Emergency surgical procedures for gallbladder perforation represent 2–10% of all gallbladder surgeries [19]. After analyzing data comprising 6,468 patients who underwent gallbladder surgeries at our clinic, we found a gallbladder perforation incidence of 1.26% (n = 82). Before classification, our incidence of perforation surgery was lower than in the literature. In the modified Niemeier gallbladder perforation classification, type I represents generalized biliary peritonitis. Patients with type I gallbladder perforations almost always require urgent surgical intervention [6, 7]. Among all patients undergoing gallbladder surgery, 0.64% (n = 42) had modified Niemeier type I gallbladder perforations, representing 51.21% of all gallbladder perforations. The incidence of type I gallbladder perforations was reported to be 8.6% by Gupta et al. [13], 49.6% by Sahbaz et al. [20], 60% by Rajput et al. [21], and 52.2% by Kumar et al. [22]. Since gallbladder perforations are rare, variable rates have been reported in the literature. Our study presented the results of our laparoscopic experience with patients with modified Niemeier type I gallbladder perforations requiring an emergency surgical procedure.
At their initial presentation to the Emergency Department, 34 (80.95%) patients complained of abdominal pain, 18 (42.85%) of vomiting, and 16 (38.09%) had a fever (> 38 °C). The presenting complaints of gallbladder perforations include abdominal pain, nausea, and vomiting [3]. Krishnamurthy et al. [11] found abdominal pain was the most common presenting symptom in 93.9% of patients. We also identified abdominal pain as the most common presenting symptom.
When we evaluated the comorbid conditions of the patients included in our study, we found that hypertension was the most common (61.9%), coronary artery disease was the second most common (52.4%), and diabetes mellitus was the third most common (42.9%). When the study groups were examined within themselves, no statistically significant difference was observed between the groups in terms of comorbid diseases. Krishnamurthy et al. [11] found diabetes mellitus in the first place (80.0%), hypertension in the 2nd place (60.0%), and ischemic heart disease in the 3rd place (33.3%) in the comorbid status evaluation of their population. Stefanidis et al. [23] found that the most common comorbid conditions in their study were cardiovascular diseases (50.0%) and diabetes mellitus (25.0%) in the 2nd place. Due to the rarity of gallbladder perforations, studies have a low patient population. Therefore, there are differences in the ranking of the most common comorbid conditions in the literature. However, as supported by our study, cardiac diseases, and diabetes mellitus are the most common comorbid conditions in gallbladder perforation. We decided to elaborate on the examination of comorbid data in the preoperative period and evaluated the ASA Physical status classification system and the Charlson comorbidity index. According to the ASA classification, the population was distributed as ASA I (2.4%), ASA II (14.3%), ASA III (57.1%), and ASA IV (26.2%). ASA III represented the most common group. Krishnamurthy et al. [11] also found the ASA III group to be the most common with 53.3%. Sahbaz et al. [20] found the ASAI group as the most common group in their study in which all perforation types were evaluated. Krishnamurthy et al. [11] evaluated surgically treated gallbladder perforations and found similar results to ours. LC (median 2 (1–3)) and COC (median 3 (1–6)) groups were evaluated by the Charlson comorbidity index (p = 0.02). When the literature was reviewed, the Charlson comorbidity index was not evaluated in gallbladder perforations. However, Ramírez-Giraldo et al. [24] found the index to be a median of 1.0 in easy cholecystectomies and a median of 2.0 in difficult cholecystectomies (p < 0.001). Although all gallbladder perforations can be classified as difficult surgery, it can be estimated that the COC group refers to the more difficult group. Our study also supported the literature in this respect. However, to provide accurate information, there is a need for contribution in this aspect of the literature.
Findings at the presentation were classified according to Tokyo Guidelines 2018. Class II (57.1%) was more common in the LC group, while Class III (71.4%) was more common in the COC group (p = 0.007). Ramírez-Giraldo et al. [24] found a significant association between difficult cholecystectomies and Tokyo Classification 2018. The components of the Tokyo Guidelines 2018, which classify the relationship with the severity of cholecystitis findings, were not evaluated in other studies relevant to our study. However, Tokyo Classification 2018 is associated with the components of studies evaluating the factors affecting difficult laparoscopic cholecystectomy in the literature. These studies found a statistically significant association of components with difficult cholecystectomy [17, 25,26,27,28,29]. In our study, we showed that more severe cholecystitis findings were observed in the COC group with the Tokyo Classification 2018.
