The mean age of LC patients was 45.77 ± 13.5 years, and the mean age of men was found 5 years greater than that of women. The ratio of males to females was 4.7:1. One third (33%) of the patients had comorbidities. The most common comorbidities were hypertension, diabetes mellitus, pulmonary and cardiac diseases. 20% of patients with comorbidities had more than one comorbidity. Comorbidity rates were similar for gender, (37% of males and 32% of females) and across all age groups (P = 0.141). Gallbladder stone was reported in the abdominal ultrasonography of all patients, while gallbladder inflammation was reported in only 15% of patients. Gallbladder inflammation was more common in males, 26.8% than females, 13.2%, (OR = 2.203, 95%CI 1.56–2.61, P = 0.000). WBC count at the time of admission was categorized as equal or below and above10,000/mm3, and similar at the time of admission for both genders (P = 0.942). The majority of patients (~ 97%) were classified as ASA I and II. Only 52 patients (3.6%) were classified as ASA III. Demographic and clinical statistics are presented in Table 1.
Table 1
Demographic and Clinical Statistics
Variables
|
Male
250 (17.5%)
|
Female
1180 (82.5%)
|
Total
1430
|
N
|
(%)
|
N
|
(%)
|
N
|
(%)
|
Age
|
|
|
|
|
|
|
15–30
|
22
|
(8.8%)
|
207
|
(17.5%)
|
229
|
(16.0%)
|
31–50
|
114
|
(45.6%)
|
582
|
(49.3%)
|
696
|
(48.7%)
|
51–70
|
106
|
(42.4%)
|
372
|
(31.5%)
|
478
|
(33.4%)
|
71 and over
|
8
|
(3.2%)
|
19
|
(1.6%)
|
27
|
(1.9%)
|
Mean ± SD
|
49.5 ± 13.1
|
44.98 ± 13.4
|
13.75 ± 13.5
|
ASA Grade
|
|
|
|
|
|
|
I
|
124
|
(49.6%)
|
647
|
(54.8%)
|
771
|
(53.9%)
|
II
|
106
|
(42.4%)
|
501
|
(42.5%)
|
607
|
(42.4%)
|
III
|
20
|
(8.0%)
|
32
|
(2.7%)
|
52
|
(3.6%)
|
Prior abdominal surgery
|
14
|
(5.6%)
|
86
|
(7.3%)
|
100
|
(7.0%)
|
Comorbidities*
|
93
|
(37.2%)
|
382
|
(32.4%)
|
475
|
(33.2%)
|
Sonogram finding**
|
|
|
|
|
|
|
GB stone
|
250
|
(100%)
|
1180
|
(100%)
|
1430
|
(100%)
|
GB inflammation
|
67
|
(26.8%)
|
156
|
(13.2%)
|
223
|
(15.6%)
|
GB mass
|
1
|
(0.4%)
|
0
|
(0.0%)
|
1
|
(0.1%)
|
Admission WBC
|
|
|
|
|
|
|
≤ 10000/mm3
|
210
|
(84.0%)
|
989
|
(83.8%)
|
1199
|
(83.8%)
|
> 10000/mm3
|
40
|
(16.0%)
|
191
|
(16.2%)
|
231
|
(16.2%)
|
* Some patients have more than one comorbidity
** Some patients have more than one sonogram finding
|
For most of the LC procedures (~ 88%), a 4 incision/port configuration was used, and its pattern was similar for both sexes (P = 0.823). Almost all patients (99.9%) had gallbladder stones found during the operation. The only patient without a gallbladder stone had a gallbladder polyp instead. 5 patients had a gallbladder polyp with stones. Gallbladder inflammation was found in 198 cases (124 acute and 74 chronic). 4 patients had CBD obstruction at the time of operation, all of which were converted to OC. Overall mean duration of anesthesia was 75 minutes (SD = 25.6), and slightly longer in males than females (P = 0.000). The mean duration of anesthesia in LC cases without conversion to open was 73.3 ± 23.3 minutes, while it was much longer in LC cases which were converted to open cholecystectomy (110.98 ± 41.0 min) (P = 0.000). However, duration of anesthesia was similar in LC cases with (77.48 ± 30.3) or without (74.53 ± 24.3 min) intraoperative complications (P = 0.098). The duration of anesthesia was longer in LC cases with post-operative complications (89.71 ± 36.2 min) than those without post-operative complications (74.67 ± 25.2 min), which was statistically significant (P = 0.001).
An abdominal tube drain was placed for 59 (4.1%) patients, most commonly for cases with intra-operative complications (N = 39, 15.6%) compared to uncomplicated cases (N = 20, 1.7%) (P = 0.000). Drain was placed in 22 males (8.8% of male patients) and 37 females (3.1% of female patients), which is statistically significant (P = 0.000). The overall conversion rate to OC was 4.6% (N = 66), with a similar pattern in both male and female patients (OR = 0.647, 95%CI 0.36–1.12; P = 0.139), ASA grades(P = 0.301), WBC count at admission (OR = 1.162, 95%CI 0.61–2.21; P = 0.647) and comorbidity (OR = 1.069, 95%CI 0.63–1.82; P = 0.805). Surgery related statistics are presented in Table 2.
