Pak. j. life soc. Sci.

(2024), 22(1): 2168-2174 E-ISSN: 2221-7630;P-ISSN: 1727-4915

www.pjlss.edu.pk

https://doi.org/10.57239/PJLSS-2024-22.1.00159
Pakistan Journal of Life and Social Sciences
RESEARCH ARTICLE

The Biochemical and Hematological Changes in Laparoscopic

Cholecystectomy
Mohammed Abdul Hameed Younis1*, Dr. Hussam Kareem2, Dr. Wissem Hmida3
1, Middle technical university, college of health and medical technique .
3. University of Sousse Tunisia /Faculty of Medicine Ibn el-Jazzar
2 MBCHB, FICM, Ministry of Health, Imam Ali Hospital
ARTICLE INFO ABSTRACT

Received: May 22, 2024 Hematological indicators, including neutrophils,

leukocytes, neutrophil-lymphocyte ratio, platelet lymphocyte
ratio, and mean
Accepted: Jul 1, 2024
platelet volume, have been observed to change following
laparoscopic surgery. Blood parameter and liver enzyme level
changes following laparoscopic cholecystectomy are the focus of this
Keywords
investigation. Participants in this study were those who had
Laparoscopic symptomatic cholelithiasis and had a laparoscopic cholecystectomy.
Those patients who had other medical conditions, such as hepatitis
Cholecystectomy and diabetes, and those who had to change from laparoscopic
Liver Function Tests cholecystectomy to open cholecystectomy were not included in the study. The pre-
operative and post-operative Hematological Mean Platelet Volume parameters and liver function tests
were documented. The noted Cholelithiasis features included body mass index (BMI), gender, age, surgery
indication, and duration, the pneumoperitoneum pressure, and
duration of hospital stay. Various hematological parameters mean pre and postoperative values were
compared using a paired sample t-test.
HCT (hematocrite), hemoglobin (Hb), platelets, and alkaline *Corresponding
Author: phosphatase (ALP) levels all decreased after surgery. After the
[email protected] procedure, there was an increase in mean corpuscular volume (MCV),
mean platelet volume (MPV), leukocytes, and alanine transaminase (ALT). The mean values of Hb, MCV,
Hct, leukocytes, MPV, and ALT showed a statistically significant difference (p<0.05). Significant alterations
in hematological parameters and liver enzymes occurred during LC.

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INTRODUCTION
The gall bladder stone (Cholelithiasis) is a common disease widespread globally. It affects
approximately 10%-15% of people in Western societies and The percentage ranges from 3% to 5%
in Asian and African communities (1). In another study found that 10.2% of subjects who
underwent ultrasonography were diagnosed with cholelithiasis [2]. Laparoscopic cholecystectomy
(LC) has become the preferred surgical treatment for removing symptomatic gallbladder disease
and cholelithiasis since the 1990s, replacing open cholecystectomy (OC). It is now regarded as one
of the most commonly done operations for these conditions [3]. Although laparoscopic
cholecystectomy has short hospitalization and rapid recovery period, surgery carries a risk of
problems in cardiovascular at vulnerable groups due to its effects on blood flow and breathing. The
elevated intraabdominal pressure and increased levels of carbon dioxide in the blood during
laparoscopic cholecystectomy operations, which are associated with changes in blood parameters
(4-6).
The aorta, inferior vena cava, splanchnic arteries, hepatic artery, portal veins, and renal blood
vessels were compressed, leading to the perioperative consequences of pneumoperitoneal
pressure.
Reduced blood flow in the hepatic artery and portal vein leads to a temporary lack of oxygen in liver
cells, causing damage to the cells. As a result, the level of ALT in the blood increases. Elevated
intraabdominal pressure is associated with increased hemodynamic Abnormalities and
irregularities in liver function tests. The alterations in liver function tests, after laparoscopic
cholecystectomy are associated with the presence of the pneumoperitoneum and the time it lasts
(4,7-9). Several investigations have documented alterations in blood parameters following the
laparoscopy surgeries (10-11). Leukocytes, neutrophils, the ratio of neutrophils to lymphocytes, the
ratio of platelets to lymphocytes, and mean platelet volume (MPV) were all significantly different
from one another, before and after insufflation. The mean platelet volume were increased when
intraabdominal pressures rise can be used clinically to diagnose intraabdominal hypertension [10-
11]. A study examined the impact of CO2 insufflation on the occurrence of more blood clotting
events. This was caused by an increase in coagulation factors and a decrease in the fibrinolytic
system activity. The rise in thromboembolic events was specifically linked to the
pneumoperitoneum pressure and the length of the surgical procedure [12]. In various situations, it
is important to establish the impact of these surgeries on the hematological parameters. This will
enable appropriate actions to be made before, during, and after the surgery to reduce the
occurrence of illness, death, hospitalization, and overall expenses for both the patient and the
hospital. The main objective of this study was to compare the levels of various parameters, such as
hemoglobin (Hb), MCHC, MCV, MCH, hematocrit(HCT), platelet,MPV, and liver function tests (LFTs),
including ALT and ALP, before and after laparoscopic cholecystectomy.
METHODOLOGY
The research was conducted prospectively at the AL-IMAM ALI Hospital/baghdad from June to
November 2022. There were 60 patients, fifteen males, and fifteen females, all with gallbladder
stones. Confirmation was obtained using liver function tests and ultrasounds of the abdomen. The
Criteria for inclusion were comprised of patients undergoing laparoscopic surgeries, those with
symptomatic gallbladder disease, and those with a physical status of I or II as determined by the
American Society of Anaesthesiologists (ASA). This study excluded those patients with related
diseases (such as diabetes and stroke), those who had undergone a conversion from laparoscopic
cholecystectomy to open cholecystectomy, and those with postoperative infections or coagulation

