Key findings:

Key findings from the study include that laparoscopic cholecystectomy (LC) is a safe and effective treatment for gallbladder empyema, although technical challenges may arise due to edema, adhesions, and distorted anatomy in Calot's triangle. Surgeon experience is crucial, and maintaining a low threshold for conversion to open surgery is recommended to ensure patient safety. In cases where resection is risky, sub-total cholecystectomy may be a viable option.

What is known and what is new?

What is known is that laparoscopic cholecystectomy (LC) has revolutionized the treatment of symptomatic gallstone disease, including potentially fatal complications like empyema of the gallbladder. What is new from this study is the detailed examination of LC's clinical outcomes and complications, highlighting the technical challenges and the importance of surgeon expertise in managing gallbladder empyema.

What is the implication, and what should change now?

The implication is that laparoscopic cholecystectomy (LC) remains a safe and effective option for treating gallbladder empyema, despite the technical difficulties that may arise. Surgeons should prioritize patient safety by maintaining a low threshold for converting to open surgery when necessary. Additionally, considering sub-total cholecystectomy in cases where resection is risky can help reduce complications and improve outcomes. Surgeons and healthcare systems should continue to refine their approach to LC for gallbladder empyema to ensure optimal patient care.

Laparoscopic cholecystectomy (LC) has dramatically changed the outlook of patients with symptomatic gallstone disease. Empyema of the gallbladder is a potentially fatal complication of gallstones. One of the current worldwide health problems, especially among adults, is gallstone disease [1]. The traditional open cholecystectomy was first performed in 1882 by Carl August Langenbach. He stated, “the gallbladder needs to be removed not because it contains stones, but because it forms them.” Then, it was replaced with laparoscopic cholecystectomy (LC). The first LC was performed in 1985 by Muhe. It is characterized by suppuration superimposed on acute cholecystitis. LC revolutionizes the treatment of gallbladder disease and is now the gold standard for the treatment of gallstones and the most ordinary operation performed [2, 3]. Laparoscopic surgery is limited in a few technical aspects, such as limited tactile feedback during manipulation of tissues and dissection, indirect contact with intra-abdominal structures, and loss of three-dimensional perception, through the relatively limited and fixed view of the operative field. When this happens, the operation becomes difficult and results in the conversion to open cholecystectomy. However, practitioners define the ''difficult LC” differently. Generally, it refers to multiple technical intra-operative challenges that intensify the risk of complications. Hence, the operation time is prolonged [4, 5]. Approximately 75% of all cholecystectomies are performed using a laparoscopic technique, while conversion to open procedure ranges between 5% and 10% nationwide [6]. However, the national institute of health (NIH) reports that the results of LC are significantly influenced by the skills the surgeons have, which include factors gained through experience, and training, which develop their maturity and confidence in making rational judgments [7]. Typically, conversion to open cholecystectomy is not preferred because it is always associated with some pulmonary infections and surgical sites, increased overall morbidity, and extended ward stays [8, 9]. The potentially fatal complication of gallstones is empyema of the gallbladder. Its categories vary, determined through suppuration superimposed on acute cholecystitis. Usually, its presentation in clinical form is more complicated than acute cholecystitis [10]. Cases involving patients with advanced atherosclerotic disease or diabetes are increasing [11]. In surgical terms, a calculus (or rarely from a malignant mass like underlying cholangiocarcinoma) prevents pus from draining through the cystic duct and obstructs the gallbladder neck [12]. Although practitioners have described multiple sonographic indicators of acute cholecystitis, which include bladder distension and sonography Murphy’s sign, the ability to predict the ease or difficulty of cholecystectomy and acute cholecystitis is still weak [13-15]. Features suggesting the seriousness of this disease and its diagnosis are still too few; it used to be a contraindication for LC in response to some fears of complications leading to life-threatening [16-18]. Accordingly, many cases have previously been decided for conversion [19]. In current advancement, the maturity of technology and experience in laparoscopic surgery has changed the scenario significantly. Regarding this, practitioners have found that LC is an effective option and is safe for acute cholecystitis and its associated conditions like empyema of the gallbladder [19]. Other people may face different complications, subjected to various factors. Generally, damage to nearby vital structures, uncontrolled bleeding, and obscured local anatomy are common factors leading to conversion (complication) [20]. However, the encouraging merits are not stagnant, while evaluation of the role of laparoscopic surgery in such acute conditions is continuously going on.

This prospective study was conducted in the Department of Surgery at Khulna City Medical College and Hospital, Khulna, Bangladesh. The study was carried out from June 2019 to July 2021. The standard 4-port technique performed the LC with few modifications depending upon the situation, such as an additional port and percutaneous decompression of the gallbladder by the spinal needle. The gallbladder was incised in cases of thick pus, and a suction cannula was introduced to aspirate directly into the gallbladder. The suction cannula was also used to dissect the dense adhesions in the area of Calot's triangle. The thickened wall of the gallbladder was also incised to apply the graspers properly in cases where it was difficult to get hold of the thick, edematous gallbladder. Data of each patient was recorded on a data form, including demographic details, operative findings, intraoperative complications, postoperative complications, and duration of hospitalization.

Inclusion Criteria:

• Patients with clinical, sonological and biochemical evidence of cholelithiasis with empyema.

• Patients of aged 20-69 years and gender.

Exclusion Criteria:

• Patients with major medical problems

• Patients with overwhelming sepsis

All data were presented in a suitable table or graph according to their affinity. A description of each table and graph was given to understand them clearly. All statistical analysis was performed using the statistical package for social science (SPSS) program, and Windows. Continuous parameters were expressed as mean±SD and categorical parameters as frequency and percentage. The significance of the results as determined by a value of P<0.05 was considered to be statistically significant.

