Home About Us Contact Us

Official Journals By StatPerson Publication

Table of Content - Volume 12 Issue 3 - December 2019


 

Comparison between early and delayed laparoscopic cholecystectomy in acute cholecystitis: A prospective study

 

Rajneesh Kumar1, Sarjeet Singh Mahi2*, RPS Walia3, Subhash Goyal4

 

1Associate Professor, 2Assistant Professor, 3,4Professor, Department of Surgery, Punjab Institute of Medical Sciences [PIMS], Jalandhar. Punjab, INDIA.

Email: drrajneeshkumar@ymail.com

 

Abstract               Background: Usual approach for management of acute cholecystitis consists of initial control of inflammation followed by interval cholecystectomy after 6-8 weeks but there is always risk of gall stones related morbidity during waiting for cholecystectomy. There are chances of recurrent acute attacks. Moreover after72hours of inflammation, adhesions, hyper vascularity, fibrosis and necrosis develop. Early surgery means within 72hours of acute attack and delayed means after 6-8weeks. Methods: We compared the outcome of patients in whom; we apply early or late cholecystectomy. In the study,100 patients were included, laparoscopic cholecystectomy was performed in early cholecystectomy of 50 cases of group A (within 72 hours of symptoms) and group B of 50 cases where conservative treatment was given and laparoscopic cholecystectomy was performed after 6-8 weeks was late cholecystectomy group, at Punjab Institute of Medical Sciences from May 2015 to June 2017.We compared duration of surgery, post-operative complications and rate of conversion to open surgery and length of hospital stay. Results: Delayed cholecystectomy took longer operating time (67.23 minutes v/s 40.83minutes), conversion to open cholecystectomy Early v/s Delayed (5/50 v/s 7/50), No. of intra peritoneal spillage of stones and bile Early v/s Delayed was (8/50 v/s 7/50)and longer hospital stay (3 v/s2 days) Conclusion: Early laparoscopic cholecystectomy in acute cholecystitis within 72hours of symptoms onset are superior to delayed treatment as it is not associated with significant complications and has advantage of less morbidity and decreasing mean duration of surgery and decreased hospital stay.

Key Word: Laparoscopic cholecystectomy, acute cholecystitis, opens cholecystectomy

 

 

INTRODUCTION

Cholelithiasis is one the most common surgical disease. About 1-15% of adult western population has gall stones1.In USA, prevalence of cholelithiasis is same as in western world but it appears somewhat lower in Asia and Africa 2.Prevalence of gall stones in Northern India is 6.12%3. Gall stone presentation is variable. Symptomatic gall stone disease leads to biliary colic, acute cholecystitis with progression to empyema and perforation, chronic cholecystitis and life threatening complications like obstructive jaundice and pancreatitis. With the introduction of gold standard procedure i.e.laparoscopic cholecystectomy for last 2 decades in general surgery4.In spite of increasing experience approx. 2-15% of laparoscopic cholecystectomy areconverted to open cholecystectomy5. Laparoscopic cholecystectomy has lower complication rate and has shorter hospital stay as compared to open cholecystectomy6,7. The common approach for management of acute calculus cholecystitis consists of initial control of inflammation followed by interval cholecystectomy after a period of 6-8 weeks8. However, it is augmented that there is an increased risk of gall stone related morbidity during the waiting period for cholecystectomy. The sequence of these inflammatory changes has led to the belief of performing surgery for acute cholecystitis during the first ‘’Golden 72hours’’ of the onset of symptoms9,11. Inflammatory tissue reaction make dissection difficult and increase the risk of serious complication mainly bile duct injury due to distorted anatomy caused by the acute inflammation12 but increasing experience and confidence in laparoscopic surgery has led the procedure accepted as standard treatment in acute stage laparoscopically13,14. Consequently more and more reports are available demonstrating feasibility of laparoscopic approach for acute cholecystitis within 48-72hours of presentation with low morbidity but at the expense of high conversion rate15,16.Surgery to be performed within 72 hours has been recommended in several guidelines17,19. Performing early cholecystectomy in patients with acute cholecystitis shortens hospital stay and lower hospital care expenses16,20. The aim of study was to compare outcome of patients undergoing early laparoscopic cholecystectomy within 72 hours of symptoms to those of patients managed conservatively and operated late after 6-8weeks after the inflammatory reaction has subsided. In addition, the study also aims to determine whether early laparoscopic cholecystectomy is associated with more complications than an elective procedure, after an initial conservative medical management.

