during pregnancy has been associated with
increased risk of preterm birth, maternal morbidity, and readmission,
12
as well as neonatal morbidity. The prevalence of biliary sludge,
gallstones, and biliary pancreatitis in pregnancy ranges from 5 to
13–16

36%, 2 to 11%, and 1/1,000 to 3/10,000, respectively. However,
the need for cholecystectomy occurs in 1 in 1.6–1 in 10,000
pregnancies and most of the patients with symptomatic gallbladder
disease in pregnancy are effectively managed conservatively, and
cholecystectomy is performed selectively during the postpartum
14
period. Many patients require cholecystectomy during pregnancy,
and the laparoscopic approach seems to be a safe alternative to
17
open surgery during pregnancy. For pancreaticobiliary diseases
in pregnancy, endoscopic retrograde cholangiopancreatography
18
(ERCP) has been suggested as an effective alternative to surgery.
Although gallstone disease in pregnancy is uncommon, the
Fig. 1: Lower segment cesarean section wound with sheath closed and potential maternal and fetal morbidities from both the disease
standard port sites for laparoscopic cholecystectomy and its surgical therapy are significant. Pregnant women who

26 World Journal of Laparoscopic Surgery, Volume 12 Issue 1 (January–April 2019)