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BACKGROUND: This study addresses the impact of laparoscopic cholecystectomy prior to kidney or pancreas transplant. PATIENTS AND METHODS: Between January 1991 and July 1993, 551 patients were listed for transplant. Gallbladder ultrasound became part of the standard evaluation for all transplant candidates in October 1991. Pretransplant laparoscopic cholecystectomy was recommended for all patients found to have gallstones. To assess the benefit of this policy, patients transplanted prior to routine ultrasound (Group I; n = 88) were compared to those listed or transplanted after routine ultrasound (Group II; n = 406). RESULTS: In Group I, 18% developed gallstone complications requiring surgery. Surgical morbidity occurred in 14% and mortality in 7% of these operations. Graft loss occurred in 20% having biliary complications versus 7% among other recipients. In Group II, gallstones were detected in 10%, and 9% subsequently had laparoscopic cholecystectomy with no morbidity or mortality. CONCLUSIONS: Transplant recipients with unsuspected gallstones were found to have a high incidence of acute biliary complications. Urgent biliary surgery carried significant morbidity and mortality in these immunosuppressed patients and appeared to increase the risk of graft failure as well. A policy of screening gallbladder ultrasound and pretransplant laparoscopic cholecystectomy seems to reduce these concerns and is recommended for all transplant candidates.

The role of laparoscopic surgery in patients presenting with acute cholecystitis remains controversial. From September 1989 through August 1992, a total of 720 patients underwent cholecystectomy. Ninety-six were unplanned admissions with a clinical diagnosis of acute cholecystitis. Laparoscopic surgery was attempted in 83 patients. Thirteen individuals were not offered laparoscopy because of the surgeon's inexperience. Twenty-two (27%) patients required the laparoscopic procedure converted to an open laparotomy. The mean postoperative hospital stay for patients undergoing laparoscopic cholecystectomy was 3.3 days versus 6.8 days for the laparotomy group. There was no mortality and no bile duct or major vascular injuries in either group. The overall operative morbidity rate was 16.9%. Laparoscopic cholecystectomy appears to be a safe and beneficial option in selected patients with acute cholecystitis. A low threshold for conversion to laparotomy appeared to be an important factor in maintaining a low incidence of operative complications. Several modifications to the technique of laparoscopic cholecystectomy have evolved over the 3-year study period and are described.

Laparoscopic cholecystectomy, or removal of the gallbladder, is a minimally invasive procedure carried out through several small abdominal incisions. A laparoscope (illuminated optical instrument) and several surgical instruments, are inserted through these incisions. Under laparoscopic visualization, the gallbladder is manipulated and finally removed. Initial favorable responses to this procedure have been tempered by concern over the incidence of major complications. Previous reports evaluating the safety of this procedure have been based on studies of relatively small numbers of patients. A report is presented of 375 consecutive patients who underwent laparoscopic cholecystectomy from September 1989 to January 1991 at one medical center. Ninety-one percent of these patients were admitted for elective procedures. Twenty procedures were converted to open gallbladder surgery, performed through an upper abdominal incision; 95 percent of the laparoscopic procedures were successful. Most patients (90 percent) left the hospital within 24 hours of surgery. A total of 141 patients underwent cholangiography (a radiographic study that outlines the major bile ducts) during the laparoscopic cholecystectomy. Five of these patients were found to have stones in the common bile duct; in four patients they were removed endoscopically and in one by common duct exploration. Of the 214 patients who did not undergo cholangiography, two patients (0.9 percent) were found to have retained stones. Three patients (0.8 percent) required a second operation because of complications. The overall complication rate was 3.5 percent. The rate of major complications was 0.6 percent (common liver duct injury and delayed cystic duct leak). One patient died (0.3 percent) as the result of a heart attack three days after the procedure. It appears that laparoscopic cholecystectomy has significant advantages over traditional abdominal gallbladder surgery. The results of this study indicate that the laparoscopic procedure can be performed with complication and death rates similar to the more invasive operation. Detailed illustrations are presented. (Consumer Summary produced by Reliance Medical Information, Inc.)