Day care laparoscopic cholecystectomy: a feasibility study in a public health service hospital in a developing country

Predictors of Difficult Laparoscopic Cholecystectomy on Humanitarian Missions to Peru Difficult LC in Surgical Missions

BACKGROUND

Laparoscopic cholecystectomy (LC) is the gold standard treatment of gallstone disease. On short-term surgical missions (STSMs), it is unclear what factors can predict safety of LC. This study evaluates patient risk factors of difficult LC in Northern Peru, towards optimizing outcomes.

MATERIALS AND METHODS

A retrospective review was performed of patients who underwent LC during short-term surgical missions to Peru from 2016-2019 under the International Surgical Health Initiative (ISHI). Difficult and routine LC groups were compared for: age, weight, gender, symptom duration, pain on presentation, history of abdominal or pelvic surgery, diabetes and hypertension.

RESULTS

68 of 194 patients underwent LC; 42 patients (62%) were classified as difficult with OR (operating room) time > 70 min (90%), 2 cases converted to open (5%) and 2 aborted cases (5%). Higher weight class was found to correlate with difficult LC.

CONCLUSION

Increased patient weight was correlated to longer operative time during STSMs. Patients undergoing LC must be selected carefully to mitigate risks of difficult operations on STSMs.

Day case laparoscopic cholecystectomy at Kilimanjaro Christian Medical Centre, Tanzania

INTRODUCTION

The Lancet Commission on Global Surgery has promoted the case for safe, affordable surgical care in low- and middle-income countries (LMICs). In 2017, Kilimanjaro Christian Medical Centre (KCMC) in Tanzania introduced a day case laparoscopic cholecystectomy (DCLC) service, the first of its kind in Sub-Saharan Africa (SSA). We aimed to evaluate this novel service in terms of safety, feasibility and acceptability by patients and staff.

METHODS

This study used mixed methods and was split into two stages. In stage 1, we reviewed records of all laparoscopic cholecystectomies (LCs) comparing day cases and admissions. These patients were followed up with a telephone questionnaire to investigate complication rates and receive service feedback. Stage 2 consisted of semi-structured interviews with staff exploring the challenges KCMC faced in implementing DCLC.

RESULTS

147 laparoscopic cholecystectomies were completed: 109 were planned for DCLC, 82 (75.2%) of which were successful, whilst 27 (24.8%) patients were admitted. No variables significantly predicted unplanned admission, the commonest causes for which were pain and nausea. In the DCLC group there was 1 readmission. 62 patients answered the follow up questionnaire, 60 (97%) of which were satisfied with the service. Stage 2 interviews suggested staff to be motivated for DCLC but revealed poor organisation of the day case pathway.

CONCLUSION

High rates of DCLC combined with low rates of complications and readmission suggests DCLC is feasible at KCMC. However, staff interviews alluded to administrative problems preventing KCMC from reaching its full DCLC potential. A dedicated day case surgery unit would address most of these problems.

The Safety of Laparoscopic Cholecystectomy in the Day Surgery Unit Comparing with That in the Inpatient Unit: A Systematic Review and Meta-Analysis

We aimed to perform a systematic review and meta-analysis on the safety of laparoscopic cholecystectomy performed in the day surgery unit versus those performed in the inpatient unit. Several databases including Ovid Embase, Medline Ovid, Cochrane Central, Web of Science, and Google Scholar were searched from inception through February 2019. Our results revealed that laparoscopic cholecystectomy can be conducted safely and effectively in day surgery units, helping bed shortage.

Outpatient laparoscopic cholecystectomy: Experience of a university group practice in a developing country

