Technical Aspects of Dealing with Difficult Laparoscopic Cholecystectomy in Overweight and Obese Patients

Muhammad Fawad; Hasnain Razzaque; Sohail Akram; Muhammad Imran; Fahad Rashid; Muhammad Sufyan

doi:10.70749/ijbr.v3i2.760

Authors

Muhammad Fawad Department of Surgery, Combined Military Hospital, Rawalpindi, Punjab, Pakistan.
Hasnain Razzaque Department of Surgery, Combined Military Hospital, Rawalpindi, Punjab, Pakistan.
Sohail Akram Department of Surgery, Combined Military Hospital, Rawalpindi, Punjab, Pakistan.
Muhammad Imran Department of Surgery, Combined Military Hospital, Rawalpindi, Punjab, Pakistan.
Fahad Rashid Department of Surgery, Combined Military Hospital, Rawalpindi, Punjab, Pakistan.
Muhammad Sufyan Department of Surgery, Combined Military Hospital, Rawalpindi, Punjab, Pakistan.

DOI:

https://doi.org/10.70749/ijbr.v3i2.760

Keywords:

Laparoscopic Cholecystectomy, Obesity, Operative Difficulty, Conversion Rate, Postoperative Complications, Surgical Modifications, Minimally Invasive Surgery

Abstract

Background: Laparoscopic cholecystectomy (LC) is the preferred surgical approach for gallstone disease; however, obesity presents unique technical challenges, including prolonged operative time, increased conversion rates, and higher postoperative complications. Limited data exist regarding the impact of obesity on LC outcomes in the Pakistani population, necessitating further investigation. Objective: This study aimed to evaluate the technical difficulties, intraoperative modifications, and perioperative outcomes of LC in overweight and obese patients compared to normal-weight individuals, with a focus on operative time, conversion rates, and postoperative complications. Methods: A quasi-experimental study was conducted at the Department of Surgery, CMH Rawalpindi, from September 2022 to April 2023, involving 300 patients categorized by BMI into normal weight (n=100), overweight (n=120), and obese (n=80). Inclusion criteria encompassed adults undergoing LC for symptomatic cholelithiasis or acute cholecystitis, while exclusions included patients with severe systemic illnesses or prior upper abdominal surgeries. Data on intraoperative challenges, operative time, conversion to open surgery, and postoperative complications were analyzed using SPSS v27. Statistical significance was set at p<0.05. Results: Obese patients had significantly longer operative times (75 ± 20 min) than normal-weight individuals (60 ± 15 min) (p<0.01). Conversion rates were highest in obese patients (10%) compared to normal-weight (2%) (p<0.05). Postoperative complications, including wound infections (10% vs. 2%) and bile leaks (3.8% vs. 1%), were significantly more common in obese individuals (p<0.05). Conclusion: Obesity complicates LC, leading to longer operative times, higher conversion rates, and increased postoperative morbidity. Surgical modifications and perioperative strategies should be tailored to mitigate these risks, ensuring optimal outcomes for obese patients.

Downloads

Download data is not yet available.

References

Joglekar, S., Rowcroft, A., & Houli, N. (2022). How to improve exposure in the obese patient at laparoscopic cholecystectomy: the looped omental retractor. ANZ Journal of Surgery, 92(5), 1206–1207. https://doi.org/10.1111/ans.17660

Turk, J, S. (2020). Effect of Obesity on Surgical Outcomes in Cholecystectomy. Turk J Surg. 36(4), 298-305.

SAGES. (2019). Robotic vs. Laparoscopic Cholecystectomy: Which Technique Is Optimal in Morbidly Obese Patients? - SAGES Abstract Archives. SAGES. https://www.sages.org/meetings/annual-meeting/abstracts-archive/robotic-vs-laparoscopic-cholecystectomy-which-technique-is-optimal-in-morbidly-obese-patients/

Wong, A., Naidu, S., Lancashire, R. P., & Chua, T. C. (2022). The impact of obesity on outcomes in patients undergoing emergency cholecystectomy for acute cholecystitis. ANZ Journal of Surgery, 92(5). https://doi.org/10.1111/ans.17513

Enami, Y., Aoki, T., Tomioka, K., Hakozaki, T., Hirai, T., Shibata, H., Saito, K., Takano, Y., Seki, J., Oae, S., Shimada, S., Nakahara, K., Takehara, Y., Mukai, S., Sawada, N., Ishida, F., Murakami, M., & Kudo, S. (2021). Obesity is not a risk factor for either mortality or complications after laparoscopic cholecystectomy for cholecystitis. Scientific Reports, 11(1), 2384. https://doi.org/10.1038/s41598-021-81963-5

Daysurgery UK. Impact of High BMI on Surgical Outcomes and Costs for Laparoscopic Cholecystectomy. J Day Surg. 2019;29(1):15-22. Available from: https://appconnect.daysurgeryuk.net/2019-journal/jods-291-february-2019/does-high-body-mass-index-impact-surgical-outcomes-and-hospital-cost-for-day-case-laparoscopic-cholecystectomy/

PMC. (2021). A Study on Acute Abdominal Pain.