 

MATERIAL AND METHODS

In this study, we aimed to compare outcomes of Patients to whom we apply early or late cholecystectomy after hospitalization from emergency and outdoor department with diagnosis of cholecystitis to evaluate the safety and feasibility of early Laparoscopic Cholecystectomy in acute Calculus Cholecytitis. In the study, 100 patients were included and laparoscopic cholecystectomy group A of 50 cases (within 72 hours of symptoms) and Group B of 50 patients where conservative treatment was given and Laparoscopic Cholecystectomy was performed after 6-8 weeks as late Cholecystectomy Group at Punjab institute of Medical Sciences from May,2015 to june,2017. We compared duration of surgery, intraoperative complications, rate of conversion to open surgery and length of hospital stay.

Inclusion Criteria

  • All Patients of symptomatic gall stone disease with recent onset within 72 hours of typical pain
  • Second group of patients was reported after 72 hours in OPD or emergency with symptomatic gall stone disease

Exclusion Criteria

  • Co-existent common bile duct stones based on imaging and biochemical criteria
  • Patients with Pancreatitis (S.Amylase >3 times normal)
  • Patients with previous upper abdominal surgery
  • Significant medical disease rendering patient unfit for Laparoscopic surgery (e.g. Uncontrolled Diabetes Mellitus, Chronic Pulmonary Disease, significant Cardiac Disease)

Diagnosis of Acute Cholecystitis was based on the following criteria:

  • Clinical Criteria - Acute onset right upper quadrant pain and tenderness, temperature > 37.5 degrees Celsius, White Blood Cell count > 10,500/cubic mm
  • Ultrasonography Criteria – Edematous GallBladder wall, presence of gall stones and pericholecystic fluid

It was basically according to Tokyo Guidelines21,22. The diagnosis was confirmed during surgery and following histopathology. All patients who reported within 72 hours of acute attack were put on Intravenous Antibiotics which were continued after surgery All the surgeries were performed by experienced laparoscopic Surgeons. Laparoscopic Cholecystectomy after induction of General Anesthesia and creation of Pneumoperitoneum was carried out by Standard four Port incisions

RESULTS

The two groups were matched and there was no significant difference regarding Age, Sex and Duration of Surgery.

Table 1: Showing Comparison according to age

Parameter

Group A (early)

Group B (delayed)

P value

Age (years)

18-58 (35.0 +/- 12.08)

23-73 (37.3+/-13.12)

0.527

 

Sex Distribution: Was found to be comparable between 2 groups with difference being statistically insignificant. In both the groups females outnumbered males.

Table 2: Showing comparison according to sex

Sex

Group A (early)

Group B (delayed)

P value

Male

08

05

0.114

Female

42

45

0.115

 

Duration of Surgery: The mean duration of surgery in early groups was 67.23 minutes as compared to 40.83 minutes in delayed group. The difference was statistically significant (P value 0.046)

 

Table 3: Showing comparison of duration of surgery

Mean duration

of surgery

(In minutes)

Group A

(early)

Group B

(delayed)

P value

 

67.23

40.83

0.046

 

Duration of Postoperative Hospital Stay: Mean duration of hospital stay postoperatively in early group was 3.0 days as compared to 2.0 days in the delayed group B. The difference was statistically insignificant (P value 0.379)

Table 4: Showing comparison of post-operative hospital stay

Mean duration

(in days)

Group A

(early)

Group B

(delayed)

P value

 

3.0

2.0

0.379

 

 

 

Intraoperative bile leakage or stone spillage: Intraoperative bile leakage or stone spillage was 8 in early group A. As compared to 7 in delayed group B. In all these patient’s spillage occurred during separation of gallbladder from the liver bed and form grasping site due to friable tissue. The difference was statistically Insignificant (p value 0.731)

Table 5: intraoperative bile or stone spillage

Number of intraoperative

bile

or stone spillage

Group A

(early)

No. of patients

Group B

(delayed)

No. of Patients

p. value

 

8

7

0.731

 

Conversion to open cholecystectomy: 5 patients were converted to open cholecystectomy in early group A and 7 were converted in delayed group B. out of 5 cases in group A 3 were because of difficult anatomy around callot’s triangle and 2 were because of haemorrhage. Where as in delayed group B, 6 were converted to open because of difficult anatomy and 1 because of haemorrhage. The difference was statistically insignificant.

