The risk of gallbladder perforation at laparoscopic cholecystectomy

The best policy to prevent the potential hazard of bile and stones spilled at laparoscopic cholecystectomy (LC) is to avoid inadvertent gallbladder (GB) perforations. No study so far has investigated the mechanisms of GB rupture and its predictive risk factors. To address these issues and help define the best strategies to reduce undesirable long-term sequelae, we did a retrospective review of the first 350 consecutive LC performed by a single surgeon at our institution.

The clinical and surgical records of our first 350 consecutive LC were reviewed. The significant variables identified on univariate analysis were eventually validated through Spearman's correlation for ordered data and finally correlated to the risk of GB perforation by means of a casewise deletion multiple regression. The equation of the linear regression thus obtained was used to predict the probability of GB perforation by number of risk factors.

Three risk factors predictive of GB perforation were identified: chronic cholecystitis with thickened walls >7 mm on preoperative ultrasound (US), GB hydrops (GB > 8 x 4 x 4 cm on US), and previous laparotomies. The incidence of GB perforation rose from a low of 3.5% in the absence of any risk factor to a high of 25% for patients with all three of the independent variables. GB hydrops yielded the highest diagnostic accuracy and probability of perforation (OR = 4.9).

Inflammation and a positive history of previous laparotomies play a crucial role in GB perforation at LC. Hydropic GB was the most accurate predictor of rupture. A prospective trial is needed to confirm the data.