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issues. Aseptically, 2 ml of blood was extracted from the antecubital vein. The blood samples,
collected a 12-hour after the procedure, were analysed to establish the patient's initial levels of
leukocytes,Hb,MCV,MCHC,MCH,MPV,HCT,the blood sugar, and platelets, serum ALT, and ALP. These
parameters were determined before and after the operation. The blood was centrifuged for three to
five minutes using the Rotofix-32 apparatus (Hettich, Massachusetts). The (Beckman Coulter
automated device, USA) was utilized to assess alanine aminotransferase (ALT) levels.
The patient's vital signs were kept within the normal range in the preoperative rooms and were
closely observed for 24 hours. A laparoscopic cholecystectomy was carried out using general
anaesthesia and four standard ports. The pneumoperitoneum was created using a closed approach
and a veress needle. The documented variables included the utilization of intra-abdominal pressure
and the duration of the surgical procedure. After twelve hours, two ML of blood was extracted from
the antecubital vein using the identical approach. This was done to measure the postoperative
levels of the variables being investigated. Additional factors, such as age, gender, body mass index,
and length of stay in the hospital, were also recorded. We compared the average values of several
blood parameters and liver enzymes before and after the operation using the sample t-test. A
comparative analysis using an independent sample t-test assessed the differences in factors that
vary between males and females. To assess the differences in these parameters among the various
groups, an analysis of variance (ANOVA) was run. The tailed two P-value of less than 0.05 was
deemed to be statistically significant. The analysis employed the Statistical Package for Social
Sciences (SPSS) (IBM Corp, Armonk, NY).
RESULTS
For the study, a total of sixty patients were chosen. There were thirty individuals, with 50% being
male and 50% female. The average age of the patients was 40.3, with a standard deviation of 15.6.
The average time of the surgery was 60.02 minutes, with a standard deviation of 18.1 minutes and a
range of 35 to 95 minutes. Simultaneously, the average pressure of the peritoneum was 13.5 mmHg
with a standard deviation of 1.8 mmHg and a range of 12-17 mmHg. All of the individuals exhibited
symptomatic cholelithiasis. Forty-five patients required fewer than twenty-four hours to recover
after their surgeries. By comparison, a total of fifteen patients remained hospitalised for a duration
of two days, while just one patient stayed for a duration of three days.
Table 1: Displays the distribution of different age groups based on gender

Age groups Male(30) Female (30)

No. % No. %

20-39 yrs. 16 53.3 17 56.5

40-59 yrs. 7 23.3 10 33.3

60+ yrs. 7 23.3 3 10

Analysis of haematological results before and after surgery

The levels of haematological variables were compared between the preoperative and postoperative
situations using a sample t-test. The average ALT level increased from 35.1 to 57.6 and the standard

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deviation from 40.6 to 64.9 after the procedure, indicating a statistically significant increase.
Similarly, there was a significant rise in leukocytes, MPV, and MCV levels after surgery compared to
levels before. There was a significant reduction in haemoglobin levels following the operation, with
the mean decreasing from 13.8 (SD=1.5) before the surgery to 10.1 (SD=1.6) after the surgery.
Furthermore, there was a significant reduction in hematocrit levels seen following the operation.
Prior to the surgery, the average hematocrit level was 38.5 with a standard deviation of 5.3.
However, after the surgery, the average hematocrit level decreased to 34.6 with a standard
deviation of 4.9.
Table 2: Comparative analysis of the variations in levels among several groups

Hematological Preoperative Postoperative t df

parameter pvalue

mean SD mean SD

Hb (g/dl) 13.8 1.5 10.1 1.6 4.1 52 0.000*

MCV (fL) 80.4 8.6 82.5 6.7 -2.3 52 0.023*

MCHC(g/dL) 34.6 2.1 34.8 2.5 -0.3 52 0.700

MCH (pg) 27.8 3.0 28.1 3.3 -0.7 52 0.436

8.4 2.4 12.5 3.7 -7.7 52 0.00*

Leukocytes
(*103/IU)

Platelets (*103/uL) 303.2 79.3 286 80.5 1.9 52 0.063

Hct 38.5 5.3 34.6 4.9 3.6 52 0.001*

MPV(fL) 9.9 0.9 10.2 0.8 -2.9 52 0.004*

ALT(U/L) 35.1 40.6 57.6 64.9 -2.7 52 0.008*

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ALP (U/L) 152.7 120 143.7 117.2 0.8 52 0.416