Table 6: reason for conversion to open cholecystectomy

Reason of conversion

Group A (early )

No. of patients

Group B ( delayed)

No. of patients

p. value

Difficult anatomy

3

6

0.045

Haemorrhage

2

1

0.721

We put romovac drains in all cases and there was no bile duct injury in both the groups. There was no death in any of these 2 groups. There was no significant wound infection in both groups.

 

DISCUSSION

Laparoscopic cholecystectomy is considered as gold standard for all gall stone disease and is most common laparoscopic surgery done in the world23. This is also used for acute cholecystitis as more and more experience was attained in this technique. Initially acute cholecystitis was considered to be a relative contraindication for laparoscopic cholecystectomy and traditionally initial treatment was done by bowel rest, i.v. hydration, and correction of electrolytes imbalance, analgesics and i.v. antibiotics. Following this treatment, patient with uncomplicated disease are managed on outpatient basis and called for laparoscopic cholecystectomy after a period of 6-8 weeks. But with the increase in general expertise, it is now considered as an option with certain reservations24.Tokyo guidelines for the management of acute cholangitis and cholecystitis were adopted as international guidelines25. Previously laparoscopic cholecystectomy was avoided for acute cholecystitis due to potential hazards of complications especially bile duct injury and high conversion rate to open cholecystectomy12. but now the studies have being comparing early and delayed laparoscopic cholecystectomy concluded .but early laparoscopic cholecystectomy was preferred treatment for acute cholecystitis6,26. Early cholecystectomy is recommended over conservative treatment followed by delayed cholecystectomy26,27. The optimal time period for cholecystectomy resulting in the lowest conversion and complications is still debatable28. A Randomised trial found that early laparoscopic cholecystectomy results in lower morbidity and hospital stay compared to delayed cholecystectomy even in acute cholecystitis with symptoms over 72 hours prior to admission29. Mean age of early group was 35.0years and the mean age of delayed group was 37.3 years. Statistically insignificant with (P value 0-527).In the similar study by Lo et al26.The difference between mean age of early group (59years) and delayed (61years) was statistically insignificant (P value 0.812).Similarly study done By Kolla et al30 were statistically similar as for age group is concerned. Sex distribution was again insignificant in both early and delayed groups and similar findings were there in studies done by Lo et al26 and Kolla et al30. Mean duration of surgery in early group was 67.23 minutes as compared to 40.83 minutes in delayed group .The difference was statistically significant (P-value 0.046).The possible causes of longer duration of surgery in early group include the time required for removal of inflammatory pericholecystic adhesions, intraoperative gall bladder decompression and longer learning curve associated with surgery in acute cholecystitis. In the study by Lo et al26, the mean duration of surgery in the early group was 135 minutes as compare to 105 minutes in the delayed group. The difference was statistically significant (p value 0.022). In the study by Kolla et al30, mean operation time was 104 minutes in early group and 93 minutes in delayed group. The difference was not statistically significant (p value 0.433). Lai el al31 had significantly longer operating time in their early group as compared to delayed group (122.8 v/s 106.6 minutes, p value 0.04). Johansson et al32 did not find statistical difference in the mean operating time in their early and delayed group (early 98 minutes v/s delayed 100 minutes, p value 0.12). Mean duration of post–operative hospital stay in early group was 3.0 days as compared to 2.0 days in delayed group. The difference was statistically insignificant. Kolla et al30 also found no statistical difference in mean total hospital stay post-operatively in both groups. However, Johansson et al32 found total hospital stay was significantly shorter in early group than the delayed group. Reason for conversion was difficult Callot’s triangle dissection suspicion of bile duct injury, transection of gall bladder at hartmann’s pouch. In early group, additional inflammation or gangrenous changes of gall bladder prevent successful dissection in some cases. Koo et al33 showed that patients who had laparoscopic cholecystectomies performed within 72 hours after the onset of symptoms have less difficult operation, less conversion rates, shorter operative time, less cost and less hospital stay. Eldar et al14 conducted a prospective study to determine the optimal timing of laparoscopic cholecystectomy for acute cholecystits. Patients who had laparoscopic cholecystectomy after 96hrs had conversion rates as compared to those who are operated earlier. Another prospective study by Lo et al26 compared early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Conversion rate of early versus delayed group was 11.6% versus 23%. Whereas in our study conversion rates in early group were 5 cases (10%) whereas in delayed were 7 cases (14%). Chandler et al34 compared safety and efficacy of early versus delayed laparoscopic cholecystectomy. Early treatment group had laparoscopic cholecystectomy within 72 hours of admission. Conversion rate in early vs delayed group was 24% and 36% respectively. Operative time, blood loss, conversion rate, hospital stay all were increased in delayed treatment group. Current data suggest that early laparoscopic cholecystectomy for acute cholecystitis is superior to late or delayed laparoscopic cholecystectomy with regard to outcome and cost of treatment35,36. Generally speaking early cholecystectomy is performed within a time interval of 72 hours, the so called golden 72 hours37. According to Zhu et al, gall bladder inflammation during first 72 hours of onset of symptoms may not involve structures within Calot’s triangle 38. Surgical dissection during this critical period is therefore easiest due to lack of organized adhesions. (Fig 1 and 2).


