|ORIGINAL RESEARCH REPORT
|Year : 2020 | Volume
| Issue : 1 | Page : 1-4
Experience with laparoscopic cholecystectomy in a tertiary hospital in Lagos, Nigeria
Thomas Olagboyega Olajide1, Adedapo Olumide Osinowo1, Olanrewaju Samuel Balogun1, Michael Olatunji Afolayan2, Christopher O Bode3, Oluwole Ayoola Atoyebi1
1 Department of Surgery, General Surgery Unit, College of Medicine, University of Lagos, Lagos University Teaching Hospital, Lagos, Nigeria
2 Department of Surgery, General Surgery Unit, College of Medicine, University of Lagos, Lagos, Nigeria
3 Department of Surgery, Paediatric Surgery Unit, College of Medicine, University of Lagos, Lagos University Teaching Hospital, Lagos, Nigeria
|Date of Web Publication||4-Feb-2020|
Dr. Thomas Olagboyega Olajide
Department of Surgery, General Surgery Unit, College of Medicine, University of Lagos, Lagos University Teaching Hospital, Lagos
Source of Support: None, Conflict of Interest: None
Background: Laparoscopic cholecystectomy has practically become the current gold standard for the removal of symptomatic gallbladders with clear advantages. Its development has been slow in Sub-Saharan Africa. We reviewed our experience of this procedure at a tertiary facility in the subregion. Patients and Methods: All patients who underwent laparoscopic cholecystectomy from October 2014 to April 2018, at Lagos University Teaching Hospital, Nigeria, were retrospectively analyzed. The focus of the study was on patients' demographics, duration of symptoms, indications for surgery, procedure performed, duration of surgery, length of hospital stay, and morbidityand mortality data. Results: A total of 33 laparoscopic cholecystectomies were performed. There were 27 (84.4%) females and 5(15.6%) males giving a male-to-female ratio of 5.4:1. The age range was from 9 to 78 years with a mean of 40.6 ± 2.9. The peak age of presentation was in the fourth decade. The most common indication was biliary colic. There was an instance of open re-exploration for a duodenal injury. There was no biliary injury during the procedures and no indication for common bile duct exploration. Most (18, 56.3%) of the patients were discharged within 24 h, 10 (30.3%) within 48 h, and the rest were discharged later. The relationship between the duration of hospital stay and the mean duration of surgery was significant (P = 0.014). There was no long-term morbidity or mortality. Conclusion: Laparoscopic cholecystectomy in our environment is safe and feasible with results comparable to other centers.
Keywords: Cholecystectomy, experience, laparoscopy
|How to cite this article:|
Olajide TO, Osinowo AO, Balogun OS, Afolayan MO, Bode CO, Atoyebi OA. Experience with laparoscopic cholecystectomy in a tertiary hospital in Lagos, Nigeria. J Clin Sci 2020;17:1-4
|How to cite this URL:|
Olajide TO, Osinowo AO, Balogun OS, Afolayan MO, Bode CO, Atoyebi OA. Experience with laparoscopic cholecystectomy in a tertiary hospital in Lagos, Nigeria. J Clin Sci [serial online] 2020 [cited 2020 Jul 9];17:1-4. Available from: http://www.jcsjournal.org/text.asp?2020/17/1/1/277750
| Introduction|| |
The surgical procedure for the removal of the gallbladder has been greatly influenced by the advent of laparoscopy. Laparoscopic cholecystectomy has practically become the current gold standard for the removal of symptomatic gallbladders worldwide, rapidly gaining almost universal acceptance as it offers a safe and effective treatment for the majority of patients with symptomatic gallstones.,, The advantages are clear and well established and these include much shorter hospital stay, decreased postoperative pain, reduced requirement for postoperative analgesia, better cosmesis, and early return to full activity.
Laparoscopic surgery development has been slow in sub-Saharan Africa due to many challenges such as resource paucity, limited workforce, and little experience.,,, In Nigeria, laparoscopic surgery is developing and is now done routinely in a few public and private centers. However, most centers still offer open cholecystectomy.,,,
We present our experience at Lagos University Teaching Hospital, a tertiary health facility in Lagos, Nigeria, with a population of over 13 million.
| Patients and Methods|| |
All patients who underwent laparoscopic cholecystectomy, using four ports and Karl Storz laparoscopy tower, from October 2014 to April 2018, in the General Surgery Unit of Lagos University Teaching Hospital, Nigeria, were retrospectively analyzed. The study was approved by the Health Research and Ethics Committee of the Hospital. Data were retrieved from the medical records department as well as the surgical theater procedure register. The focus of the study was on patient demographics, duration of symptoms, indications for surgery, procedure performed, duration of surgery, length of hospital stay, and morbidity and mortality data.