Aims: In developed countries, efforts to improve outcome and minimize costs prompted the performance of laparoscopic cholecystectomy as an outpatient procedure. In the Philippines and in most developing countries, most laparoscopic cholecystectomies are still performed on admitted patients who are discharged one or more days after the surgery. No local experience has been published in the Philippines demonstrating the safety and feasibility of outpatient laparoscopic cholecystectomy. Materials and Methods: This study is a retrospective study investigating the outcome of outpatient performed laparoscopic cholecystectomy in the University of the Philippines, Philippine General Hospital Faculty Medical Arts Building (UP-PGH FMAB), an ambulatory surgical facility within UP-PGH. The patients were admitted to the ambulatory facility on the day of surgery, underwent laparoscopic cholecystectomy under general anesthesia and discharged on the same day. Results: From June 2012 to June 2016, 122 patients underwent laparoscopic cholecystectomy at the UP-PGH Faculty medical arts building. There were 80 women (85%) and 42 men (15%) with a mean age of 46 years. The mean operating time was 58 minutes. The unplanned admission rate was 2.4% (two patients), one for conversion to open and two for unrelieved postoperative nausea and vomiting. Conclusion: Outpatient laparoscopic cholecystectomy is safe and technically feasible even in developing countries. It has potential for much economical and social benefit when employed judiciously. Prospective, randomized trials must be conducted in the local setting to refine technique, standardize patient selection and address system deficiencies to allow safe performance of outpatient laparoscopy in the Philippines.

Practice, training and safety of laparoscopic surgery in low and middle-income countries

Surgical management of diseases is recognised as a major unmet need in low and middle-income countries (LMICs). Laparoscopic surgery has been present since the 1980s and offers the benefit of minimising the morbidity and potential mortality associated with laparotomies. Laparotomies are often carried out in LMICs for diagnosis and management, due to lack of radiological investigative and intervention options. The use of laparoscopy for diagnosis and treatment is globally variable, with high-income countries using laparoscopy routinely compared with LMICs. The specific advantages of minimally invasive surgery such as lower surgical site infections and earlier return to work are of great benefit for patients in LMICs, as time lost not working could result in a family not being able to sustain themselves. Laparoscopic surgery and training is not cheap. Cost is a major barrier to healthcare access for a significant population in LMICs. Therefore, cost is usually seen as a major barrier for laparoscopic surgery to be integrated into routine practice in LMICs. The aim of this review is to focus on the practice, training and safety of laparoscopic surgery in LMICs. In addition it highlights the barriers to progress in adopting laparoscopic surgery in LMICs and how to address them.

Day Care vs Overnight Stay after Laparoscopic Cholecystectomy even with Co-morbidity and a Possible Second Surgery: A Patient's Choice

INTRODUCTION

Laparoscopic Cholecystectomy (LC) has become the gold standard for symptomatic gall stone disease. It is being practiced as a day care procedure in healthy individuals in American Society of Anaesthesialogists (ASA) grade I and II. It is not yet established in presence of co-morbidity and when a second surgery is added. In most of the study, patient's choice and the psycho-social factors were not considered in deciding the day care procedure.

AIM

To find the safety of LC and a second surgery as day care in presence of compensated co-morbidity. To study the choice of the patient whether to stay in hospital or go home after declaring them fit for day care.

MATERIALS AND METHODS

All the patients of symptomatic cholelithiasis with co-morbidity and associations were evaluated and made uncompromising for elective surgery. All the LC were done at 8mmHg CO₂ peumo-peritoneal pressure using harmonic scalpel as the energy source for dissection of gall bladder from the liver bed. Cases with conversion and placement of drain were excluded.

RESULTS

A total of 1029 out of 1042 patients was included from Jan 2005 to Jan 2015. The age range was 38 to 91years (mean 44.65, SD 14.15). There were 634 females and 395 males. A total of 121(11.7%) of them had co-morbidity and associations. A total of 72(7%) had undergone a second surgery. Only 0.8% had real day care. A total of 95.7% had overnight stay even after fulfilling all the criteria. Only 0.2% needed re-admission in 30 days and one required intervention.

CONCLUSION

Patients like to stay over night in the hospital even if found fit for day care after LC. Overnight stay makes them happy, psycho-socially confident in developing nation and best suited for all patients including co-morbidity.

Short-stay daycare laparoscopic cholecystectomy at a dedicated daycare centre: Feasible or futile

BACKGROUND

In the last decade, laparoscopic cholecystectomy (LC) has become a regular daycare surgery at many centres across the world. However, only a few centres in India have a dedicated daycare surgery centre, and very few of them have reported their experience. Concerns remain regarding the feasibility, safety and acceptability of the introduction of daycare laparoscopic cholecystectomy (DCLC) in India. There is a need to assess the safety and acceptability of the implementation of short-stay DCLC service at a centre completely dedicated to daycare surgery.