Laparoscopy was the first choice for emergency surgery in all patients included in our study. We evaluated the feasibility of minimally invasive surgery by dividing the patients into two groups (LC and COC). Krishnamurthy et al. [11] (86.8%) and Xaio et al. [12] (60%) found the most common perforation site to be the fundus. The fundus was also the most common perforation site in our study (57.1%). This observation has been attributed to low blood flow in the fundus in the literature. When the feasibility of minimally invasive surgery was evaluated according to the perforation location, there were significant differences between the fundus (n = 24) and the trunk (n = 8; p = 0.009) and between the fundus and the neck (n = 10; p < 0.001) but not between the body and the neck (p = 0.18). We concluded that the closer the gallbladder perforation site was to Calot’s triangle, the higher the likelihood of conversion to open surgery. The most common cause of conversion in gallbladder surgery is the inability to perform safe surgery due to adhesions in Calot’s triangle [30]. Due to the inflammatory process in gallbladder perforation, we believe that adhesions increase with proximity to Calot’s triangle, with a concomitant increase in the possibility of termination of minimally invasive surgery.
We found no significant difference in complications between groups (p = 0.346). When we searched the literature, we found no studies with sufficient patients to evaluate only type I gallbladder perforations. Therefore, we compared all gallbladder perforations with type I. The most common morbidity in our study was intraabdominal sepsis (14.2%). Zhang et al. [1] evaluated the incidence of postoperative complications, finding that 4.5% of patients developed wound infections, 2.3% developed paralytic ileus, 2.3% developed heart failure and acute respiratory distress syndrome, and 2.3% developed renal failure. Sahbaz et al. [20] identified wound infection as the most common morbidity in all types (5.26%). The literature shows that the most common morbidity in all types of gallbladder perforation is wound infection. We attribute the fact that the most common morbidity in our study was not wound infection to the feasibility of minimally invasive surgery. Complications were classified according to the Clavien-Dindo classification. Clavien-Dindo II (n = 6 (35.3%)) was more common in the LC group and Clavien-Dindo IIIB (n = 5 (38.5%)) in the COC group (p = 0.011). Ramírez-Giraldo et al. [24] compared easy and difficult laparoscopic cholecystectomies and found a relationship between the groups according to the Clavien-Dindo classification. In our study, all cholecystectomies were performed due to gallbladder perforation. So actually all surgical procedures can be considered as difficult. Therefore, it was expected that there would be no statistical relationship between the groups. Major complications (Clavien-Dindo ≥ III) were evaluated in the LC (n = 6) and COC (n = 11) groups (p = 0.007). The higher incidence of major complications in the COC group may be explained by the minimally invasive nature of the surgery and intraoperative difficulty. Modified Nassar scales were used to evaluate intraoperative surgical difficulty. Modified Nassar scales III in the LC group (n = 12 (46.2%)) and IV (n = 6 (46.2%)) were more frequent in the COC group. It was not surprising that major complications were more common in the COC group, which was more difficult in terms of intraoperative findings.
We evaluated the postoperative hospitalization duration in the LC (median = 4.5 days, range = 2–19) and COC (median = 5.0 days, range = 3–25) groups. Rajput et al. [21] performed open surgery for gallbladder perforations and reported a mean hospitalization duration of 12 days for patients with type I gallbladder perforations. We found that it was shorter with the laparoscopic approach (p = 0.483). The mortality rate in our study cohort was 11.9% (p = 0.650). Sahbaz et al. [20] reported a mortality rate of 8.27% for all gallbladder perforations. While we found a significant difference in surgical procedure duration between groups, we believe this difference reflects the preparation process during the transition from laparoscopic to open surgery.
The age of the primary surgeon correlated significantly with the completion of minimally invasive surgery in our study (p = 0.001). Younger surgeons were able to rectify gallbladder perforations with laparoscopic surgery. A review of the literature showed varying regarding minimally invasive surgery. While some studies indicated that the learning curve is superior in the younger age group, others have demonstrated the success of the older group in minimally invasive surgery due to experience [30,31,32]. Another important detail at this point is to evaluate whether young surgeons lack experience in the transition to open surgery. In our study, there was no statistical difference between the groups in terms of complications. Larger series are needed to evaluate this point. We also think that the age of the surgeon should be included in the evaluation criteria in studies evaluating difficult cholecystectomies [33, 34].
Five (11.9%) patients had Candida tropicalis and Escherichia coli growth in the intraoperative bile fluid cultures. We did not find any comparable data in the literature on gallbladder perforation. In a study evaluating patients who underwent laparoscopic surgery for acute cholecystitis, there was a much higher growth rate [35]. We think that the low growth rates in bile cultures in our study may be due to the small number of patients and the broad-spectrum empiric antibiotic treatment applied due to the preoperative diagnosis of gallbladder perforation.
Our study demonstrates the results of minimally invasive surgery in treating modified Niemeier type I gallbladder perforations. Its limitations include its retrospective design and small sample size due to the condition’s rarity. Additionally, only patients with gallbladder perforation detected on preoperative imaging and who underwent minimally invasive surgery with this diagnosis were included in this study. The exclusion of patients with gallbladder perforation detected intraoperatively and patients who underwent direct open surgery may affect the results of the study. However, our results show that the minimally invasive approach in gallbladder perforation reduces complications, and hospital stay.
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