**5. Patients with renal diseases**

Management of gallstones in renal transplant patients was always questioned because of the related complications. It has been found out that patients with renal disease have a higher incidence of coronary artery disease (CAD) and peripheral vascular disease (PVD) compared to the general population because they have the traditional risk factors for CAD such as advanced age, diabetes, hypertension and lipid disorders as well as a high prevalence of such as hyperhomocysteinemia, abnormal calcium phosphate metabolism, anemia, increased oxidative stress and uremic toxins.[27]

### **5.1 Cases**

30 Updated Topics in Minimally Invasive Abdominal Surgery

Among the genetic disorders, sickle cell disease is the most common around the world. People who are affected are at an increased risk of developing pigmented gallstones [10] and it is said that this risk increases with age. Perioperative and postoperative complications which are mainly vaso-occlusive crises (VOC) may occur as a result of surgeries for symptomatic stones. Minimal risks have been associated with the introduction laparoscopic

It is believed that minimally invasive therapy can reduce morbidity and mortality in sickle cell disease patients. The safety of laparoscopic cholecystectomy in such patients has already been recognized. Rachid et al [10] reported the results of their experience on laparoscopic cholecystectomy in sickle cell disease patients in Niger, which is included in the sickle cell belt. Their study covered 45 months and included 47 patients operated by the same surgeon. The average age was 22.4 years (range: 11 to 46 years) and eleven (23.4%) of them were aged less than 15 years. The types of sickle cell disease found were 37 SS, 2 SC, 1 S betathalassemia and 7 AS. The indications for their surgeries were biliary colic in 29 cases (61.7%) and acute cholecystitis in 18 cases (38.3%). Their mean operative time was 64 minutes. Reports from the authors states that there were conversions to open cholecystectomy in 2 cases (4.2 %) for non recognition of Calot's triangle structures. They reported four cases of postoperative complications of vaso-occlusive crisis and one case of acute chest syndrome. Their mean postoperative hospital stay was 3.5days (range: 1 to 9 days). There was no mortality encountered. The authors concluded that laparoscopic cholecystectomy is a safe procedure in sickle cell patients and that it should be a multidisciplinary approach and involve the haematologist, anaesthesiologist and a surgeon.

Haberkem et al [12] studied a group of 364 patients who underwent cholecystectomy. There were ninety-eight percent of their patients who had symptomatic cholelithiasis. Their total perioperative morbidity was 39% and they reported that while total morbidity is not affected by preoperative transfusion, the incidence of specific sickle cell events is higher in those patients who were not transfused preoperatively than in those who were. Laparoscopic cholecystectomy was accompanied by shorter hospitalization time (6.4 days)

cholecystectomy because of its advantages over the traditional open surgeries.

**4. Patients with sickle cell diseases** 

**4.1 Cases** 

Ekici et al [25] conducted a study where they assessed laparoscopic cholecystectomy (LC) in patients with end-stage renal disease treated with continuous ambulatory peritoneal dialysis. There were eleven patients receiving peritoneal dialysis treatment and 33 patients without end-stage renal disease who had undergone an elective LC were compared. They reviewed all their medical records and the laboratory values as well as the outcomes and results. Their peritoneal dialysis group showed a higher frequency of associated disease and previous abdominal surgery, a lower hemoglobin and platelet count and elevated alkaline phosphatase, blood urea nitrogen and creatinine values. There was one procedure in each group that was converted to an open cholecystectomy. There were no other catheter-related complications that occurred. The authors concluded that laparoscopic cholecystectomy may be performed with low complication rates in patients undergoing continuous ambulatory peritoneal dialysis with an experienced team.

Banli et al [26] evaluated the outcomes of laparoscopic cholecystectomy in renal transplant patients with symptomatic gallstone disease. They reviewed the records of 155 kidney transplant patients, including 16 patients who underwent laparoscopic cholecystectomy. They found out that the shortest interval time between transplantation and cholecystectomy was 2 years. Surgical morbidity were seen in two of the patients with no mortality and no

Laparoscopic Cholecystectomy in High Risk Patients 33

Leone et al [16] presented their cases between January 1994 and December 2000 where there were 1,100 laparoscopic cholecystectomies for symptomatic gallbladder diseases. They reported that there were 24 cirrhotic patients who had well-compensated cirrhosis (Child's class A or B). The authors reported that there were no operative mortality and the postoperative complication rates were 20.8%. They estimated that the intraoperative blood loss was 37.08 ml in average. Their average hospital stay 3.61 days. The authors concluded that laparoscopic cholecystectomy in patients with compensated cirrhosis is safe and should be the treatment of choice for these patients. They further stated that laparotomy should be applied only if the surgeon considers the operation inadequate to be continued

Diseases in the abdomen requiring surgical intervention during pregnancy present unique challenges to their diagnosis and management [17]. These are said to be due to the changes in physiology and abdominal anatomy characteristic of pregnancy. These changes make laparoscopic surgery technically more difficult, the obstetrician must determine the status of pregnancy such as gestational age, viability and inform the patient about the risks related to

There are several mechanisms that have been proposed by specialists for increased fetal morbidity and mortality associated with laparoscopic surgery during pregnancy including direct uterine trauma, fetal trauma, intraamniotic CO2 insufflation, trauma to maternal abdominal organs and vessels, decreased uterine blood flow and oxygen delivery, teratogenic effects of anesthetic drugs, fetal acidosis due to CO2 pneumoperitoneum, adverse effects of anesthesia on maternal hemodynamic and acid-base balance, increased risk of thromboembolic disease, the effect of underlying abdominal pathology, manipulation during surgery and effects of postoperative medications [18,20] Therefore laparoscopic cholecystectomy has been used cautiously in pregnant women. This is due to the possible mechanical problems related to the pregnant uterus and the other is fear of fetal injury

To assess the effects of laparoscopic cholecystectomy on both the mother and the unborn fetus, Abuabara et al [19] reviewed their surgical experience over a 5-year period where 22 patients ranging from 17 to 31 years underwent laparoscopic cholecystectomy during pregnancy. They noted that the gestational ages ranged from 5 to 31 weeks where there are two patients who are in their first trimester, 16 in the second and four in the third. Their indications for surgery were persistent nausea, vomiting, pain, and inability to eat in 17 patients, acute cholecystitis in three and choledocholithiasis in two. The surgeons established pneumoperitoneum in all patients and their results were all 22 patients survived the surgical procedure without complications and there were no fetal deaths or premature births related to the procedure. The authors concluded that laparoscopic cholecystectomy during pregnancy is safe for both the mother and the unborn fetus and if at all possible, when laparoscopic cholecystectomy is indicated, it should be performed either in the second

Wishner et al [21], members of the Norfolk Surgical Group, gathered their data for the laparoscopic cholecystectomy cases from May 1991 to June 1994 where they performed the

laparoscopically.

**7.1 Cases** 

**7. Patients who are pregnant** 

pregnancy and surgery itself [18].

trimester or early in the third.

resulting from instrumentation or the pneumoperitoneum.

graft loss. They concluded that laparoscopic cholecystectomy can be performed safely with low morbidity in renal transplant patients who have symptomatic gallstone disease.