The data were directly inputted into SPSS version 20.0 (Armonk, NY, USA: IBM Corp.), which was used for the statistical analysis. Continuous data are presented as the mean ± standard error of mean or median, whereas categorical data are presented as absolute or relative frequencies. The data are also presented as tables and graphs. In univariate analyses, the Mann–Whitney U-test was used to compare continuous variables, whereas Fisher's exact test or the Chi-square test was used to assess categorical variables. Two-tailed P ≤ 0.05 was considered statistically significant.
| Results|| |
Laparoscopic cholecystectomy commenced at our center on October 15, 2014 and was performed by a faculty from another tertiary center in Southwest Nigeria. The second one was by a Nigerian surgeon in diaspora. All subsequent surgeries were performed by members of our unit except in one instance, during a workshop when a surgeon that was in diaspora was invited to perform the surgery. During the study period, a total of 33 laparoscopic cholecystectomies were performed; data for 32 patients were analyzed as available data for one of the patients were incomplete. There were 27 (84.4%) females and 5 (15.6%) males giving a male-to-female ratio of 5.4:1. The age range was from 9 to 78 years with a mean of 40.6 ± 2.9 years. The peak age of presentation was in the fourth decade. [Figure 1] shows the age distribution of the patients.
The most common indication for laparoscopic cholecystectomy was biliary colic (symptomatic cholelithiasis) with sonographically demonstrable stones in 65.6% of patients. Other indications were calculous cholecystitis in 21.9% of patients and symptomatic cholelithiasis with a history of jaundice from suspected choledocholithiasis in 9.4% of patients; however, magnetic resonance cholangiopancreatography did not reveal bile duct stones in those suspected to have choledocholithiasis and mucocele of the gall bladder in 3%. Four patients (one-eight) also had sickle cell disease. The duration of symptoms ranges from 5 days to 5 years and was not related to duration of surgery, hospital stay, or outcome.
Although a single obese patient who became physiologically unstable during the procedure had open re-operation about 48 h after the primary procedure, there was no other instance of conversion to open surgery. She developed hypotension during the procedure, and thus the procedure was hastened. She had laparotomy and repair of duodenal injury, which manifested in the postoperative period. There was no biliary injury during the procedures and no indication for common bile duct exploration. Most of the patients, 18 (56.3%), were discharged within 24 h with one done as day case, 10 (30.3%) within 48 h, and the rest were discharged later. The one done as day case was toward the end of the study period when our experience was improving. The longest duration of hospital stay was 14 days in the patient that was re-operated, but this was an outlier and also captured in the analysis of those who stayed for more than 24 h.
Patients were thus categorized into two groups: those who spent 24 h or less on admission postoperatively and those who spent more than 24 h. The mean duration of surgery for the first group (24 h or less on admission) was 179 min in contrast to a mean duration of 274 min for the second group. Independent t-test comparing the mean of the two groups was significant (t = −2.715, df = 18.729, and P = 0.014) [Table 1]. We, thus, explored to find out the main factor for this difference.
The patients were also categorized into two groups of those operated during the earlier period of the study and those operated later. The mean duration of surgery for procedures performed in the latter half of the study revealed an approximately 20 min reduction.
The relationship between the duration of surgery and the duration of symptoms, when this bivariate analysis was done between these variables, was statistically significant (P = 0.006). Two patients (6.3%) had umbilical port site infection, which were treated by cleaning and dressings [Table 2].
There was no other complication. There was no statistically significant correlation between obesity and complications [Table 3]. Ninety-two percent of the histology that was retrieved revealed cholelithiasis with chronic cholecystitis. One revealed chronic cholecystitis with no stones. Follow-up of the patients, till date, has not identified any morbidity, and there was no mortality.
| Discussion|| |
The most common indication for laparoscopic cholecystectomy in our study was calculous cholecystitis, similar to the findings in other studies, locally and globally.,,,
The number of cases in our study was low comparable to findings in other centers in Nigeria.,, However, this is in contrast to findings in Europe, North and South America, and parts of Asia.,,, This may be due to the difference in diet and easier access to health care in advanced economies.
A significant female preponderance (5.4:1) was observed comparable to the findings encountered in a series in Nigeria, West Africa, and worldwide.,,,, This is due to the higher occurrence of gall bladder diseases in females. The age distribution was similar to those in other studies carried out in Nigeria and elsewhere with most patients presenting in the third to fifth decade with a mean age of 40.6 ± 2.9 years and a median of 36 years.,,,
In spite of the widespread practice of routine ultrasonography in identifying asymptomatic gall stones in sickle cell patients, 12.5% of our patients had sickle cell disease and were already symptomatic before presentation. This is contrary to the general consensus that this group should have elective procedure regardless of the absence of symptoms as they are at a greater risk for the development of complications.,
The mean duration of surgery was reduced in the second half of the study, most probably due to improving proficiency of the surgeons. It has been shown that as the laparoscopic teams become more experienced and proficient, the mean duration of surgery reduces., This should lead to the reduction in length of hospital stay and improved overall outcome.
