Gallbladder inflammation is referred to as " cholecystitis, Cholecystitis is best treated surgically, Gallstones are present in about 95% of patients with cholecystitis, As the prevalence of age increases development of gallstones increases, and females are more susceptible to gallstones more than males [1] Laparoscopic cholecystectomy is the gold standard treatment of symptomatic gallstone disease. It offers an unquestionable advantage over open cholecystectomy to the patient and the health care system. It was introduced in the late 1980s and quickly gained popularity among patients with symptomatic gallstones. It has a clear advantage over the traditional approach with decreased morbidity, less pain ,and quicker recovery; however, it remains associated with a three- to five-fold increase in bile duct injury (BDI).
Moreover, the traditional absolute contraindications for laparoscopic cholecystectomy in certain specialized situations have largely been resolved and rendered relative, including the presence of acute cholecystitis, a history of previous abdominal surgery, morbid obesity, pregnancy, cirrhosis, and even situs inversus total is, Operative conversion from Laparoscopic cholecystectomy to open cholecystectomy is 1%-15%.
Two previous reviews agreed on only two important risk factors when considering conversion, namely, male gender and old age. Acute cholecystitis, a gallbladder wall thickness > 3 mm, and a history of previous surgeries are all predictive factors for conversion [2]. One of the prevailing complications of LC, which is less addressed in the literature, is gallbladder perforation. The rate of gallbladder perforation differs from 1.3% to 40% (2). Moreover, gallbladder perforation is increasing in frequency because of increased efforts to perform minimally invasive surgery, which has limited the visual field and mobility of the surgical instruments, Gallbladder perforation can lead to gallstone spillage and, in many cases, an unsuccessful retrieval of the stones. Several studies have demonstrated the effect of intraperitoneal contamination on the spillage of bile juice and gallstones. Previously the majority of surgeons believed that gallstone spillage during laparoscopic cholecystectomy is a benign complication and it does not justify conversion to laparotomy, even if a large number of gallstones remain in the abdomen, However ,some reports have demonstrated the complications of gallstone spillage, such as intraperitoneal abscesses, adhesions, small bowel obstruction, cutaneous fistulas ,and septicemia [2]. The leading causes of gallbladder perforation during LCs are injury to the gallbladder during diathermy dissection from the gallbladder fossa, traction injury to Hartmann’s pouch, and extraction from the epigastric port. Gallbladder perforation causes an increase in the time of surgery, prolongation of postoperative hospital stay, and, an increase in the total hospital costs, this leads to a reduction of the advantages of LC compared with classic laparotomy. The average operative time was longer in the perforated group this was likely due to the time needed for abundant irrigation to get a clear aspiration and retrieve the gallstones. The postoperative hospital stay was also prolonged in the perforated group, as a result of increased pain and ileus, with constipation. There are a few studies on the correlation between gallbladder perforation and pain, which may result from irritation of the peritoneum due to the spillage of bile juice and gallstones [3] Statistically significant risk factors that lead to gallbladder perforation are the experience of the surgeon and the difficulty of the surgery (acute cholecystitis ,adhesions and previous surgery , pain before surgery >96 hours, and palpable gallbladder preoperatively. Patient factors include high BMI ,older age ,and systemic disease like DM and male gender . Although recent technical approaches and procedures were applied to dissect the gallbladder free from the liver bed such as ultrasonic dissector, harmonic scalpel diathermy, and laser instead of the standard dissection with monopolar electrocautery, but are not helpful in minimizing the risk of gallbladder perforation during the surgery .
The present study was aimed to investigating the risk factors for accidental intraoperative gallbladder perforation during laparoscopic cholecystectomy and outcome.
It is a prospective comparative observational study designed to assess the risk factors of accidental gall bladder perforation and its outcome during laparoscopic cholecystectomy. The study was conducted at Al-Basrah Teaching Hospital, General Surgery Dept, spanning from January 2022 to September 2025.
A total of 210 participants who underwent elective laparoscopic cholecystectomy by different surgeons were enrolled in this study involving ( 100)participants who experienced accidental gall bladder perforation during the procedure compared with (110) participants who did not experience gall bladder perforation during the procedure.