Table 2
Surgery related statistics
Variables
|
Male
250 (17.5%)
|
Female
1180 (82.5%)
|
Total
1430
|
|
N
|
(%)
|
N
|
(%)
|
N
|
(%)
|
P value
|
Incision/port
|
|
|
|
|
|
|
|
3 ports
|
32
|
(12.8%)
|
207
|
(12.3%)
|
177
|
(12.4%)
|
0.823
|
4 ports
|
218
|
(87.2%)
|
582
|
(87.7%)
|
1253
|
(87.6%)
|
Mean duration of anesthesia (min) ± SD
|
80.7 ± 29.0
|
73.9 ± 24.7
|
75.04 ± 25.6
|
0.000
|
Drain placed
|
22
|
(8.8%)
|
37
|
(3.1%)
|
59
|
(4.1%)
|
0.000
|
Converted to OC
|
16
|
(6.4%)
|
50
|
(4.2%)
|
66
|
(4.6%)
|
0.139
|
Intraoperative complications
|
55
|
(22.4%)
|
194
|
(16.4%)
|
249
|
(17.4%)
|
0.035
|
Postoperative complications
|
6
|
(2.4%)
|
29
|
(2.5%)
|
35
|
(2.4%)
|
0.957
|
ALOS (days) ± SD
|
2.25 ± 1.4
|
2.22 ± 1.4
|
2.23 ± 1.4
|
0.814
|
Conversion rate was 26.3% among patients with gallbladder inflammation (29.8% for acute and 20.3% for chronic cholecystitis). While conversion rate was significantly higher among patients preoperatively diagnosed with gallbladder inflammation by ultrasonography (OR = 11.44, 95%CI 6.76–19.34; P = 0.000), it was much higher for acute cholecystitis (OR = 18.727, 95%CI 10.997–31.893; P = 0.000) than for chronic cholecystitis (OR = 6.505, 95%CI 3.458–12.240; P = 0.000). Of patients with prior abdominal surgery (N = 100), none was converted to OC. Indications for conversion are listed in Table 3.
Table 3
Indications for conversion to OC
Indications for conversion
|
N
|
(%)
|
Dens adhesions at Callot's triangle
|
54
|
(3.8%)
|
Bleeding- vascular/GB bed
|
5
|
(0.4%)
|
CBD stone/obstruction
|
1
|
(0.1%)
|
CBD stone + Mirrizi syndrome
|
1
|
(0.1%)
|
CBD stone + bleeding
|
1
|
(0.1%)
|
CBD injury
|
3
|
(0.2%)
|
Duodenal injury
|
1
|
(0.1%)
|
Total
|
66
|
4.6%
|
Intraoperative complications occurred in 249 patients (17.4%), where bile/stone spillage was the most common intra-operative complication. Intraoperative complications are listed in Table 4. There were 10 complications (0.7%) requiring conversion to OC. While bile/stone spillage in this series was higher than what is reported in other studies, bleeding and organ injury in this series was lower or comparable to other studies. Intraoperative complication rate was significantly higher in male than in female patients (OR = 1.47, 95%CI 1.05–2.05, P = 0.024). Intraoperative complication rate was not significantly different in terms of number of incision/port (P = 0.200), mean duration of anesthesia (P = 0.98) and mean of hospital stay after operation (P = 0.326). However, intraoperative complication rate was significantly higher among cases with chronic cholecystitis (OR = 1.19, 95% CI 1.02–1.38, P = 0.004), those with prior abdominal surgery (OR = 1.14, 95% CI 1.01–1.29, P = 0.009), and age older than 70 (N = 11, 40.7%, P = 0.001). There were 1153 symptomatic patients, from whom 249 (21.6%) suffered intraoperative complications. There was no intraoperative complication in asymptomatic cases. Only Immediate postoperative complications were reported, because a significant number of patients came from other provinces and did not return for follow-up or contacted the hospital by phone to inform about any complications. Overall immediate postoperative complication rate was 2.4% (N = 35), where the most common complication was bleeding that required transfusion or reoperation. Postoperative complications were similar in terms of sex (OR = 0.98, 95% CI 0.40–2.38, P = 1.000), presence of comorbidity (OR = 1.12, 95% CI 0.60–2.39, P = 0.717), prior abdominal surgery (P = 0.749), number of incision/ports (P = 0.171), intraoperative complications (OR = 0.98, 95% CI 0.40–2.38, P = 0.586) and conversion to OC (OR = 0.51, 95% CI 0.15–1.69, P = 0.217). Postoperative complications were significantly higher in ASA grade III than ASA grade I and II (P = 0.43), and WBC count > 10000/mm3 at admission (P = 0.002).
Table 4
Intraoperative complications
Complications during surgery
|
N
|
(%)
|
Bile/stone spilled
|
235
|
(16.4%)
|
Port–site bleeding requiring suture
|
4
|
(0.3%)
|
Hepatic fossa bleeding requiring conversion
|
4
|
(0.3%)
|
Other bleeding requiring conversion
|
2
|
(0.1%)
|
CBD injury
|
3
|
(0.2%)
|
Duodenal injury
|
1
|
(0.1%)
|
Total
|
249
|
17.4%
|
ALOS after all cases was 2.23 ± 1.43 days (1–19 days). ALOS was 2.15 ± 1.3 days for LC cases not converted to OC and 3.67 ± 2.7 days for cases that were converted to OC. About a third of patients (N = 426) were discharged after one day, while more than half of them (N = 826, 57.8%) stayed for 2–3 days; only 178 patients (12.4%) stayed more than 3 days in the hospital after LC. ALOS after LC was similar for both sexes, and those with intraoperative complications (P = 0.326); but it was significantly higher in patients who were classified as ASA grade III before LC (P = 0.001), had comorbidities (P = 0.001), 4 incision/port approach (P = 0.000), had drains placed after LC (P = 0.000), LC converted to OC (P = 0.000), who suffered postoperative complications (P = 0.000). Fortunately, there was no mortality in this series.