 

1

Figure 1: Early cholecystectomy Figure 2: Delayed Cholecystectomy

We had no case of bile duct injury in both groups. This rate is comparable to those reported for patients with acute cholecystitis in other series, in which bile duct injury rate ranges from 0% to 0.9% (39-43).

CONCLUSION

So, it was concluded that a delay in operation until resolution of symptoms showed no advantage with regards to age, sex, duration of hospital stay, intraoperative complications, conversion rate. However statistical significance of mean operative time was there in early cases as compared to delayed cases. Most surgeons with sufficient laparoscopic experience manage patients of acute cholecystits laparoscopic ally within 72 hours of admission and evidence suggests that these patients have no increased morbidity or mortality than patients that undergo delayed laparoscopic cholecystectomy. Because during delayed approach, some patients may have recurrence of symptoms before the planned delayed treatment and this failure can lead to emergency surgery with increased chance of morbidity and mortality. Laparoscopic cholecystectomy in acute stage is technically demanding but safe and effective.

 

REFERENCES

  1. Jorgensen T. Prevalence of gall stones in Danish population. Am J Epidemoil 1987; 126:912-21.
  2. Halldestam I, Kullman E; Borch K. Incidence of and potential risk factors for gall stones disease in a general population sample. Br J Surg 2009;96:1315-22.
  3. Khuroo MS, Mahajan R, Zargar SA, Javid G, Sapru S. Prevalence of biliary tract disease in India: a sonographic study in adult population in Kashmir. Gut 1989; 30; 201-5.
  4. Vecchio R, Mac Fayden BV, Palazzo F. History of Laparoscopic Surgery. Panminerva Med 2000 Mar; 42(10:87-90.
  5. Kama NA, Kologu M, Dogany M, Reis, Atli M, Dolapci M. A risk score for conversion from laparoscopic to open cholecystectomy. Am J Surg 2001; 181: 520-525.
  6. Kiviluoto T, Sirén J, Luukkonen P, Kivilaakso E. Randomised trial of laparoscopic versus open cholecystectomy for acute and gangrenous cholecystitis. Lancet. 1998; 351:321–5.
  7. Boo YJ, Kim WB, Kim J, Song TJ, Choi SY, Kim YC, et al. Systemic immune response after open versus laparoscopic cholecystectomy in acute cholecystitis: A prospective randomized study. Scand J Clin Lab Invest. 2007; 67:207–14.
  8. Cuschieri A. Approach to the treatment of acute cholecystitis: open surgical, laparoscopic or endoscopic? Endoscopy. 1993 Aug; 25(6):397-8
  9. Cuschieri A. Cholecystitis. In colon Blumgart L.H., Fong Y, editors. Surgery of the liver and biliary tract, vol.1,3rd ed., UK colon W.B. Saunders: 2000.p.667-72.
  10. Bender JS, Zenilman ME. Immediate laparoscopic cholecystectomy as definitive therapy for acute cholecystitis. Surg Endosc. 1995;9: 1081-4.
  11. Papi C, Catarci M, D’Ambrosio L, Gili L, Koch M, Grassi GB, Capurso L. Timing of cholecystectomy for acute calculous cholecystitis: a meta-analysis. Am J Gastroenterol.2004; 99(1): 147-55.
  12. Cuscheiri A, Dubois F, Mouiel J, Mouret P, Becker H, Buess G. The European with laparoscopic cholecystectomy. Am J Surg 1991; 161:385-7.
  13. Flowers JL, Bailey RW, Scovill WA, Zucker KA. The Baltimore experience withlaparoscopic management of acute cholecystitis. Am J Surg 1991; 161:388-392.
