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Background:
Since the advent of laparoscopic cholescystectomy in 1987, there have not been noteworthy changes in technique for ligation and transection of cystic artery and duct: metal clips and sharp transection. Laparoscopic staplers (LS) have been suggested as a safe alternative in severe inflammation or when the cystic duct appears too wide for complete clip occlusion. We hypothesized an increased rate of adverse postoperative events following use of LS.
Methods:
All patients who underwent laparoscopic cholecystectomy for biliary colic, cholecystitis, pancreatitis or choledocholithiasis at our institution were identified using billing records. Operative notes were reviewed for use of LS. A 2:1 control group was selected using propensity score matching on age, gender and operative diagnosis. Presenting features, operative characteristics and postoperative outcomes were analyzed. Continuous variables were compared using Student's t-test. Categorical variables were compared using chi-square or Fisher's exact test. Prediction models were constructed using logistic regression.
Results:
Between 1997 and 2009 , LS was used in 58 (0.9%) of 6272 patients. These were matched to 116 patients in whom cystic duct was divided between metal clips (MC). Differences in age, gender, race, ASA status, admission diagnosis, as well as in presence of leukocytosis, hyperbilirubinemia, or elevation in pancreatic enzymes were not statistically significant (p>0.05) between LS and MC groups, though LS was used more often in acute compared with elective cases (40% vs. 24%, p=0.05). Compared with MC, average intraoperative blood loss (50 vs 25ml, p<0.001) and postoperative length of stay (2 vs 1 day, p=0.016) were both significantly greater for LS. When intraoperative cholangiography (IOC) was attempted, successful cannulation was achieved in only 2 of 8 (25%) LS cases, versus 28 of 31 (90%) controls (p<0.001) . Patients in the LS group required post-operative ERCP for clinically evident post-operative choledocholithiasis at twice the rate of those in the MC group (p=0.009). Controlling for preoperative and demographic factors, LS remained the only statistically significant predictor of requiring postoperative ERCP (OR=4.0, p=0.03). There were no bile duct injuries.
Conclusions:
Stapling of the cystic duct during laparoscopic cholescystectomy is associated with an increased need for unintended postoperative ERCP. We suspect this is secondary to passage of stone fragments into the common bile duct after crushing by the stapler, or leaving a remnant infundibulum/neck after incomplete dissection and stapling. Prior to using a stapling device, we advocate for more meticulous dissection or conversion to open cholescystectomy in order to complete the operation safely and with minimal postoperative complications.