OMENTUM PIECE FOR PREVENTION OF BILE LEAKAGE AFTER SUBTOTAL CHOLECYSTECTOMY

Abstract

Introduction: Acute cholecystitis is an acute inflammatory condition of the gallbladder of which 95% of cases of acute cholecystitis are due to an obstructing calculus in the gallbladder neck or cystic duct. Acute cholecystitis and difficult gall bladder have severe inflammation and anatomical deformities i.e. empyema, Mirizzi syndrome and sometimes gangrene. In recent years, there is an increasing trend towards subtotal cholecystectomy and general acceptance is higher due to higher incidence of complications in difficult gall bladder. Although, the results of subtotal cholecystectomy are satisfactory but the post-operative bile leak is a problem of great concern. There are many techniques that have been adopted, but bile leakage compared to closing of cystic duct directly is very high in subtotal cholecystectomy. 

Material and Methods:   The Omentum Plugging Technique (OPT) and Primary Closure Technique (PCT) was done to prevent bile leak in cases were total cholecystectomy could not be performed. Patients were included in the study with the diagnosis of cholelithiasis and patients who had undergone subtotal cholecystectomy for gallstone diseases with both OPT and PCT Technique. Under general anaesthesia patients were operated. Patients were first decompressed at the fundus with the suction and harmonic scalpel or l-hook was used for transection of gall bladder and wash was given and both the anterior and posterior walls were excised leaving an anterior and posterior wall intact and OPT, a piece of omentum that matches the size of the opening of the gallbladder stump is resected from the greater omentum and plugged into the gallbladder stump.

Results: A total of 486 patients were operated, of which 36 patients (7.4%) underwent subtotal cholecystectomy because it was not possible to close their cystic ducts because they had difficult gallbladders, of which 18 patients in taken in OPT and 18 patients taken in PCT group. Average age in OPT group was 49.48 ± 9.59 years while in PCT group was 54.47 ± 16.21. In OPT group there were 10 (62.5%) male and 6 (37.5%) female, in PCT group 11 (68.75%) male and 5 (31.25%) female were observed. History of CBD Stone was recorded in 3 (18.75%) and 2 (12.50%) patients in OPT and PCT group respectively. No History of Abdominal Surgery was noted in both the group. Intra-operative Haemorrhage in OPT Group was 118 (16-359) ml while in PCT group was 164 (10-578) ml. Duration of Operation Time OPT Group was 156 ± 15.77 ml while in PCT group it was 105 ± 17.35 minutes. Total post-operative complications and post-operative bile leakage were seen in 2 patients in OPT group while in PCT group it was seen in 10 patients. (P= 0.0040). Post-operative intervention was done on one patient in OPT group and on 9 patients in PCT group. Mean Duration of drain was 3.5 ± 1.24 days in OPT group and 8.59 ± 2.46 days in PCT group (P< 0.0001). Post-operative hospital stay was 8.84 ± 2.14days in OPT group and 13.45 ± 2.11days (P< 0.0001). Conclusion: In a difficult gall bladder SC is required during cholecystectomy and for prevention of postoperative bile leakage OPT technique can be safe and more feasible alternative than conventional procedures.

Keywords: Subtotal cholecystectomy (SC), Omentum Plugging Technique (OPT), Primary Closure Technique (PCT), gall bladder.