  14. Eldar S, Sabo E, Nash E, Abrahamson J, Matter I. Laparoscopic cholecystectomyfor acute cholecystitis: Prospective trial. World J Surg 1997; 21:540-545.
  15. Kum CK, Goh PM, Issac J. Laparoscopic cholecystectomy for acute cholecystitis. Br. J Surg 1994; 81: 1651-4.
  16. Gursamy K, Samraj K, Gluud C, Wilson E, Davidson BR. Meta analysis of randomized controlled trials on the safety and effectiveness of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Br J Surg 2010; 97: 141-50.
  17. Mayumi T, Takada T, Kawarada Y, Nimura Y, Yoshida M, Sekimoto M, Miura F, Wada K, Hirota M, Yamashita Y, Nagino M, Tsuyuguchi T, Tanaka A, Gomi H, Pitt HA: Results of the Tokyo Consensus Meeting Tokyo Guidelines. J Hepato-Biliary-Pancreat Surg. 2007, 14 (1): 114-121. 10.1007/s00534-006-1163-8.
  18. Miura F, Takada T, Strasberg SM, Solomkin JS, Pitt HA, Gouma DJ, Garden OJ, Buchler MW, Yoshida M, Mayumi T, Okamoto K, Gomi H, Kusachi S, Kiriyama S, Yokoe M, Kimura Y, Higuchi R, Yamashita Y, Windsor JA, Tsuyuguchi T, Gabata T, Itoi T, Hata J, Liau KH, Tokyo Guidelines Revision Comittee: TG13 flowchart for the management of acute cholangitis and cholecystitis. J Hepato-Biliary-Pancreat Sci. 2013, 20 (1): 47-54. 10.1007/s00534-012-0563-1.
  19. Takada T, Strasberg SM, Solomkin JS, Pitt HA, Gomi H, Yoshida M, Mayumi T, Miura F, Gouma DJ, Garden OJ, Büchler MW, Kiriyama S, Yokoe M, Kimura Y, Tsuyuguchi T, Itoi T, Gabata T, Higuchi R, Okamoto K, Hata J, Murata A, Kusachi S, Windsor JA, Supe AN, Lee S, Chen XP, Yamashita Y, Hirata K, Inui K, Sumiyama Y, et al: TG13: Updated Tokyo Guidelines for the management of acute cholangitis and cholecystitis. J Hepato-Biliary-Pancreat Sci. 2013, 20 (1): 1-7. 10.1007/s00534-012-0566-y.
  20. Wilson E, Gurusamy K, Gluud C, Davidson BR. Cost-utility and value-of-information analysis of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Br J Surg. 2010; 97:210–9.
  21. Sekimoto M, Takada T, Kawarada Y, Nimura Y, Yoshida M, Mayumi T, Miura F, Wada K, Hirota M, Yamashita Y, Strasberg S, Pitt HA, Belghiti J, de Santibanes E, Gadacz TR, Hilvano SC, Kim SW, Liau KH, Fan ST, Belli G, Sachakul V: Need for criteria for the diagnosis and severity assessment of acute cholangitis and cholecystitis: Tokyo Guidelines. J Hepato-Biliary-Pancreat Surg. 2007, 14 (1): 11-14. 10.1007/s00534-006-1151-z.
  22. Yokoe M, Takada T, Strasberg SM, Solomkin JS, Mayumi T, Gomi H, Pitt HA, Garden OJ, Kiriyama S, Hata J, Gabata T, Yoshida M, Miura F, Okamoto K, Tsuyuguchi T, Itoi T, Yamashita Y, Dervenis C, Chan AC, Lau WY, Supe AN, Belli G, Hilvano SC, Liau KH, Kim MH, Kim SW, Ker CG, Tokyo Guidelines Revision Committee: TG13 diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepato-Biliary-Pancreat Sci. 2013, 20 (1): 35-46. 10.1007/s00534-012-0568-9.
  23. National Institute of Health Organization. Gallstones and laparoscopic cholecystectomy, NIH Consensus statement 1992 Sep14-16, Natcher Conference Center, NIH, Bethesda, Maryland: PMC.1992:45-68.
  24. Mc Arthur P, Cushieri A, Selles RA, Shields R. Controlled clinical trial comparing early with interval cholecystectomy for acute cholecystitis. Br J Surg. 1975;62:850–852 
  25. Takada T, Kawarada Y, Nimura Y, Yoshida M, Mayumi T, et al (2007) Tokyo Guidelines for the management of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Surg 14: 1-121.
