Original single-incision laparoscopic cholecystectomy for acute inflammation of the gallbladder

Table 1 Tokyo guideline diagnostic criteria and severity assessment of acute cholecystitis

Diagnosis criteria

A: Local signs of inflammation

Murphy’s sign

Rright upper quadrant mass/pain/tenderness

B: Systemic signs of inflammation

Fever

Elevated C-reactive protein

Elevated white blood cell count

C: Imaging findings

Sonographic Murphy sign

Thickened gallbladder wall

Enlarged gallbladder

Pericholecystic fluid collection

Sonolucent layer in the gallbladder wall

Definite diagnosis

One item in A and one in B are positive

C confirms the diagnosis when acute cholecystitis is suspected clinically1

Severity assessment

Mild (grade I)

Acute cholecystitis does not meet the criteria of severe (grade III) or moderate (grade II) acute cholecystitis or acute cholecystitis in a healthy patient with no organ dysfunction and mild inflammatory changes in the gallbladder, making cholecystectomy a safe and low risk operative procedure

Moderate (grade II)

Elevated WBC count (> 18 000/mm3)

Palpable tender mass in the right upper quadrant

Duration of complains > 72 h2

Marked local inflammation (biliary peritonitis, pericholecystic abscess, hepatic abscess, gangrenous cholecystitis, emphysematous cholecystitis)

Severe (grade III)

Acute cholecystitis associated with dysfunction of any one of the following organs/systems

Cardiovascular dysfunction (hypotension requiring treatment with dopamine ≥ 5 μg/kg per minute, or any dose of dobutamine)

Neurological dysfunction (decreased level of consciousness)

Respiratory dysfunction (PaO2/FiO2 ratio < 300)

Renal dysfunction (oliguria, creatinine > 2.0 mg/dL)

Hepatic dysfunction (PT-INR > 1.5)

¹Acute hepatitis, other acute abdominal disease, and chronic cholecystitis should be excluded;

²Laparoscopic surgery should be performed within 96 h of the onset of acute cholecystitis. WBC: White blood cell; PT-INR: Prothrombin time and international normalized ratio.

Table 2 Tokyo guideline diagnosis criteria and severity assessment of acute cholangitis

Diagnosis criteria (suspected diagnosis and definite diagnosis)

Severity assessment

A: Clinical context and clinical manifestations

History of biliary disease

Fever and/or chills

Jaundice

Abdominal pain (right upper quadrant or upper abdominal)

B: Laboratory data

Evidence of inflammatory response1

Abnormal liver function tests2

C: Imaging findings

Biliary dilation, or evidence of etiology (stricture, stone, stent, etc.)

Two or more items in A

Charcot’s triad (2 + 3 + 4)

Two or more items in A + both items in B + C

Severity assessment

Mild (grade I)

Acute cholangitis that responds to initial medical treatment3

Moderate (grade II)

Acute cholangitis that does not respond to initial medical treatmentc and is not accompanied by organ dysfunction

Severe (grade III)

Acute cholangitis that is associated with the onset of dysfunction at least in any one of the following organs/systems

Cardiovascular system; hypotension requiring dopamine ≥ 5 μg/kg per minute, or any dose of dobutamine

Nervous system: disturbance of consciousness

Respiratory system: PaO2/FiO2 ratio < 300

Kidney: serum creatinine > 2.0 mg/dL

Liver: PT-INR > 1.5

Hematological system: platelet count < 100 000/μL

Compromised patients, for example, elderly (> 75 years old) and patients with comorbidity, should be monitored closely.

¹Abnormal white blood cell count, increased serum C-reactive protein level, and other changes including inflammation;

²increased serum alkaline phosphatase, γ-glutamyltransferase, aspartate aminotransferase and alanine aminotransferase levels;

³general supportive care and antibiotics. PT-INR: Prothrombin time and international normalized ratio.

Table 3 Comparison of patients’ demographics and operative outcome between dingle-incision laparoscopic cholecystectomy for acute inflamed gallbladder and single-incision laparoscopic cholecystectomy for non-acute inflamed gallbladder

Patient demographics	SILC for AIG	SILC for non-AIG	P value
n	26	84
Age (yr) median (range)	61.5 (22-81)	56.5 (31-81)	0.06
Sex (male/female)	12/14	42/42	0.82
BMI median (range)	22.0 (18.4-29.4)	22.2 (16.0-30.0)	0.85
ASA score I/II/III	14/11/1	65/19/0	0.02
Previous upper abdominal surgery (yes/no)	2/24	4/80	0.63
Indication for operation	Acute cholecystitis 15	Symptomatic gallstone 65
	Acute gallstone cholangitis 11	Choledochlithiasis 2
		No inflammation 17
Operative outcome
Operative time (min)			0.03
Median (range)	97.5 (60-163)	85 (45-195)
mean (SD)	105.7 (31.9)	91.0 (29.3)
Intra-abdominal adhesion none to mild/moderate/severe	8/15/3	52/27/15	0.02
Gallbladder wall thickening	16/2/8	66/14/4	< 0.01
none to mild/moderate/severe
IOC completion1	23/24	81/82	0.4
Conversion to open cholecystectomy	2	2	0.24
Bile spillage	9	15	0.1
Use of additional port site	5	3	0.01
Complication (total)	1	3	1.00
Wound infection	1	2
Bile duct injury	0	1

¹Excluded open converted cases. BMI: Body mass index; ASA: American Society of Anesthesiologists; SILC: Single-incision laparoscopic cholecystectomy; AIG: Acute inflamed gallbladder; IOC: Intraoperative cholangiography.

Table 4 Comparison of patient demographics and operative outcome between single-incision laparoscopic cholecystectomy for acute inflamed gallbladder and traditional laparoscopic cholecystectomy for acute inflamed gallbladder

	SILC for AIG	TLC for AIG	P value
Patient demographics
n	26	54
Age (yr) median (range)	61.5 (22-81)	61 (25-89)	0.94
Sex (male/female)	14/12	34/20	0.47
BMI median (range)	22.0 (18.4-29.4)	22.8 (15.4-32.0)	0.53
ASA score I/II/III	14/11/1	25/25/4	0.73
Previous upper abdominal surgery (yes/no)	2/24	5/49	0.59
Indication for operation	Acute cholecystitis 14	Acute cholecystitis 29	0.81
	Acute gallstone cholangitis 11	Acute gallstone cholangitis 25
Max WBC count in acute phase			0.78
WBC > 14 000	5	13
WBC < 14 000	21	41
Max CRP in acute phase			0.44
CRP > 10	6	18
CRP < 10	20	36
Severity assessment by Tokyo Guidelines Grade I/II/III	19/5/2	38/13/3	0.85
Day from onset to operation	19 (6-111)	20 (8-104)	0.82
Clinical result
Operative time (min)			0.12
Median (range)	97.5 (60-163)	87.5 (35-245)
mean (SD)	105.7 (31.9)	94.7 (34.4)
Surgeon	26/0	16/39
Staff surgeon/surgical resident
IOC completion1	23/24	42/49	0.26
Conversion to open cholecystectomy	2	5	1
Bile spillage	9	14	0.44
Complication	1	7	0.26

¹Excluded open converted cases. ASA: American Society of Anesthesiologists; BMI: Body mass index; WBC: White blood cell; CRP: C-reactive protein; IOC: Intraoperative cholangiography; SILC: Single-incision laparoscopic cholecystectomy; TLC: Traditional laparoscopic cholecystectomy; AIG: Acute inflamed gallbladder.