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PubMed1993

Laparoscopic cholecystectomy. A statewide experience. The Connecticut Laparoscopic Cholecystectomy Registry.

The explosion in laparoscopic cholecystectomy has posed many questions about its safety compared with the "gold standard" of open cholecystectomy. A statewide database was established in Connecticut to study these issues. Thirty-three (97%) of 34 hospitals in Connecticut participated in the study, which began at the inception of the laparoscopic procedure. Four thousand six hundred forty laparoscopic cholecystectomies were performed between May 1, 1990, and September 30, 1991. The overall conversion rate to open cholecystectomy was 6.9%. Conversions were more frequent with acute cholecystitis, in the elderly, and early in a surgeon's experience. The overall technical complication rate was 4.7%; common bile duct injuries occurred in 15 patients (0.3%). Complications decreased with increasing experience, to 0.98% after a surgeon's 75th procedure. Six patients (0.13%) died following laparoscopic cholecystectomy. The overall mortality rate associated with cholecystectomy fell during the study period. The frequency of cholecystectomy in Connecticut increased 29% with the advent of the laparoscopic procedure. The introduction of laparoscopic cholecystectomy has resulted in an increased frequency of surgery without an increase in surgical mortality. The incidence of common bile duct injuries was low. The decreasing incidence of technical complications demonstrates the learning curve for the procedure.

Adult↗
PubMed2000

Laparoscopic cholecystectomy: a good buy? A cost comparison with small-incision (mini) cholecystectomy.

OBJECTIVES: To compare inpatient costs for laparoscopic and small-incision cholecystectomy. DESIGN: Retrospective analysis using results of a single blind prospective randomised trial. SETTING: Teaching hospital, UK. SUBJECTS: 200 patients having elective cholecystectomy. INTERVENTIONS: Standard laparoscopic cholecystectomy with conversion to open cholecystectomy if necessary. Small-incision cholecystectomy using high right transverse epigastric incision, enlarged if necessary for safe exposure. MAIN OUTCOME MEASURES: Providers inpatient costs. RESULTS: Small-incision cholecystectomy cost Pound Sterling 995 and was 29% less expensive than the laparoscopic procedure which cost Pound Sterling 1397. Costs of equipment and operations themselves accounted for most of the difference. Results also suggest that costs to patients and society from time lost away from work may be lower for mini-cholecystectomy. CONCLUSIONS: The national health service could be spending over Pound Sterling 10m a year by encouraging laparoscopic rather than small-incision operations for cholecystectomy. Commissioners of health care should question whether the benefits of laparoscopic surgery justify the additional costs.

Cholecystectomy↗
PubMed1996

Increased cholecystectomy rate after the introduction of laparoscopic cholecystectomy in Scotland.

This survey determined the effect of the introduction of laparoscopic cholecystectomy on the rates of cholecystectomy (total and laparoscopic) in Scotland. From 1977 to 1990, the Scottish cholecystectomy rate fell by an average of almost 1% per annum. With the advent of laparoscopic cholecystectomy, the total cholecystectomy rate (open and laparoscopic) rose considerably--by 18.7% from 1989-93 (p < 0.05). The largest increase (25%) was observed in the 45-64 years age group but it was also particularly evident (19%) in elderly patients (65-74 years). Subjects were more likely to undergo laparoscopic cholecystectomy than open cholecystectomy if they were young and female. The increased cholecystectomy rate observed merits careful scrutiny and health economic evaluation.

Adolescent↗
PubMed1993

[Perioperative pain and stress: a comparison between video laparoscopic cholecystectomy and "open" cholecystectomy].

Pain and endocrine-metabolic response to surgical stress, during surgery and in the early postoperative period, was compared in two groups of patients affected by gallstones and randomly assigned to Laparoscopic Cholecystectomy or Open Cholecystectomy. Pain was assessed by the VAS method also taking into account the need of analgesic administration in the postoperative period. The so called "stress hormones" (Prolactin (PRL), Cortisol (CORT), Human Growth Hormone (HGH)) and glycaemia were monitored during surgery and in the first postoperative 24 hours. The minimal invasive technique of laparoscopic cholecystectomy accounted for a very limited analgesic administration. In the intraoperative period laparoscopic cholecystectomy plasma hormone levels overlapped the open cholecystectomy ones, while in the postoperative period a constant increase in PRL and CORT levels was registered in the open cholecystectomy group demonstrating a prolonged stressful condition. The end results of this study show that laparoscopic cholecystectomy has major advantages than open cholecystectomy in the treatment of gallstones as far as pain and endocrine-metabolic response are concerned.