  26. Lo CM, Liu CL, Fan ST, Lai EC, Wong J (1998) Prospective randomized study of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Ann Surg 1998; 27: 461-467.
  27. Gutt CN, Encke J, Koninger J, Harnoss J-C, Weigand K, Kipfmuller K, et al. Acute cholecystitis: early versus delayed cholecystectomy, a multicenter randomized trial (ACDC study, NCT00447304). Ann Surg. 2013; 258:385–93.
  28. Ansaloni L, Pisano M, Coccolini F, Peitzmann AB, Fingerhut A, Catena F, et al. 2016 WSES guidelines on acute calculous cholecystitis. World J Emerg Surg. 2016; 11:25.
  29. Roulin D, Saadi A, Di Mare L, Demartines N, Halkic N. Early Versus Delayed Cholecystectomy for Acute Cholecystitis, Are the 72 hours Still the Rule? A Randomized Trial Ann Surg. 2016; 264:717–22.
  30. Kolla SB, Aggarwal S, Kumar R, Kumar A, Chumber S, Parshad R. Early versus delayed Laparoscopic cholecystectomy for acute cholecystitis: a prospective randomized trial. Surg Endosc 2004; 18:1323-7.
  31. Lai PB, Kwong KH, Leung KL, Kwok SP, Chan AG, Chung SC. Randomized trial of early versus delayed Laparoscopic Cholecystectomy for acute cholecystitis. Br J Surg.1998; 85:764-7.
  32. Johanson M, Thune A, Lundell L. A prospective randomized trial comparing early versus delayed Laparoscopic Cholecystectomy in the treatment of acute cholecystitis. Gastroenterology 2002; 123-24.
  33. Koo KP, Thirlby RC. Laparoscopic cholecystectomy in acute cholecystitis: Arch Surg. 1996; 131:540-5.
  34. Chandler CF, Lane JS, Ferguson P, Thompson JE, Ashley SW. Prospective evaluation of early versus delayed laparoscopic cholecystectomy for treatment of acute cholecystitis. Am J Surg. 2000; 66: 896-900.
  35. Gurusamy KS, Koti R, Fusai G, Davidson BR: Early versus delayed laparoscopic cholecystectomy for uncomplicated biliary colic. Cochrane Database Syst Rev. 2013, 6: CD007196-
  36. Johner A, Raymakers A, Wiseman SM: Cost utility of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Surg Endosc. 2013, 27 (1): 256-262. 10.1007/s00464-012-2430-1.
  37. Ambe P, Esfahani BJ, Tasci I, Christ H, Köhler L: Is laparoscopic cholecystectomy more challenging in male patients?. Surg Endosc Interv Tech. 2011, 25 (7): 2236-2240. 10.1007/s00464-010-1539-3.
  38. Zhu B, Zhang Z, Wang Y, Gong K, Lu Y, Zhang N: Comparison of laparoscopic cholecystectomy for acute cholecystitis within and beyond 72 h of symptom onset during emergency admissions. World J Surg. 2012, 36 (11): 2654-2658. 10.1007/s00268-012-1709-7.
  39. Lujan JA, Parrilla P, Robles R, et al. Laparoscopic cholecystectomy in the treatment of acute cholecystitis. J Am Coll Surg 1995; 181:75-77. [PubMed ID: 7599776]
  40. Navez B, Mutter D, Russier Y, et al. Safety of laparoscopic approach for acute cholecystitis: Retrospective study of 609 cases. World J Surg 2001;25:1352-1356. [http:// doi.org/10.107/s00268-001-0122-4]
  41. el Madani A, Badawy A, Henry C, et al. Laparoscopic cholecystectomy in acute cholecystitis. Chirurgie 1999; 124:171-175. [PubMed ID: 10349755]
  42. Adamsen S, Hansen OH, Funch-Jensen P, Schulze S, Stage JG, Wara P. Bile duct injury during laparoscopic cholecystectomy: a prospective nationwide series. J Am Coll Surg 1997; 184:571-578. [PubMed ID: 9179112]
  43. Suter M, Meyer A. A 10-year experience with the use of laparoscopic cholecystectomy for acute cholecystitis. Is it safe? Surg Endosc 2001; 15:1187-1192. [http://doi. org/10.1007/s004640090098]