PATIENTS AND METHODS

Comprehensive care and operative data were retrospectively collected from a daycare centre of our hospital. Postoperative recovery was monitored by telephone questionnaire on days 0, 1 and 5 postoperatively, including adverse outcomes.

RESULTS

A total of 211 patients were admitted for DCLC during the period from November 2011 till November 2014, of whom 211 were discharged on the day of surgery. Two hundred and two patients could be discharged within 6 h of surgery. Mean operation time was 72 min. No patient required admission. No patient needed conversion to open surgery. Only 1 patient was re-admitted due to bilioma formation and was managed with minimal intervention.

CONCLUSION

The introduction of short-stay DCLC in India is feasible and acceptable to patients. High body mass index (BMI) in otherwise healthy patients and selective additional procedures are not contraindications for DCLC.

Impact of seniority on operative time and short-term outcome in laparoscopic cholecystectomy: Experience of an academic Surgical Department in a developing country

INTRODUCTION:

Resident participation in laparoscopic cholecystectomy (LC) is one of the first steps of laparoscopic training. The impact of this training is not well-defined, especially in developing countries. However, this training is of critical importance to monitor surgical teaching programmes.

OBJECTIVE:

The aim of this study was to determine the impact of seniority on operative time and short-term outcome of LC.

DESIGNS AND SETTINGS:

We performed a retrospective study of all consecutive laparoscopic cholecystectomies for gallbladder lithiasis performed over 2 academic years in an academic Surgical Department in Morocco.

PARTICIPANTS:

These operations were performed by junior residents (post-graduate year [PGY] 4–5) or senior residents (PGY 6), or attending surgeons assisted by junior residents, none of whom had any advanced training in laparoscopy. All data concerning demographics (American Society of Anesthesiologists, body mass index and indications), surgeons, operative time (from skin incision to closure), conversion rate and operative complications (Clavien–Dindo classification) were recorded and analysed. One-way analysis of variance, Student's t-test and Chi-square tests were used as appropriate with statistical significance attributed to P < 0.05.

RESULTS:

One hundred thirty-eight LC were performed. No differences were found on univariate analysis between groups in demographics or diagnosis category. The overall rate of operative complications or conversions and hospital stay were not significantly different between the three groups. However, mean operative time was significantly longer for junior residents (n = 27; 115 ± 24 min) compared to senior residents (n = 37; 77 ± 35 min) and attending surgeons (n = 66; 55 ± 17 min) (P < 0.001).

CONCLUSION:

LC performed by residents appears to be safe without a significant difference in complication rate; however, seniority influences operative time. This information supports early resident involvement in laparoscopic procedures and also the need to develop cost-effective laboratory training programmes.

Feasibility and safety of day-surgery laparoscopic cholecystectomy: a single-institution 5-year experience of 1140 cases

Backgrounds/Aims

We report our experience with day-surgery laparoscopic cholecystectomy and assess its feasibility and safety.

Methods

Data was collected on all the patients who underwent day-surgery laparoscopic cholecystectomy between February 2009 and February 2014 at Prince Sultan Military Medical City, Riyadh, Kingdom of Saudi Arabia. All patients had symptomatic cholelithiasis that was proven on imaging studies with clearance of the common bile duct. The patient biographical data (age, gender, American Society of Anaesthesiology status, medical comorbidities) and surgical outcomes were then obtained. There was an evaluation of the success rate of day-surgery laparoscopic cholecystectomy, reasons for unexpected admission, and the re-admission rate.

Results

A total of 1,140 patients were included in this study. The success rate for day-surgery laparoscopic cholecystectomy was 96%. The reasons for unexpected hospital admission for 46 patients (4%) included persistent abdominal pain and postoperative emesis. The postoperative re-admission rate was 0.4% (5 patients). There were no major complications, and the conversion rate was 0.5% (6 patients).

Conclusions

We suggest that day-surgery laparoscopic cholecystectomy is both safe and feasible in a local setting. Careful patient selection is essential in ensuring a high success rate.

Systematic review of laparoscopic surgery in low- and middle-income countries: benefits, challenges, and strategies

BACKGROUND

Laparoscopy may prove feasible to address surgical needs in limited-resource settings. However, no aggregate data exist regarding the role of laparoscopy in low- and middle-income countries (LMICs). This study was designed to describe the issues facing laparoscopy in LMICs and to aggregate reported solutions.