Anesthesia, General↗
PubMed1993

Post-cholecystectomy symptoms after laparoscopic cholecystectomy.

Abdominal symptoms persist in up to 40% of patients after laparotomy cholecystectomy and biliary lithotripsy. Laparoscopic cholecystectomy is now the treatment of choice for symptomatic gallstone disease. However, no data exist as to the influence of laparoscopic cholecystectomy on symptoms. We analysed 100 patients who had undergone laparoscopic cholecystectomy at a median of 12 months (range 10-19 months) previously. Pre- and postoperative symptoms were compared and patient satisfaction was graded from 1 (best) to 5 (worst). Time to resumption of full activity (mean +/- SD) was recorded. All patients had more than two symptoms preoperatively. Postoperatively, 61 patients had complete absence of symptoms, 14 patients complained of only one symptom during the postoperative period and 25 patients continued to have at least two symptoms. The mean time taken to return to full activity was 2.4 +/- 1.7 weeks. In patients without any symptoms postoperatively, time taken to return to full activity was 2.3 +/- 1.5 weeks, 2.7 +/- 1.4 weeks for patients with one symptom postoperatively, while patients with two or more symptoms returned to full activity in 2.3 +/- 1.3 weeks and 2.6 +/- 1.7 weeks, respectively. Notwithstanding that 25% of patients reported two or more symptoms postoperatively, most patients (n = 84) considered the procedure to be a complete success. A further 10 patients had significant improvement after laparoscopic cholecystectomy. Five patients considered themselves only slightly improved, while a single patient was no better off postoperatively. These data indicate that after laparoscopic cholecystectomy most patients return to full activity within 3 weeks. Thus, the incidence of post-cholecystectomy symptoms is similar after laparoscopic and laparotomy cholecystectomy and biliary lithotripsy.Patients should be advised of the risk of persistent symptoms after these procedures.

Adult↗
PubMed1998

[Mortality during the first six years after cholecystectomy. A review of all cholecystectomies in women in Denmark during 1977-1981].

It has been a prevailing assumption that cholecystectomy patients by and large follow a pattern of survival similar to that of the normal population. This paper presents a population-based study of the long-term survival after cholecystectomy in order to reassess this assumption. Based on data available in the Danish National Hospital Register, the records of all Danish women who were operated between 1977 and 1981 were examined and studied up to six years subsequent to surgery. Cholecystectomy patients who were free of diagnosed cancer and who had no major co-surgery (n = 11,123) were compared to both hysterectomy patients and a sample of the female population. Adjusting for age and other covariates, patients with psychiatric hospital admissions prior to surgery experienced a threefold risk of dying within six years after surgery. Patients with prior somatic admissions and patient with acute admissions had a relative risk (RR) of about 1.5. Cholecystectomy patients had a significantly increased mortality when compared to hysterectomy patients, RR = 1.3 (1.1-1.6), and to the population sample. Heart diseases and cancer occurred significantly more often as causes of death among cholecystectomy patients when compared to hysterectomy patients, but our data suggest that the occurrence of many other causes of death may be increased among cholecystectomy patients as well. The authors concluded that cholecystectomy patients are subject to relatively higher levels of mortality than previously assumed in parts of the literature. Furthermore, the increase seems to be attributable to a multitude of causes of death. The most likely explanation of the excess mortality among cholecystectomy patients is that gallbladder patients are relatively fragile. Indeed, with this vulnerable group of patients the potential trauma of the surgical intervention itself needs careful consideration.

Adult↗
PubMed2006

Laparoscopic cholecystectomy for early gallbladder carcinoma: long-term outcome in comparison with conventional open cholecystectomy.