Inclusion Criteria:
- Individuals aged 18 to 65 years
- Both male and female participants.
- Patients undergoing laparoscopic cholecystectomy for symptomatic gallstone disease.
Exclusion Criteria:
- Patients with a history of biliary tract surgery.
- Patients with severe cardiopulmonary disease or other serious comorbidities.
- Patients who were converted to open cholecystectomy for other causes rather than gall bladder perforation.
- Patients with CBD stone.
- Patients with liver disease
- Patients with Acute pancreatitis .
Ethical approval was obtained from the Institutional Review Board the scientific council of the Iraqi Board of Health Specialization. All patients were fully informed and a written consent was taken. Also, a predesigned proforma which included: age, gender, stage at which gallbladder perforation occurred, operative time post-operative pain, postoperative complications(ileus, port site infection ), and duration of hospital stay was made for all patients. Pre-operative evaluation includes the clinical assessment which focuses on detailed history- taking to understand the symptoms, the presence/absence of previous surgery; the experience of the operator (resident, surgeon), past medical history of Diabetes mellitus, Ischemic heart disease, hypertension, smoking and alcoholics, and allergies. This physical examination focuses on the abdominal region and specifically on the right upper quadrant tenderness, which is typical in gallbladder diseases, laboratory and Imaging Investigations that include: blood tests including (complete blood count, liver function tests, and coagulation profile), and imaging studies to assess the gallbladder and surrounding structures, and lastly the anesthesia assessment which had been evaluated by an anesthesiologist to assess the risk of anesthesia and to plan the anesthetic management.
Meanwhile, the post-operative evaluation included: immediate post-operative assessment (monitoring vital signs, pain, and signs of complications in the recovery room), and follow-up appointments, Port site infection is diagnosed based on clinical findings such as increased redness and pain with pus discharge .review any pathology reports(no malignancy), and monitor for any late complications. If required, conduct investigations such as blood tests or imaging to assess the liver and biliary tract.
The surgical procedures involved pre-operative preparation that focused on fasting for 8 hours. prophylactic antibiotics (ceftriaxone 1g) were administered one hour preoperatively. Classical laparoscopic cholecystectomy with four ports was performed, and in all patients with gallbladder perforation, bile was aspirated and irrigation of the gallbladder bed with sterile saline solution was done, removal of spilled stones, most gallbladders were removed from the epigastric port, with about seventeenth cases of accidentally perforated gallbladder tube drains inserted.
Operative time ( in minutes): mean time starts from skin incision till finishing the skin closure. Postoperative hospital stay: means the number of days spent in the hospital from the day of the operation till the discharge of the patients to their homes .
Ilieus: failure of return of bowel functions after 48 hours after surgery
The surgeons assessed the suitability for discharge, considering the clinical symptoms. And continue to follow up with the patients.
Statistical analysis was performed using Statistical Package for the Social Sciences version 26 (SPSS Inc.). Categorical data were represented in numerical and percentage formats, and the distinctions among the groups were assessed using the chi-square test (X²) and Fisher’s exact test. A 95% confidence interval was used for statistical analysis, and p-values below 0.05 were regarded as statistically significant.
The table compares two groups: patients with accidental intraoperative gallbladder perforation during laparoscopic cholecystectomy and those without gallbladder perforation during laparoscopic cholecystectomy. Significant differences were observed in age (mean
54.86 years in the accidentally perforated gall bladder group vs. 35.94 years in the non- perforated) and gender distribution (32% male in perforated vs 7% in the non-perforated group), with P values less than 0.001 indicating high statistical significance.
*Odd ratio
The table outlines predisposing risk factors for accidental gallbladder perforation during laparoscopic cholecystectomy. Key observations include a higher Body Mass Index (BMI) and increased prevalence of diabetes mellitus in the perforated group. No significant difference was noted in hypertension rates. Higher smoking rates were observed in the accidentally GB perforated group, but without statistical significance, similar to alcohol consumption. A notable correlation exists between prior abdominal surgeries and accidental intraoperative gallbladder perforation during laparoscopic cholecystectomy. Chronic cholecystitis is more common in the non-perforated group, while acute on chronic cases are exclusive to the perforated group, which also sees more frequent drain usage.