It is a prospective study, a total of 120 patients were enrolled and analyzed in this study. Most of the 44(36.67%) patients were from the age range of 50-59 (Table 1). According to gender distribution, 65% of patients were male, and 35% were female (Figure 1). Table 2 shows the clinical feature and ultrasound findings; all patients had pain in the right hypochondrium, 90(75.00%) patients had a fever, 69(57.67%) patients had palpable gallbladder, and 34(28.33%) patients had vomiting. Almost 97% of patients had intraluminal sludge of stone, 99(82.50%) patients had thickened walls of the gallbladder, 94(78.33%) patients had distended gallbladder, and 68(56.67%) patients had pericholecystic fluid accumulation (Table 2). In Table 3 it shows the reasons for conversion to open cholecystectomy in the study, where 56(46.47%) patients with totally obscured anatomy in Calot’s triangle, 39(32.50%) patients had bleeding, 17(14.17%) patients had common bile duct injury and only eight patients had duodenal perforation. According to operational complication, 13(10.83%) patients had to bleed, 9(7.50%) patients with perforation of the gallbladder, four patients had minor trauma to the common bile duct, and the same number of patients had duodenal perforation (Table 4). In this study, we successfully operated on 94 patients and converted 26 patients. There were 25 patients who had complications after a successful operation, and 21 converted patients had complications (Table 5).

Table 1: Gender distribution of the study population (N=120).

Figure 1: Gender distribution of the study population (N=120).

Table 2: Clinical Features and Ultrasound Findings of the Study Population (N=120).

Table 3: Reasons for conversion to open cholecystectomy

Table 4: Operative complications

Table 5: Postoperative complications of the study population

Laparoscopic cholecystectomy (LC) has become a preferred choice even in the most difficult situations associated with complicated gallbladder disease [21-23]. Several encouraging reports are answering earlier arguments about its safety and efficacy. More laparoscopic surgeons are being persuaded to perform LC in acute cholecystitis [24-27]. Few reports have specifically evaluated the safety of LC in empyema of the gallbladder. Our study presents details of 28 LCs performed on empyema gallbladders within 24 hours of admission to evaluate the safety and appropriateness of the laparoscopic approach in this condition. The difficulties we encountered in dissection in the area of Calot's triangle are more or less the same as mentioned by other similar studies [28]. The overall conversion rate in this study (19.40%) is consistent with other reports [29, 30]. History of recurrent acute cholecystitis and an undue delay in the surgery are the main contributing factors for conversion in this study, a finding consistent with other similar studies [28, 31-33]. The nature of the study population must also be known, as suggested by Gouma [34]. The study population in this report is mainly from poor socio-economic backgrounds, coming from remote areas of Khulna, Bangladesh. There is a general reluctance for surgery in these patients because of economic reasons and a general fear of surgery. Their presentation is therefore delayed, and operation is technically complex due to fibrosis and firm adhesions. These are the common factors producing a distortion of local anatomy [35, 36]. This has been the main factor in conversions in this series, with an additional contribution to our standing on the learning curve. The conversion rate can be significantly reduced by patience, clear display, and identification of the anatomy of Calot's triangle before cutting or applying clips. The dissection should proceed cautiously, and gentle adhesion separation should be done. The duodenum should be identified and gently pushed down to avoid injury. The use of diathermy should be minimal, and the threshold for conversion should be kept low to ensure patients’ safety. We decompressed the distended gallbladder before proceeding to Calot's triangle to facilitate dissection. Tseng et al. have also favored this procedure to make surgery safe and easier [37]. Another way of handling such life-threatening situations is to perform subtotal cholecystectomy after removing all the stones to ensure the safety of the patient’s life instead of continuing dissection in the frozen Calot's triangle with totally obscured anatomy. The rate of major complications is not significant in the current study to preclude the laparoscopic approach in this condition. However, there should always be a word of caution while operating in such difficult conditions. This is consistent with the findings of Hobbs et al claiming that the increased risk of complications with LC has stabilized [38]. However, a few cases of major cystic artery bleeding and duodenal perforation occurred, and we had to resort to the open technique considering the safety of the patients. The cystic artery bleed was initially attempted to be controlled by tamponade and gauze pressure, failing which we converted the cases and the bleeding controlled. The duodenal perforation was identified then and there, and the operation was converted with subsequent primary closure of the duodenum. There is always a risk of common bile duct (CBD) injury if the operating surgeon is impatient and the anatomy of the field is not displayed before clipping and cutting. Undue use of diathermy is also a significant factor in causing CBD injury and should be avoided in the area of Calot's triangle. The total hospital stay in the converted population was prolonged, with an average of 10 days. This is, however, contrary to the finding of Johansson et al. claiming that conversion did not prolong the postoperative hospital stay in the study population [39]. LC in empyema has shown less morbidity and no mortality in our study. The analysis of our study and literature review has shown that this procedure was associated with less intraoperative blood loss, shorter hospital stays, less wound infection, and less postoperative pain.

Limitations of the study:

Every hospital-based study has some limitations and the present study undertaken is no exception to this fact. The limitations of the present study are mentioned. Therefore, the results of the present study may not be representative of the whole of the country or the world at large. The number of patients included in the present study was less in comparison to other studies. Because the trial was short, it was difficult to remark on complications and mortality.

Laparoscopic cholecystectomy (LC) is a safe and acceptable option in gallbladder empyema. However, there are significant technical difficulties due to edema, adhesions, and distorted anatomy in the area of ​​Calot's triangle. The experience of the surgeon plays an important role. We recommend that patient safety be prioritized and that the conversion threshold be kept low. Sub-total cholecystectomy may be considered where resection proves dangerous.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee of Khulna City Medical College Hospital

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