BACKGROUND: The role of laparoscopic surgery for malignant gallbladder tumors remains uncertain. This study compared the surgical results of laparoscopic versus conventional open cholecystectomy for patients with early-stage gallbladder carcinoma and examined the role of laparoscopic surgery for early gallbladder carcinomas. METHODS: Data for the treatment of gallbladder carcinomas were gathered from Chang Gung Memorial Hospital (Linkou, Taiwan). A retrospective analysis of 40 patients with either stage 0 or stage 1 gallbladder carcinoma was performed. The patients were categorized into two groups on the basis of cholecystectomy procedures. The long-term outcomes for the two groups were compared. RESULTS: During the follow-up period, which ranged from 6.5 to 197.6 months, four patients in the conventional open cholecystectomy group encountered tumor recurrence, and one patient in the laparoscopic cholecystectomy group experienced distant tumor recurrence (p = 0.216). No local port-site tumor recurrence was identified in patients who underwent laparoscopic cholecystectomy. The overall 5-year survival rate in this series was 87.1%. A comparison of survival rates between the two groups demonstrated no significant difference (p = 0.340). CONCLUSION: The laparoscopic cholecystectomy procedure did not adversely influence the prognosis of patients with early-stage gallbladder carcinomas. Furthermore, meticulous removal of gallbladders during laparoscopic surgery, in which early gallbladder carcinoma can be managed successfully using laparoscopic cholecystectomy, achieved a satisfactory surgical result and a low port-site tumor recurrence rate.

Adult↗
PubMed1993

Cost-effectiveness of laparoscopic cholecystectomy versus open cholecystectomy.

To assess the cost-effectiveness of laparoscopic cholecystectomy versus open cholecystectomy from the payer's perspective, we estimated the probabilities of potential outcomes of each procedure, associated quality-of-life effects, and related direct medical charges and incorporated these estimates into a computerized simulation model. The model projects that laparoscopic cholecystectomy will be more effective than open surgery in terms of total mortality and quality-adjusted survival, for both sexes and all ages. Projected 5-year cumulative charges are lower for laparoscopic cholecystectomy than for open cholecystectomy ($5,354 versus $5,525 for 45-year-old women; $6,036 versus $6,830 for 45-year-old men), and the differences increase substantially with increasing age. We concluded that laparoscopic cholecystectomy is likely to be less costly and more effective than open cholecystectomy for most patients, as long as it does not routinely require preoperative cholangiography and is not associated with increased professional fees or increased risks of retained stones or bile duct injury.

Adult↗
PubMed2004

Abdominal pain and patient overall and cosmetic satisfaction one year after cholecystectomy: outcome of a randomized trial comparing laparoscopic and minilaparotomy cholecystectomy.

BACKGROUND: Previous studies with long-term follow-up after cholecystectomy have shown that residual abdominal symptoms are common. Laparoscopic cholecystectomy (LC) and minilaparotomy cholecystectomy (MC) can both give a smoother, early postoperative course than conventional open cholecystectomy (OC). The present study concerns abdominal pain and patient overall and cosmetic satisfaction one year after LC and MC. METHODS: In a prospective, single-blind study, 724 patients were randomly allocated to LC or MC. Patients completed questionnaires including items concerning abdominal pain before and one year after surgery and overall and cosmetic satisfaction one year after surgery. RESULTS: There was no difference in reduction of abdominal pain between LC and MC patients. For four different aspects of abdominal pain, 31%, 24%, 30% and 16% of patients operated with LC reported residual abdominal pain one year after surgery. The corresponding figures for MC were 28%, 20%, 27% and 18% (P values 0.55, 0.32, 0.55 and 0.63, respectively). According to questionnaire answers, there was no significant difference in the cosmetic result and overall patient satisfaction between LC and MC patients. CONCLUSIONS: There are no differences between laparoscopic and minilaparotomy cholecystectomy in long-term outcome regarding abdominal pain and patient overall and cosmetic satisfaction. A large proportion of patients have abdominal pain one year after cholecystectomy. Future studies should include preoperative assessment and indications for cholecystectomy.

Abdominal Pain↗
PubMed2003

Mini-laparotomy cholecystectomy in the era of laparoscopic cholecystectomy: a community-based hospital perspective.