The table shows the frequency of accidental intraoperative gallbladder perforations during various surgical steps. The least frequent cause, occurring in only 3% of cases, is during the Callot Triangle dissection. Bile spillage during traction accounts for 8% of perforations. An accidental gall bladder perforation also occurs during gallbladder extraction from the epigastric port, contributing to 14% of cases. Notably, the majority (75%) of perforations occur during separation from the liver bed, highlighting this as the most critical phase for avoiding perforations.
The table compares outcomes of patients with accidental perforated gall bladder versus non-perforated gallbladders during laparoscopic cholecystectomy. Key findings include a 45% occurrence of Ilieus in the perforated group with an Odds Ratio (OR) of 4.896, indicating a higher likelihood of this condition post-perforation. The accidentally perforated gall bladder group during laparoscopic cholecystectomy also experiences longer hospital stays (63%). Port site infections and intra-abdominal abscesses are more common in the perforated group, with ORs of 2.437 and 5.628, respectively. Prolonged operation times are significantly higher in the perforated group, with 83% of cases experiencing extended surgery. All variables show a P value less than 0.001, denoting significant statistical differences between the groups.
* Significant at P value <0.05
This study warranted the importance of understanding the risk factors associated with accidental gallbladder perforation during laparoscopic cholecystectomy. It also aims to investigate and compare the postsurgical outcomes between cases with accidental perforation and those without.
Altuntas et al. stated that demographic factors like age and gender distribution were not significant(37).
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It was also observed that accidental gallbladder perforation during laparoscopic cholecystectomy correlates with an increased likelihood of adverse postoperative outcomes compared to cases without perforation.
We also expected that there is a risk of adhesion and an increased chance of intestinal obstruction in the patients who sustained accidental gall bladder perforation during laparoscopic cholecystectomy.
This study on accidental gall bladder perforation during laparoscopic cholecystectomy, while comprehensive, has inherent limitations. It is a single-center study, which may affect the generalizability of its findings to other settings. Additionally, the follow-up period might not be sufficient to assess long-term postoperative outcomes. There could also be potential biases in participant selection and data interpretation. These factors should be considered when evaluating the study's conclusions and applying them in broader clinical contexts.
This study underscores that accidental intraoperative gall bladder perforation during laparoscopic cholecystectomy prolonged operative time and complicated postoperative outcomes like ileus, more pain and use of analgesia and prolonged hospital stay and predispose for more use of antibiotics duration and increased chance of surgical infection (intra-abdominal infection /abscess and port site infection) and late complication due to increasing risk of adhesion, thereby increase the cost and economical effect. this study also illuminated that male gender, higher BMI, increasing age and specific medical history were the main risk factors for an accidental GB perforation.
1. Enhanced Surgical Precision: Surgeons are strongly advised to exercise heightened diligence during the dissection of the gallbladder. This includes a thorough understanding and proficiency in the anatomical nuances of the biliary tree, including its common variants and potential anomalies.
2. Tissue Integrity and Handling: Paramount importance should be placed on maintaining tissue integrity. This involves meticulous handling and precise dissection techniques to respect the delicate nature of the tissue structures involved. Surgeons should be committed to minimizing tissue trauma to the greatest extent possible.
3. Prevention of Gallbladder Perforation: Utmost efforts should be made to avoid accidental intraoperative gallbladder perforation. In cases where such an event occurs, it is imperative to implement strategies that reduce the risks associated with spilled gallstones and bile.
4. Management of Intraoperative Complications: In the event of accidental intraoperative gallbladder perforation, immediate steps should be taken. These include abundant irrigation of the peritoneal cavity to minimize contamination and stone extraction, Endobag also may be beneficial.
5. Prophylactic Antibiotic Therapy: Additionally, consideration should be given to the administration of extended prophylactic antibiotic therapy. The duration of such therapy may necessitate extension beyond the usual period, particularly in cases of accidental gallbladder perforation.