Cholecystectomy for Gallstone: Types and Findings

: Gall stone disease remains a common and significant cause of suffering in most parts of the world. Gallstones are the most common biliary pathology. A descriptive study covered 80 patients underwent surgical treatment for gallstone diseases. Ultrasound study and plain abdominal X-ray were done to confirm the presence of gallstone. More than half of the sample 58.8% were in the oldest age group 50-69 year. Female were 68(85%) and the remaining 12(15%) patients were male. Most of patients 60(75.0%) operated upon by open cholecystectomy, laparoscope used in 18(22.5%). The main finding on exploring the abdomen was inflammatory adhesion in 54(67.5%) of the patients, thick wall gallbladder came next in 12 (15%) patients. Many complications and clinical findings associated with gallstone, some of them are serious other are even fatal. That is why cholecystectomy is highly indicated even for silent gallstone.

suspected macroscopically. Biochemical analysis of the removed stones from only 30 cases was performed to identify the chemical constitution of the stones. T-tube cholangiography done for (7) patients, at day tenth postoperative by injection of sodium diatrizote dye down into T-tube, before removal of T-tube to visualize the biliary tree especially common bile duct & to see any filling defect & patency of biliary tree.

Results
Total number of patients with gall stone disease participated in the study were 80 patients. Three patients were in the age group 18-29 year, two out of the three patients were known to had hereditary spherocytosis. In the age group 30-49 year there were 30(37.5%) patients. In the oldest age group 50-69 year we had 47 patients constituted more than half of the sample 58.8% (Table-1). Female were 68(85%) and the remaining 12(15%) patients were male, with a female: male ratio of (5.7:1). plain radiology of abdomen was done for 40 patients. Rt-hypochondria radio-opaque shadow was seen in only 5(12.5%) of the cases. Two cases showed calcified GB wall.
Ultrasound study done for all patients, gallstones were present in (71) cases, while common bile duct stone was found only in (5) cases.  Table 3 represented the type of surgery performed for the patients. Most of patient 60(75.0%) operated upon by open cholecystectomy. The gallstones in 18 patients (22.5%) were removed by laparoscope.  Table 4 showed the main finding on exploring the abdomen via laparoscope or open surgery. The most common finding was inflammatory adhesion in 54 patients (67.5%) of the total patients. Thick wall GB came next in 12 patients (15%). Perforated GB was the least reported, only one patient (1.3%).  Traditionary obese, older, females with multiple pregnancies, have a higher risk of developing gallstones (Al-Saad et al. 2018). In this study there were some change in this trend of GS disease to a high incidence in non-obese female less than 50 years old 32.3% this could be attributed to the expansion in the use of contraceptive pills in some female, this agreed with Gupta study, also to multiple pregnancies in others (Gupta et al. 2008). Our study showed the rate of GS in female aged more than 50 years was (51.3%) which is again comparable to the results of Gupta et al. 2008. There has also been a remarkable shift in the trend of gall-stone disease from middle aged, fertile, fat females to young asthenic females in their twenties (Sachdeva et al. 2011). There has been a significant increase in the incidence of gallstones in patient under 30s of age in the past 10 years also there is a change toward asthenic female (Abdul Hassan 2011).
The female to male ratio in our study was (5.7:1) which was higher than Gupta study where it was (4:1) ( Gupta et al. 2008).
A higher prevalence of GS among females, observed in the current study, has been agreed with several studies (Farzaneh Sheikh Ahmad et al. 2007, Sun et al. 2009). Pregnancy and sex hormones are believed to be a causes for a higher risk, and this had been supported by several epidemiologic studies (Friedman et al. 1966, Barbara et al. 1987. The clinical relevance found by Agrusa et al (2014) is further broadened by the fact that the prevalence of gallstone disease increases with age.
In this study about (9) cases (11.3%) pre-operative presented with acute cholecystitis, and (3) cases (3.7%) with acute cholangitis biliary jaundice & fever Charcot's triad. Silent gallstones were 14 cases (17.4%). Abraham et al (2014) stated that gallstones are often discovered incidentally during ultrasonography or computed tomography of the abdomen. Only 10% to 20% of asymptomatic patients will eventually become symptomatic within five to 20 years of diagnosis.
Pain in abdomen, dyspepsia and jaundice were common presentation of patients in many studies (Pimpale et al. 2019).
According to the guideline forwarded by Pisano, laparoscopic cholecystectomy should be considered for all; the age, on its own, is not a contraindication for surgery (Pisano et al. 2019). While Nassar in his study found that age of the patient is a significant factor determining the likelihood of death and the length of hospital stay after any type of procedure of gallstones removal (Nassar & Richter 2019). Laparoscopic and open cholecystectomy were used for our patients in this study, with a conversion from laparoscopic to open procedure at a rate of 2.5%. this was less than the rate in Shrestha et al. (2014) study where it was (11.1%), and less than the conversion rate of Pimpale et al. (2014) study (6.57%).
Open method still common procedure done for our patients in current study this is probably due to lack in instruments and in some to low experience. This agree with Shrestha et al. (2014) study, who also reported several possible factors responsible for this conversion. These include age, sex, obesity, diabetes mellitus, acute cholecystitis, history of biliary diseases such as jaundice, cholangitis, history of pancreatitis (Shrestha et al. 2014).
Conversion to open surgery from laparoscopic cholecystectomy was encountered because of recurrent management of multiple episodes of acute cholecystitis and avoiding definitive surgery because of associated comorbidities. The conversion decision is considered as a sound judgment to avoid complications and reduce morbidity (Hussain et al. 2017).

Conclusion
Gallstones in our patients were more in female than male, there were some changes in the traditional presentation of patients toward less obese and younger age group. Many complications and clinical pictures associated with