Laparoscopic cholecystectomy is clearly the gold standard for symptomatic cholelithiasis. Open cholecystectomy is now reserved for difficult and problematic cases. The purpose of this paper is to propose that mini-laparotomy cholecystectomy (minicholecystectomy) can be as effective as laparoscopic cholecystectomy. This paper compares the two techniques in well-matched patients. In addition mastery of this technique is practical and rewarding and should be part of the repertoire of the general surgeon. We conducted a retrospective review of the experience of a single surgeon at a community-based teaching hospital over a 2-year period for minicholecystectomy and laparoscopic cholecystectomy. Sixty-six patients were matched for age, sex, body surface area, and Acute Physiology and Chronic Health Evaluation II score. The absolute cost was lower for the minicholecystectomy group than for the laparoscopic cholecystectomy group. The operating room times were not significantly different in the two groups (P value 0.79). The average length of stay and the average amount of intramuscular analgesia required for the two groups were also not significantly different (P values 0.69 and 0.35, respectively). Although subjective postoperative satisfaction was equal for both groups the minicholecystectomy group had no complications whereas the laparoscopic group had two (myocardial infarction and cystic duct stump leak) complications. We conclude that minicholecystectomy can be used as a viable alternative to laparoscopic cholecystectomy especially in patients who cannot tolerate laparoscopic procedures and in areas where cost containment is critical.

Adult↗
PubMed1996

Incidence and nature of bile duct injuries following laparoscopic cholecystectomy: an audit of 5913 cases. West of Scotland Laparoscopic Cholecystectomy Audit Group.

The rapid introduction of laparoscopic cholecystectomy has been associated with an apparently increased incidence of bile duct injury which has provoked worldwide concern. The true incidence and mechanism of iatrogenic ductal injury during the development of this procedure remain unclear. To assess this, the introduction of laparoscopic cholecystectomy in the West of Scotland has been audited prospectively over a 5-year period. All cases of biliary ductal injury have been independently reviewed. Some 48 surgeons undertaking laparoscopic cholecystectomy in 19 hospitals submitted prospective data between September 1990 and September 1995. A total of 5913 laparoscopic cholecystectomies were attempted with 98.3 per cent completion of data collection. During this period 37 laparoscopic bile duct injuries occurred. The annual incidence peaked at 0.8 per cent and has fallen to 0.4 per cent in the final year of audit. Injuries occurred after a median personal experience of 51 (range 3-247) laparoscopic cholecystectomies in 22 surgeons. Major bile duct injuries occurred in 20 of 37 patients, giving an incidence of 0.3 per cent. Five mechanisms for laparoscopic ductal injury were identified, including tenting, confluence and diathermy injuries as well as the classical and variant classical types. Ductal injuries were discovered at operation in 18 patients with consequent repair giving a good clinical outcome in 17. Contributory factors (severe inflammation, aberrant anatomy and poor visualization) were present in only 13 of 37 cases. This audit suggests that, at least in the introductory period, laparoscopic cholecystectomy is associated with an overall bile duct injury rate higher than that reported previously after open cholecystectomy, although the incidence of major ductal injury is similar. The late downward trend in bile duct injury, however, suggests there may be a prolonged learning curve for this procedure. Improved understanding of the mechanism of injury may lead to yet further reductions in this complication.

Bile Ducts↗
PubMed2006

Zeus robot-assisted laparoscopic cholecystectomy in comparison with conventional laparoscopic cholecystectomy.