Choi, S. B, Han, H. J, Kim, W. B, Song, T, J, Suh, S, O, & Kim, Y. C. (2020). Laparoscopic Cholecystectomy in Obese Patients: Improved Outcomes with Modified Port Placement. World J Surg. 44(5), 1538-45.

Caglià, P, Tracia, A, Borzì, L, Amodeo, L, Veroux, P, & Veroux M. (2021). Laparoscopic Cholecystectomy in Obese Patients: The Role of Preoperative Weight Reduction. Updates Surg. 73(4), 1403-10.

Nickel, F., Haney, C. M., Kowalewski, K. F., Probst, P., Limen, E. F., Kalkum, E., Diener, M. K., Strobel, O., Müller-Stich, B. P., & Hackert, T. (2020). Laparoscopic Versus Open Pancreaticoduodenectomy. Annals of Surgery, 271(1), 54–66. https://doi.org/10.1097/sla.0000000000003309

Fathy El-sayed Darwish, A. E. R., Mohamed El-Banna, A., & Salem, A. (2022). Assessment of perioperative predictors of difficult laparoscopic cholecystectomy. Al-Azhar Medical Journal, 51(1), 13-30. https://dx.doi.org/10.21608/amj.2022.210627

Ary Wibowo, A., Tri Joko Putra, O., Noor Helmi, Z., Poerwosusanta, H., Kelono Utomo, T., & Marwan Sikumbang, K. (2022). A scoring system to predict difficult Laparoscopic cholecystectomy: A five-year cross-sectional study. Minimally Invasive Surgery, 2022, 1-6. https://doi.org/10.1155/2022/3530568

Bansod, A. N., Patil, I. G., Awachar, N. S., Umalkar, R. K., Wankhede, A. M., & Jadhav, V. K. (2022). A study of preoperative factors predicting a difficult laparoscopic cholecystectomy. International Surgery Journal, 9(5), 972. https://doi.org/10.18203/2349-2902.isj20221141

Deng, S. X., Greene, B., Tsang, M. E., & Jayaraman, S. (2022). Thinking your way through a difficult Laparoscopic cholecystectomy: Technique for high-quality subtotal cholecystectomy. Journal of the American College of Surgeons, 235(6), e8-e16. https://doi.org/10.1097/xcs.0000000000000392

Genser, L., Lim, C., Barbier, L., Regimbeau, J., Hobeika, C., Goumard, C., Laurent, A., Fuks, D., Chiche, L., Vibert, E., & Scatton, O. (2022). Assessment of factors associated with morbidity and textbook outcomes of Laparoscopic liver resection in obese patients: A French nationwide study. Journal of the American College of Surgeons, 235(2), 159-171. https://doi.org/10.1097/xcs.0000000000000221

Habeeb, T. A., Kermansaravi, M., Giménez, M. E., Manangi, M. N., Elghadban, H., Abdelsalam, S. A., Metwalli, A. M., Baghdadi, M. A., Sarhan, A. A., Moursi, A. M., & El‐Taher, A. K. (2022). Sleeve gastrectomy and cholecystectomy are safe in obese patients with asymptomatic cholelithiasis. A multicenter randomized trial. World Journal of Surgery, 46(7), 1721-1733. https://doi.org/10.1007/s00268-022-06557-2

Hasan, M. M., Md Muhsin, S., Alam, M. E., Anwar, S. M., Mostafa, F., Momin, M. N., & Khan, M. R. (2022). Predicting difficult Laparoscopic cholecystectomy based on Clinicoradiological assessment. IAHS Medical Journal, 4(2), 70-73. https://doi.org/10.3329/iahsmj.v4i2.62533

Karim, S. T., Chakravarti, S., Jain, A., Patel, G., & Dey, S. (2022). Difficult Laparoscopic cholecystectomy predictors and its significance. Journal of West African College of Surgeons, 12(4), 56-63. https://doi.org/10.4103/jwas.jwas_162_22

Nassar, A. H., Khan, K. S., Ng, H. J., & Sallam, M. (2022). Operative difficulty, morbidity and mortality are unrelated to obesity in elective or emergency Laparoscopic cholecystectomy and bile duct exploration. Journal of Gastrointestinal Surgery, 26(9), 1863-1872. https://doi.org/10.1007/s11605-022-05344-7

Paul, S., Khataniar, H., Ck, A., & Rao, H. K. (2022). Preoperative scoring system validation and analysis of associated risk factors in predicting difficult laparoscopic cholecystectomy in patients with acute calculous cholecystitis: A prospective observational study. Turkish Journal of Surgery, 38(4), 375-381. https://doi.org/10.47717/turkjsurg.2022.5816

