Laparoscopic cholecystectomy for acute cholecystitis and the consequences of gallbladder perforation, bile spillage, and "loss" of stones.

Objective: To study the factors associated with accidental perforation of the gallbladder and spillage of bile and stones and to assess the consequences of these mishaps. Design: Prospective study with retrospective bacteriological evaluation. Setting: Teaching hospital, Israel. Subjects: 189 Patients who were treated for clinical acute cholecystitis between January 1994 and August 1996. Interventions: Emergency laparoscopic cholecystectomy. Main outcome measures. Incidence of accidental perforation of gallbladder and spillage of bile and stones and of conversion and complications in relation to preoperative and operative findings. Results: Bile was spilt in 65 (34%) and gall-stones were "lost" in 27 (14%), 44 (23%) required conversion to an open approach and 36 (19%) developed complications. Preoperative duration of symptoms >96 hours and a palpable gallbladder were associated with accidental perforation of the gallbladder and spillage of bile. A palpable gallbladder, gangrenous cholecystitis, and WBC > 15 x 10(9)/L were associated with stones "lost" in the peritoneum. A history of biliary disease was inversely related to "lost" stones. Conversion of laparoscopic to open cholecystectomy was associated with male sex, age >60 years, a nonpalpable gallbladder, WBC > 15 x 109/L, and a gangrenous gallbladder. Complications of surgery were more common among men and associated with fever of >38 degrees C. Neither the conversion nor the complications were associated with perforation of the gallbladder or "lost" stones. Conclusion: Perforation of the gallbladder and intraperitoneal spillage of bile or stones during laparoscopic cholecystectomy for acute cholecystitis are not associated with undesirable events, are not indications for conversion, and are not associated with further complications. When patients are given appropriate antibiotics perioperatively and the spilt bile is properly aspirated and the peritoneum irrigated, the operative and postoperative courses are similar to those of patients with unperforated gallbladder.