BACKGROUND: The robotic surgical system overcomes many technological obstacles of conventional laparoscopic surgery, and possesses enormous clinical applied potential. The aim of this study was to compare the efficacy of Zeus robot-assisted laparoscopic cholecystectomy with conventional laparoscopic cholecystectomy. METHODS: Forty patients undergoing elective cholecystectomy were randomly divided into two groups. Patients in group A (n=20) underwent Zeus robot-assisted laparoscopic cholecystectomy, and patients in group B (n=20) received conventional laparoscopic cholecystectomy. The parameters on operative field, operative time, the number of actions, the rate of operative errors and minimal trauma were evaluated and compared between the two groups. RESULTS: The number of clearing camera (1.1+/-1.0 times) and the time of adjusting the operative field (2.2+/-0.7 minutes) in group A were significantly less than those (4.5+/-1.5 times) and (7.5+/-1.2 minutes) in group B. The number of dissection actions (337+/-86 times) and the rate of operative errors (10%) in group A were less than those (389+/-94 times), (25%) in group B. The total operation time (104.9+/-20.5 minutes) and setup time (29.5+/-9.8 minutes) in group A were significantly longer than those (78.6+/-17.1 minutes), (12.6+/-2.5 minutes) in group B. Blood loss and postoperative hospitalization were similar. No postoperative complications occurred in both groups, and open cholecystectomy was performed in each group. CONCLUSIONS: Zeus robot-assisted cholecystectomy inherits the benefits of minimally invasive surgery. The Zeus robotic surgical system is better than conventional laparoscopic technique in controlling the operative field and can be manipulated precisely and stably though it requires more operative time.

Adult↗
PubMed1994

Increased cholecystectomy rates among Medicare patients after the introduction of laparoscopic cholecystectomy.

A study was undertaken of Medicare claims coded for cholecystectomy and those coded for laparoscopic cholecystectomy for the four year period 1990-1993 in New York State. During this time period there was a 28.12% increase in total cholecystectomies performed and an increase in the proportion of laparoscopic cholecystectomies from 15.86% to 50.0%. The increase in total cholecystectomies appears to be driven by a dramatic increase in laparoscopic procedures. Possible reasons for this increase include the performance of laparoscopy on patients previously assessed as too risky to undergo the conventional procedure, laparoscopy on mildly symptomatic patients who had previously put off a perceived higher risk open procedure and a possible broadening of indications for gallbladder surgery. The dramatic increase in the numbers of cholecystectomies performed in the early 1990s may be due in part to procedures performed on a large pool of procrastinating mildly symptomatic patients. If this is the case, then these increased rates should decline to baseline levels as soon as this pool of patients is exhausted. However, if surgeons are performing laparoscopy on asymptomatic patients with gallstones, then these rates may well be sustained. Such a broadening of indications for gallbladder surgery is of concern to many and has prompted the issuance of guidelines concerning the treatment of gallstones. Any broadening of indications for gallbladder surgery also has significant implications for health care costs and the use of health care resources.

Aged↗
PubMed1996

A cost-minimization analysis of laparoscopic cholecystectomy versus open cholecystectomy.

BACKGROUND: Earlier economic analyses have evaluated charges but not costs, and have not considered the cost of production losses associated with open and laparoscopic cholecystectomy. This study attempted to accomplish an economic evaluation of open versus laparoscopic cholecystectomy from the point of view of society. METHODS: A cost-minimization analysis, using a clinical decision model, was performed. The data used were taken from different clinical studies, Swedish national registers, local patient statistics, and hospital accounting systems. The direct and indirect costs were measured. RESULTS: Laparoscopic cholecystectomy resulted in cost savings per patient amounting to about 2,400 SEK (as of 31 August 1994, Pound = 11.90 SEK; $1 = 7.76 SEK) compared with open surgery. CONCLUSIONS: From the point of view of society, laparoscopic cholecystectomy was a cost-saving strategy if at least 68 patients were operated on yearly. However, with regard to hospital costs, open cholecystectomy was less expensive than laparoscopic cholecystectomy.

Cholecystectomy↗
PubMed2002

Laparoscopic cholecystectomy versus open cholecystectomy in elderly patients with acute cholecystitis: retrospective study.

OBJECTIVE: To study the safety and efficacy of laparoscopic cholecystectomy for acute cholecystitis in elderly patients by comparing the results with open cholecystectomy. DESIGN: Retrospective study. SETTING: Regional hospital, Hong Kong. SUBJECTS AND METHODS: Patients aged 75 years or older undergoing laparoscopic cholecystectomy for acute cholecystitis between January 1994 and December 1999 were selected from the database. The comparison group comprised patients from the same age-group who underwent open cholecystectomy for acute cholecystitis during the same period. MAIN OUTCOME MEASURES: Operating time, hospital stay, morbidity, and mortality. RESULTS. Thirty-one patients underwent laparoscopic surgery and 42 had open surgery. The demographic data and co-morbidities were comparable between the two groups. The postoperative hospital stay was significantly shorter for patients undergoing laparoscopy (P=0.03). The overall morbidity rate was significantly lower for patients undergoing laparoscopy (P<0.05). There was, however, no statistical significant difference in the mortality rate. There was no major bile duct injury for patients in either group. CONCLUSION: Laparoscopic cholecystectomy is a safe procedure for acute cholecystitis in elderly patients, resulting in fewer complications and shorter hospital stay than open cholecystectomy.

