Laparoscopic cholecystectomy and liver cirrhosis.

INTRODUCTION: Historically the presence of liver cirrhosis has been an absolute or relative contraindication to laparoscopic cholecystectomy (LC). Accumulating experience in LC has resulted in an increasing number of investigators reporting that LC can be safely performed in cirrhotic patients. The aim of this study was to report the efficacy and safety of LC in the treatment of symptomatic cholelithiasis in cirrhotic patients, and a review of the literature in the matter. METHODS: Between January 2006 and July 2010, from 503 patients under LC, we reviewed 43 cirrhotic patients of Child-Pugh Classification A, B, and C, with symptomatic gallstones. RESULTS: Conversion to an open procedure was necessary in 5 patients due to multiple factors. The mean operative time and length of hospital stay were significantly longer and higher in cirrhotic group (P<0.05). Postoperative complications were observed in 37.2% of patients. Trocar site hematoma (P=0.02), wound complications (P=0.02), and intra-abdominal collection (P=0.01) occurred more frequently in patients with cirrhosis (Child B and C class) than in patients without cirrhosis. One case of continuing hemorrhage from the gallbladder bed required a reoperation for hemostasis. Two patients with Child-Pugh class C and 1 patient with class B cirrhosis developed ascites after surgery; 1 patient with Child-Pugh class A had bile leakage. No deaths occurred. CONCLUSIONS: LC is an effective and safe procedure and should be the treatment of choice for symptomatic cholelithiasis or cholecystitis in patients with compensated cirrhosis.

Predictive model of failure of outpatient laparoscopic cholecystectomy.

INTRODUCTION: The aim of our study was to review our experience and to determine a predictive model of factors for unanticipated admissions after ambulatory laparoscopic cholecystectomy (LC). MATERIALS AND METHODS: Between January 1999 and June 2003, 410 consecutive LCs were performed as outpatient procedures. We performed univariate analysis and logistic regression models of preoperative and intraoperative variables. The scoring system developed allowed calculating the ambulatorization probability of LC in each patient. Validation and calibration of the model were realized by means of Hosmer-Lemeshow test. RESULTS: Three hundred sixty-three patients were strictly ambulatory (86.8%). Forty-two patients required overnight admission (10.2%), most of them because of social factors, and 5 patients were admitted. Predictive factors related to overnight stay or admission were: age of patient over 65 years [P=0.021; odds ratio (OR)=2.225; 95% confidence interval (CI), 1.130-4.381], operation duration superior to 60 minutes (P=0.046; OR=2.403; 95% CI, 1.106-5.685), and "dissection difficulty" intraoperative score superior to 6 (P=0.034; OR=3.063; 95% CI, 1.086-8.649). The right classification index of the predictive system was 91.7%, reaching a sensibility of 99.7% and specificity of 31.9%. CONCLUSIONS: Outpatient LC is safe and feasible. Age of the patient, operation duration, and complexity of surgical dissection during LC are independent factors influencing ambulatorization rate.

Laparoscopic repair of vaginal evisceration: a case report.

Vaginal evisceration, although rare, is usually present in postmenopausal women with a history of vaginal surgery and high-grade pelvic floor dysfunction. Operative management is directed toward resecting any compromised bowel, repairing vaginal defect, and correcting the defect in the pelvic floor, which is associated with most cases, either in the same intervention or in a second procedure. Laparoscopy allows for assessment of the viability of the compromised bowel and the vaginal defect suture with advantages common to minimally invasive techniques. We report the first case in the international literature of vaginal evisceration managed by laparoscopy.

The learning curve in ambulatory laparoscopic cholecystectomy.

Whether laparoscopic cholecystectomy (LC) should be performed as an outpatient procedure is still under discussion. The aim of this study was to evaluate the influence of surgeon's experience in ambulatory management of LC. Three hundred eighty-one consecutive elective LCs were planned as outpatient procedures. An anesthetic protocol that includes free-opiates anesthesia, preemptive analgesia, and somatovisceral blockade was used. Percentages of ambulatory, overnight, and admitted patients were evaluated, and time series variation was also analyzed. Postoperative pain, nausea and vomiting incidence, postoperative recovery, and complications were examined. Two hundred ninety-one patients were strictly ambulatory (76.3%), 71 (18.6%) required overnight admission, and 19 (4.9%) were admitted. Percentage of ambulatory LC increased from 22% to 90% in 4 years of experience. Readmission rate was 0.01%. Free-opiates anesthetic techniques, preemptive analgesia, and somatovisceral blockade allowed us to obtain over 90% of ambulatory LC. The learning curve related to postoperative evaluation is crucial in obtaining those results.