Subtotal laparoscopic cholecystectomy for gangrenous gallbladder during recovery from COVID-19 pneumonia

Abstract

Introduction: Management of acute abdomen during COVID-19 pandemic may be challenging.

Presentation of case: A 42-year old man was hospitalized for Covid-19 pneumonia. Fever, respiratory symptoms and hypoxemia significantly improved over the next 2 weeks, but the patient developed abdominal pain, nausea, and low-grade fever. Computed tomography scan revealed absence of contrast enhancement of gallbladder wall and a micro-perforation of the fundus. At laparoscopy, gallbladder gangrene was confirmed and a subtotal cholecystectomy performed. Special precautions were adopted for patient transportation from the ward to a dedicated operating room, and two teams with adequate personal protective equipment took charge of the procedure. The patient was discharged home on postoperative day 7 under protective lockdown measures for 2 weeks.

Discussion: The pathogenesis of acute acalcolous gangrenous cholecystitis is multifactorial. It is unknown whether a prothrombotic state induced by COVID-19 contributes to wall ischemia and perforation. Percutaneous cholecystostomy should be avoided in patients with gallbladder gangrene. Contraindications to laparoscopy are not evidence-based since aerosolization is produced during both open and laparoscopic surgical procedures. However, personal protective equipment is key for prevention.

Conclusion: Early diagnosis and surgical therapy are critical in patients with gangrenous cholecystitis. Subtotal laparoscopic cholecystectomy for gangrenous gallbladder is safe and effective.

Fig. 1

Pathway for surgical team protection.

Fig. 2

A-B. Intraoperative picture showing lysis of dense inflammatory adhesions and evidence of acute gangrenous cholecystitis (A). Intraoperative image showing stapling of the infundibulum after clipping of the cystic artery, opening of the gallbladder, and cystic duct identification. (B).

Fig. 3

A-B. Macroscopic aspect of the gallbladder (A); microphotograph showing acute cholecystitis with extensive ulceration, full-thickness necrosis, hemorrhage, and widespread fibroblastic proliferation.