Acute Disease↗
PubMed1996

[Postoperative nausea, vomiting and pain in laparoscopic cholecystectomy: a comparison with minilaparotomy-cholecystectomy].

Postoperative nausea, vomiting and pain were compared between laparoscopic cholecystectomy group and minilaparotomy-cholecystectomy group. All patients were women, and ranged in age from 20 to 60 years. The body mass index of the patients was less than 30, and duration of operation was within 120 minutes in both groups. All patients received general anesthesia combined with epidural analgesia. Morphine hydrochloride 4 mg was administered into epidural space before incision. No significant differences were found in the incident of nausea and vomiting among the two groups. Postoperative analgesic requirement of laparoscopic cholecystectomy group was significantly less than that of minilaparotomy-cholecystectomy group. No significant differences were found in the incidence of nausea and vomiting between the group which required postoperative analgesic drugs and the group which required no postoperative analgesic drugs. These results suggest that laparoscopic operation and postoperative pain do not influence the incidence of nausea and vomiting. Postoperative pain after laparoscopic cholecystectomy is less than that after minilaparotomy-cholecystectomy.

Adult↗
PubMed2006

Mini-laparotomy cholecystectomy versus laparoscopic cholecystectomy: which way to go?

PURPOSE: The aim of this paper is to report the results of a prospective clinical trial investigating traditional laparoscopic cholecystectomy versus "mini-lap" cholecystectomy in a tertiary care University Hospital. MATERIALS AND METHODS: This is a prospective, randomized, single-center observational study. Forty-four patients were allocated in each group; patients in group L underwent laparoscopic cholecystectomy, whereas patients in group M had open "mini-laparotomy" cholecystectomy with a small incision through the rectus abdominis muscle. RESULTS: The operation lasted significantly longer in group L compared with group M, whereas patients of group L had a shorter hospital stay. There was no difference between groups regarding postoperative day on which patients commenced eating. There was no significant difference between groups regarding doses of analgesics used during surgery or in the recovery room. However, patients in group M used significantly more opioids in the postoperative period. Time to resume normal activity was significantly shorter in group L. A very good aesthetic result was obtained in 97.7% of patients in group L and 77.3% of patients in group M. CONCLUSIONS: Cholecystectomy through a mini-laparotomy incision is a lower-cost, versatile, and safe alternative to laparoscopic cholecystectomy.

Cholecystectomy, Laparoscopic↗
PubMedDate not supplied

The evolution of postoperative ileus after laparoscopic cholecystectomy. A comparative study with conventional cholecystectomy and sympathetic blockade treatment.

Our study is prompted by the arrival of laparoscopic cholecystectomy in connection with the evolution of postoperative ileus (PI) and by its avoidance of the intraabdominal handling implied in conventional cholecystectomy. With this aim a prospective, controlled, randomized, and blind clinical trial was designed using 100 patients divided into five groups (n = 20): I, conventional cholecystectomy (CC): II, CC+injection of 20 ml bupivacaine 0.5% into the mesentery root; III, CC + 7.5 mg propranolol i.v. and 0.5 mg neostigmine s.c., postoperatively until the first defecation; IV, II+III; and V, laparoscopic cholecystectomy. The shortest period of PI was observed in group V. This period increases notably in group IV (53 h), group II (72 h), and group III (84 h) relative to the control group with (89 h). This reduction in PI time runs parallel with an improvement in the patient's general state of well-being. We concluded that after laparoscopic cholecystectomy PI is nonexistent. Furthermore, this study confirms the correlation between the avoidance of intraabdominal manipulation and the evolution of postoperative ileus.

Autonomic Nerve Block↗