Laparoscopic cholecystectomy after pancreatic debridement A. Vezakis, S. P. L. Dexter, I. G. Martin, M. Larvin, M. J. McMahon Leeds Institute for Minimally Invasive Therapy, The Centre for Digestive Diseases, The General Infirmary at Leeds and the Division of Surgery, Great George Street, Leeds LS1 3EX, England Received: 20 August 1997/Accepted: 12 November 1997 Abstract Background: Pacreatic debridement is a lifesaving opera- tion in patients with severe acute pancreatitis and pancreatic or peripancreatic necrosis. Even in the presence of gall- stones, cholecystectomy may be avoided during the proce- dure, but definitive treatment of the stones is needed at a later stage. Methods: Five patients (median age 58 years) underwent laparoscopic cholecystectomy, at a median time interval of 15 months, after pancreatic debridement via a dome-shaped upper abdominal incision for severe acute pancreatitis. The use of alternative methods for primary access, additional cannulae to enable division of adhesions, the harmonic scal- pel, and the fundus first technique made the laparoscopic approach possible and safe. Results: The median operating time was 130 min. Four patients were discharged home the first or second postop- erative day. One patient required a ‘‘mini-laparotomy’’ for drainage of a periumbilical hematoma and was discharged on the 13th day. Conclusions: Laparoscopic cholecystectomy can be consid- ered an effective and safe approach for the treatment of gallstones in patients who have undergone pancreatic de- bridement. Key words: Severe pancreatitis — Debridement — Lapa- roscopic cholecystectomy Pancreatic necrosis develops in approximately 20% of pa- tients with acute pancreatitis. Conservative treatment for sterile pancreatic necrosis carries a mortality of 10–15%, and infected necrosis is usually always fatal without surgi- cal drainage [3, 5]. Pancreatic debridement is a lifesaving operation in these cases. In patients with gallstones, chole- cystectomy is often deferred until a later date because it can be a difficult procedure to carry out at the time of debride- ment. The formation of dense adhesions in the upper abdo- men occurs as a result of the severe peripancreatic inflam- mation and the surgical intervention, and may complicate the subsequent cholecystectomy. In this report we present our experience of laparoscopic cholecystectomy in five patients who had previously under- gone pancreatic debridement for severe acute pancreatitis. Materials and methods Between May 1991 and October 1996, five patients with a median age of 58 years (range, 35–63), who had previously undergone pancreatic de- bridement, underwent laparoscopic cholecystectomy. The median interval between initial debridement and cholecystectomy was 15 months (range, 8–44). The details of the patients are shown in Table 1. Insufflation was achieved by use of a Veress needle in four patients and by open primary cannulation in one. After primary cannulation at 15 mm Hg, intraperitoneal pressure was reduced to 12 mm Hg. An additional 5-mm port was used in three patients to facilitate the division of adhesions. Adhesions were divided either with diathermy scissors or the harmonic scalpel shears (Ultracision, Ethicon). An intraoperative cholangiogram was performed in four of the patients. In two patients, fundus first dissection of the gallbladder was used. Results The median duration of surgery was 130 min (range, 80– 300). Median hospital stay was 1 day (range, 1–13). There Presented at the 5th International Congress of the European Association for Endoscopic Surgery (E.A.E.S.), Istanbul, Turkey, 17–21 June 1997 Correspondence to: A. Vezakis Table 1. Patients details Sex Age ASA score Months after pancreatic debridement Patient 1 m 58 2 32 Patient 2 m 59 2 44 Patient 3 m 56 1 9 Patient 4 f 63 2 15 Patient 5 m 35 1 8 Surg Endosc (1998) 12: 865–866 © Springer-Verlag New York Inc. 1998