The calculation involved finding the difference between the pre- and post-operation levels of all
variables. To measure the differences between the two gender, a two-sample independent t-test
was used. On the other hand, the study found no statistically significant difference in the genders for
any of the characteristics that were considered. This study were using an analysis of variance
(ANOVA) to investigate the differences in haematological variable levels after surgery across
various BMI groups. Nevertheless, there were no detected alterations that were statistically
significant.
DISCUSSION
Laparoscopy has become a fundamental component of contemporary surgical practice. Therefore, it
is crucial to closely evaluate both the advantages and disadvantages of it to sustain its positive
impact on society. Our investigation has yielded intriguing findings that will enhance our
understanding of the effects of this surgical procedure. There were notable disparities in the
number of factors being examined. This implies that even while laparoscopy may seem harmless, it
nevertheless necessitates proper caution and preventive measures to ensure the patient's safety
and well-being. Multiple studies examining the frequency of the condition or focusing on surgical
techniques for cholelithiasis have documented comparable results (13). A study conducted in China
revealed a greater prevalence of cholelithiasis in females (14). The development of gallstones is
thought to be more common in females. according to a number of research (15).
The main objective of this study was to elucidate the alterations in the blood composition resulting
from laparoscopic cholecystectomy. Initially, we saw a substantial decrease in the levels of Hb and
hematocrit. Lindberg et al. provide support for the results (16). The dilutional effect of intravenous
(I/V) fluids utilized in treatment explains this phenomenon. Furthermore, these increases in mean
corpuscular volume (MCV) is also understandable. Intravenous fluids are provided continuously
during the procedure to prevent the occurrence of shock and after the surgery to prevent the
development of dehydration. Prolonged use of laparoscopic operations with minimal bleeding
results in hemodilution and decreased plasma osmolality.
Consequently, this causes water to move into cells, potentially increasing Mean Corpuscular Volume
(MCV). Leukocytes exhibited an increase in levels after the surgery. The Turkish study by Bitkin et
al. [11] lends credence to this. An increase in white blood cell (WBC) numbers is inevitable after
surgery because the stress triggers immune pathways.
An important indicator of elevated intra-abdominal pressure is the MPV [11]. In line with the
results of Bitkin et al. (11) and our own observations, it is evident that the mean platelet volume
(MPV) increased significantly following the operation. Research conducted by Celep et al. ()
provides more evidence of this expansion.(10). However, Marakis et al. conducted a research that
found a decrease in the mean size of platelets among the people they analyzed (17). Possible
explanations for this occurrence include the elevated thrombolytic activity and coagulation
activation noted in these people, as described in many investigations (16, 18). It follows that the
platelet count drops, which is in agreement with what (Marakis et al.) found: a significant drop in
platelet count. Nevertheless, our investigation (17) revealed no significant difference in platelet
count.
Several studies have identified these individuals as having higher thrombolytic activity and
coagulation activation, which may explain this incidence (16, 18). The result is a decrease in platelet

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count, which is consistent with the findings of (19) however, there was an observed rise in the
average size of platelets. This phenomenon can be elucidated by prior studies indicating that only
platelets with a larger volume are initially discharged during stressful circumstances, such as
surgical interventions. The total number of circulating cells increases within a minimum time frame
of one to two days (20-21). The variable ALT had a significant surge during the process, rendering it
the ultimate variable of interest. Consistent and statistically significant findings are presented by
many investigations (7, 22–23). After three to ten days, the enzyme levels will be back to their
original state, indicating that the changes are temporary (24). An intra-abdominal pressure of 8
mmHg is considered normal. A pneumoperitoneum, created during laparoscopy, causes a pressure
rise of about 13–14 mmHg. Several clinical and experimental studies have shown that
pneumoperitoneum can cause hepatic hypoperfusion. As an example, it has been shown by
Jakimowicz et al. that portal venous flow is reduced during laparoscopic insufflation (25). As a
result, this leads to liver damage, which in turn causes an elevation in ALT levels. Nevertheless, the
levels of ALP exhibited no substantial alterations, aligning with the results of previous studies,
including the one undertaken. As stated by Hasukic et al. (23).
This study has some drawbacks. Initially, data was gathered exclusively from a solitary institution.
Furthermore, this study, which involved observing subjects over time, required a significant
amount of time and, as a result, had a limited number of participants. Therefore, conducting a study
with a more extensive sample size is advisable to achieve more reliable and transferable outcomes.
CONCLUSION
Notable alterations were observed in the hematological parameters and liver enzymes. It is
important to exercise caution to prevent these parameters from reaching harmful levels, therefore
minimizing the risk of additional problems and morbidity. Moreover, this study can work as a
catalyst for individuals to explore further the alterations of these parameters in response to other
controllable elements during the operation and identify strategies to mitigate these changes.
Acknowledgment
A great thank you was submitted to the staff of the anesthesia department in the Bagdad Teaching
Hospital and the anesthesia technique department at the College of Health and Medical Technique/
Iraq/ Baghdad.

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