Ramírez-Giraldo, C., Alvarado-Valenzuela, K., Isaza-Restrepo, A., & Navarro-Alean, J. (2022). Predicting the difficult laparoscopic cholecystectomy based on a preoperative scale. Updates in Surgery, 74(3), 969-977. https://doi.org/10.1007/s13304-021-01216-y

Santharaj, S., & Marahanumaiah, S. (2022). Pre-operative predictors of difficult laparoscopic cholecystectomy: A comparative study between two scoring systems. International Surgery Journal, 9(5), 960. https://doi.org/10.18203/2349-2902.isj20221002

Suleimanov, V., Al Asker, H., Al Hawaj, K., Alhashim, I. W., & Al Rebh, F. N. (2022). Laparoscopic cholecystectomy in a morbidly obese patient with situs Inversus Totalis: A case report. Cureus. https://doi.org/10.7759/cureus.32304

Timerbulatov, M., Grishina, E., Aitova, L., & Aziev, M. (2022). Modern principles of safety in laparoscopic cholecystectomy. Khirurgiya. Zhurnal im. N.I. Pirogova, (12), 104. https://doi.org/10.17116/hirurgia2022121104

Tranter-Entwistle, I., Eglinton, T., Hugh, T. J., & Connor, S. (2022). Use of prospective video analysis to understand the impact of technical difficulty on operative process during laparoscopic cholecystectomy. HPB, 24(12), 2096-2103. https://doi.org/10.1016/j.hpb.2022.07.013

Wong, A., Naidu, S., Lancashire, R. P., & Chua, T. C. (2022). The impact of obesity on outcomes in patients undergoing emergency cholecystectomy for acute cholecystitis. ANZ Journal of Surgery, 92(5), 1091-1096. https://doi.org/10.1111/ans.17513

Yadav, A., Kumawat, S., & Agarwal, L. (2022). An observational study on prediction of difficulties during laproscopic cholecystectomy in cases of cholelithiasis by preoperative ultrasonography. Basrah Journal of Surgery, 28(2), 27-33. https://doi.org/10.33762/bsurg.2022.176624

Alius, C., Serban, D., Bratu, D. G., Tribus, L. C., Vancea, G., Stoica, P. L., Motofei, I., Tudor, C., Serboiu, C., Costea, D. O., Serban, B., Dascalu, A. M., Tanasescu, C., Geavlete, B., & Cristea, B. M. (2023). When critical view of safety fails: A practical perspective on difficult Laparoscopic cholecystectomy. Medicina, 59(8), 1491. https://doi.org/10.3390/medicina59081491

Gupta, V. (2023). How to achieve the critical view of safety for safe laparoscopic cholecystectomy: Technical aspects. Annals of Hepato-Biliary-Pancreatic Surgery, 27(2), 201-210. https://doi.org/10.14701/ahbps.22-064

Ramírez-Giraldo, C., Isaza-Restrepo, A., Conde Monroy, D., Castillo-Barbosa, A. C., Rubio-Avilez, J. J., & Van-Londoño, I. (2023). What is the best score for predicting difficult laparoscopic cholecystectomy? A diagnostic trial study. International Journal of Surgery, Publish Ahead of Print. https://doi.org/10.1097/js9.0000000000000354

Tongyoo, A., Liwattanakun, A., Sriussadaporn, E., Limpavitayaporn, P., & Mingmalairak, C. (2022). The Modification of a Preoperative Scoring System to Predict Difficult Elective Laparoscopic Cholecystectomy. Journal of Laparoendoscopic & Advanced Surgical Techniques, 33(3). https://doi.org/10.1089/lap.2022.0407

Trehan, M., Mangotra, V., Singh, J., Singla, S., Gautam, S. S., & Garg, R. (2023). Evaluation of Preoperative Scoring System for Predicting Difficult Laparoscopic Cholecystectomy. International Journal of Applied and Basic Medical Research, 13(1), 10. https://doi.org/10.4103/ijabmr.ijabmr_553_22

Al-Azzawi, M., Abouelazayem, M., Parmar, C., Singhal, R., Amr, B., Martinino, A., Atıcı, S., & Mahawar, K. (2023). A systematic review on laparoscopic subtotal cholecystectomy for difficult gallbladders: a lifesaving bailout or an incomplete operation? The Annals of the Royal College of Surgeons of England, 106(3). https://doi.org/10.1308/rcsann.2023.0008

Dominguez, J. L., Tariq, N., Martins, R. S., Jawad, G., Fisher, A. D., & Maqbool, B. (2024). Bailout Surgery for Difficult Gallbladders: Surgical Approach and Outcomes. The American Surgeon, 90(6), 1324–1329. https://doi.org/10.1177/00031348241227186