The effect of local instillation of tranexamic acid on the gallbladder bed after laparoscopic cholecystectomy on the risk of postoperative bleeding in difficult cases: a randomized controlled study

Abstract

Introduction: Bleeding during laparoscopic cholecystectomy can occur from the gallbladder bed, especially if there is difficulty during the dissection due to acute inflammation. The bleeding is usually minor from the small arteries running between the gall bladder and its bed. Tranexamic acid (TXA) is a drug that used topical and parenteral to decrease the bleeding during cardiac and spine, and trauma surgeries. It has antifibrinolytic effect by inhibiting degradation of blood clot and also probably degradation of platelet aggregation. We hypothesized that the local instillation of TXA in the gall bladder bed after laparoscopic cholecystectomy can decrease the bleeding in the form of decrease in the haematocrit and haemoglobin levels in the drain after surgery.

Objective: to evaluate the efficacy of local instillation of TXA in the gallbladder bed in reducing postoperative bleeding following difficult laparoscopic cholecystectomy.

Methods: This randomized double-blinded clinical study involved 80 adult patients treated at our university institution from December 2021 to January 2024. The patients were categorized into two groups. Group A consisted of 40 patients who, after achieving meticulous hemostasis of the bleeding points in the liver bed, received 500 mg of TXA dissolved in 20 ml of normal saline locally in the liver bed. Group B, also comprising 40 patients, underwent the same hemostatic procedure until no significant bleeding was observed, followed by the instillation of 20 ml of normal saline in the gall bladder bed. In both groups, the drain was occluded for one hour. Drain output was measured, and the haematocrit and haemoglobin levels of the drain fluid were evaluated at 6 hours and 24 hours. The haemoglobin level was compared to preoperative levels. Postoperative complications were documented.

Results: 80 patients were eligible and after excluding 20 patients that were easy dissection of the gallbladder without potential risk of bleeding, so sixty patients were the scope of the study and divided into two groups. No serious bleeding was observed in any case, and hemoglobin and hematocrit levels in the drain were assessed at 6 and 24 hours’ post-procedure. In the TXA group, there was significant decrease in the 6h hematocrit concentration in the drain from 7.59±3.09 % to 5.76±2.88 % (P= 0.0213), and also hemoglobin decreased in the drain from 2.29±1.48 gm/dl to 11.21± 1.09 gm/dl (P=0.002), but these differences were not significant after 24 hours. Additionally, there was statistically insignificant difference between the two groups regarding the preoperative and 6 hours’ postoperative hemoglobin concentration in blood (P=0.521 and 0.710, respectively).

Conclusion: The local administration of Tranexamic acid in the gallbladder bed following dissection may serve as an effective method to enhance hemostasis in the operative field, improve laparoscopic visibility, and reduce the likelihood of conversion to open surgery.