METHODS

A search was conducted using Medline, African Index Medicus, the Directory of Open Access Journals, and the LILACS/BIREME/SCIELO database. Included studies were in English, published after 1992, and reported safety, cost, or outcomes of laparoscopy in LMICs. Studies pertaining to arthroscopy, ENT, flexible endoscopy, hysteroscopy, cystoscopy, computer-assisted surgery, pediatrics, transplantation, and bariatrics were excluded. Qualitative synthesis was performed by extracting results that fell into three categories: advantages of, challenges to, and adaptations made to implement laparoscopy in LMICs. PRISMA guidelines for systematic reviews were followed.

RESULTS

A total of 1101 abstracts were reviewed, and 58 articles were included describing laparoscopy in 25 LMICs. Laparoscopy is particularly advantageous in LMICs, where there is often poor sanitation, limited diagnostic imaging, fewer hospital beds, higher rates of hemorrhage, rising rates of trauma, and single income households. Lack of trained personnel and equipment were frequently cited challenges. Adaptive strategies included mechanical insufflation with room air, syringe suction, homemade endoloops, hand-assisted techniques, extracorporeal knot tying, innovative use of cheaper instruments, and reuse of disposable instruments. Inexpensive laboratory-based trainers and telemedicine are effective for training.

CONCLUSIONS

LMICs face many surgical challenges that require innovation. Laparoscopic surgery may be safe, effective, feasible, and cost-effective in LMICs, although it often remains limited in its accessibility, acceptability, and quality. This study may not capture articles written in languages other than English or in journals not indexed by the included databases. Surgeons, policymakers, and manufacturers should focus on plans for sustainability, training and retention of providers, and regulation of efforts to develop laparoscopy in LMICs.

Laparoscopic cholecystectomy: consensus conference-based guidelines

INTRODUCTION

Laparoscopic cholecystectomy (LC) is the gold standard technique for gallbladder diseases in both acute and elective surgery. Nevertheless, reports from national surveys still seem to represent some doubts regarding its diffusion. There is neither a wide consensus on its indications nor on its possible related morbidity. On the other hand, more than 25 years have passed since the introduction of LC, and we have all witnessed the exponential growth of knowledge, skill and technology that has followed it. In 1995, the EAES published its consensus statement on laparoscopic cholecystectomy in which seven main questions were answered, according to the available evidence. During the following 20 years, there have been several additional guidelines on LC, mainly focused on some particular aspect, such as emergency or concomitant biliary tract surgery.

METHODS

In 2012, several Italian surgical societies decided to revisit the clinical recommendations for the role of laparoscopy in the treatment of gallbladder diseases in adults, to update and supplement the existing guidelines with recommendations that reflect what is known and what constitutes good practice concerning LC.

A successful model for laparoscopic training in Mongolia

The benefits of laparoscopic surgery have not been available to the majority of Mongolians. Mongolian surgical leaders requested assistance in expanding laparoscopy. A capacity-building approach for teaching laparoscopic cholecystectomy throughout Mongolia is reviewed. A laparoscopic cholecystectomy training program was developed. The program included a didactic course and an intensive 2-week practical operating experience. Courses were taught in Ulaanbataar and at 3 of the 4 regional diagnostic referral and treatment centers from 2006 to 2010. During this training period, a total of 303 teaching laparoscopic cholecystectomies were performed. There was one common bile duct injury and one duodenal injury. The conversion rate was 2.0%. This program has been successful in creating a self-sustaining practice of training. The traditional surgical approach to gallbladder disease in Mongolia has been challenged and has, in turn, been a stimulus for improvement in the medical community.

Laparoscopic cholecystectomy under spinal anaesthesia: A prospective, randomised study

CONTEXT:

Spinal anaesthesia has been reported as an alternative to general anaesthesia for performing laparoscopic cholecystectomy (LC).

AIMS:

Study aimed to evaluate efficacy, safety and cost benefit of conducting laparoscopic cholecystectomy under spinal anaesthesia (SA) in comparison to general anaesthesia(GA)

SETTINGS AND DESIGN:

A prospective, randomised study conducted over a two year period at an urban, non teaching hospital.