The port site infection rate of 6.3% may be explained by spillage of bile during extraction of the gall bladder when not using retrieval bags, as this was not readily available due to its high cost.
A limitation of this study is the relatively small number of patients. However, gallstone disease in our subregion is uncommon, in contrast to the Western Hemisphere and Asia.,,,
Despite various challenges such as the low volume of patients and limited facilities such as intraoperative imaging, and other support, our outcome was comparable to those from developed economies.
| Conclusion|| |
Laparoscopic cholecystectomy in our environment is safe and feasible, despite several challenges. Our results were comparable to those from other centers. Collaboration among surgeons will increase the spread and acceptability of laparoscopic cholecystectomy as the gold standard procedure in our subregion.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Grass F, Cachemaille M, Blanc C, Fournier N, Halkic N, Demartines N, et al
. Is standardized care feasible in the emergency setting? A case matched analysis of patients undergoing laparoscopic cholecystectomy. BMC Surg 2016;16:78.
Baron TH, Grimm IS, Swanstrom LL. Interventional approaches to gallbladder disease. N Engl J Med 2015;373:357-65.
Misauno M. Pilot experience with laparoscopic cholecystectomy in Jos, Nigeria: Challenges and prospects. J West Afr Coll Surg 2011;1:37-43.
Rafiq MS, Khan MM. Scar pain, cosmesis and patient satisfaction in laparoscopic and open cholecystectomy. J Coll Physicians Surg Pak 2016;26:216-9.
Gyedu A, Bingener J, Dally C, Oppong J, Price R, Reid-Lombardo K. Starting a laparoscopic surgery programme in the second largest teaching hospital in Ghana. East Afr Med J 2014;91:133-7.
Baraza R. Laparoscopic cholecystectomy at the Nairobi hospital: A personal experience with 42 cases. East Afr Med J 2005;82:473-6.
Clegg-Lamptey JN, Amponsah G. Laparoscopic cholecystectomy at the Korle Bu teaching hospital, Accra, Ghana: An initial report. West Afr J Med 2010;29:113-6.
Ekwunife CN, Nwobe O. First 100 laparoscopic surgeries in a predominantly rural Nigerian population: A template for future growth. World J Surg 2014;38:2813-7.
Afuwape OO, Akute OO, Adebanjo AT. Preliminary experience with laparoscopic cholecystectomy in a Nigerian teaching hospital. West Afr J Med 2012;31:120-3.
Adisa AO, Lawal OO, Arowolo OA, Akinola DO. Laparoscopic cholecystectomy in Ile-Ife, Nigeria. Afr J Med Med Sci 2011;40:221-4.
United Nations Department of Economic and Social Affairs, Population Division. The World's Cities in 2018-Data. Booklet (ST/ESA/SER.A/417); 2018. Available from: http://www.unpopulation.org
. [Last accessed on 2019 Nov 22].
Ayandipo O, Afuwape O, Olonisakin R. Laparoscopic cholecystectomy in Ibadan, Southwest Nigeria. J West Afr Coll Surg 2013;3:15-26.
CholeS Study Group, West Midlands Research Collaborative. Population-based cohort study of outcomes following cholecystectomy for benign gallbladder diseases. Br J Surg 2016;103:1704-15.
Teixeira UF, Goldoni MB, Machry MC, Ceccon PN, Fontes PR, Waechter FL. Ambulatory laparoscopic cholecystectomy is safe and cost-effective: A Brazilian single center experience. Arq Gastroenterol 2016;53:103-7.
Reynolds I, Bolger J, Al-Hilli Z, Hill AD. Breaking barriers to successful implementation of day case laparoscopic cholecystectomy. Ir Med J 2015;108:202-4.
Rosenmüller M, Haapamäki MM, Nordin P, Stenlund H, Nilsson E. Cholecystectomy in Sweden 2000-2003: A nationwide study on procedures, patient characteristics, and mortality. BMC Gastroenterol 2007;7:35.
Chang SK, Tan SS, Kok YO. Early experience in single-site laparoscopic cholecystectomy. Singapore Med J 2012;53:377-80.
Ekwunife CN, Njike CI. Intent at day case laparoscopic cholecystectomy in Owerri, Nigeria: Initial experiences. Niger J Surg 2013;19:16-9.
] [Full text]
Suell MN, Horton TM, Dishop MK, Mahoney DH, Olutoye OO, Mueller BU. Outcomes for children with gallbladder abnormalities and sickle cell disease. J Pediatr 2004;145:617-21.
Gurusamy K, Junnarkar S, Farouk M, Davidson BR. Meta-analysis of randomized controlled trials on the safety and effectiveness of day-case laparoscopic cholecystectomy. Br J Surg 2008;95:161-8.
[Table 1], [Table 2], [Table 3]