MATERIALS AND METHODS:

Patients meeting inclusion criteria e randomised into two groups. Group A and Group B received general and spinal anaesthesia by standardised techniques. Both groups underwent standard four port laparoscopic cholecystectomy. Mean anaesthesia time, pneumoperitoneum time and surgery time defined primary outcome measures. Intraoperative events and post operative pain score were secondary outcome measure.

STATISTICAL ANALYSIS USED:

The Student t test, Pearson′s chi-square test and Fisher exact test.

RESULTS:

Out of 235 cases enrolled in the study, 114 cases in Group A and 110 in Group B analysed. Mean anaesthesia time appeared to be more in the GA group (49.45 vs. 40.64, P = 0.02) while pneumoperitoneum time and corresponding the total surgery time was slightly longer in the SA group. 27/117 cases who received SA experienced intraoperative events, four significant enough to convert to GA. No postoperative complications noted in either group. Pain relief significantly more in SA group in immediate post operative period (06 and 12 hours) but same as GA group at time of discharge (24 hours). No late postoperative complication or readmission noted in either group.

CONCLUSION:

Laparoscopic cholecystectomy done under spinal anaesthesia as a routine anaesthesia of choice is feasible and safe. Spinal anaesthesia can be recommended to be the anaesthesia technique of choice for conducting laparoscopic cholecystectomy in hospital setups in developing countries where cost factor is a major factor.

Randomised Controlled Trial of Day-Case Laparoscopic Cholecystectomy vs Routine Laparoscopic Cholecystectomy

Many randomised controlled trials conducted worldwide favours for day-case laparoscopic cholecystectomy, but questions have been raised regarding its application in developing country like ours. Hence, considering it a high time to review current practices, we conducted this trial to report our experience with day-case laparoscopic cholecystectomy and to access its feasibility and safety in our set-up. Data from 65 patients with symptomatic gallstone were randomised to perform laparoscopic cholecystectomy either as day-case procedure or as routine (conventional) procedure. Complication, quality of life, satisfaction, post-operative nausea and vomiting and pain were assessed. Ninety-seven per cent (31/32) of day-case laparoscopic cholecystectomy patients were successfully discharged with mean duration of 8.9 ± 4.54 h, which was 3.33 ± 1.45 days (72.92 ± 34.8 h) in routine (conventional) laparoscopic cholecystectomy group. There was no significant difference in complication, quality of life, satisfaction, post-operative nausea and vomiting and pain between the two groups. Day-case laparoscopic cholecystectomy is a safe, feasible and beneficial procedure in our set-up. Patient acceptance in terms of quality of life and satisfaction was similar to that of routine laparoscopic cholecystectomy.

Day Care Laparoscopic Cholecystectomy: Next Standard of Care for Gall Stone Disease

Background

To access the feasibility, safety and success of day care laparoscopic cholecystectomy in a tertiary center in India.

Methods

This is a retrospective analysis of prospectively collected data between 2004 and 2009 from a tertiary center in north India. All patients of symptomatic gallstone diseases having age less than 70 years, American Society of Anesthesiologists (ASA) grade I and grade II, living within 20 Kilometers of the hospital, availability of a responsible adult care taker at home, access to a telephone and a means of transportation to hospital if needed, underwent laparoscopic cholecystectomy under the care of the two participating surgeons, were considered for day care laparoscopic cholecystectomy. Clinical and operative data were recorded prospectively. All patients were discharged 6 to 8 hours after surgery with the advice to contact the surgical team over phone whenever necessary or on the day after discharge.

Results

A total of 602 laparoscopic cholecystectomies were performed over a period of 6years, among them 309 (51.32%) were operated on day care basis. Nine patients in day care procedure group had conversion to open procedure (5 due to distorted anatomy of calot’s triangle, 2 due to common bile duct stones, 1 due to bile duct injury and 1 due to bleeding from cystic artery stump). One patient had myocardial infarction and 3 had nausea and vomiting which failed to resolve by intravenous ondensteron and all these (13) patients (4.20%) needed unplanned admission to the hospital. Two hundred and ninety-six patients (95.79%) were discharged on same day.

Conclusions

In conclusion day care laparoscopic cholecystectomy is feasible, safe and equally effective in selected patients in Indian setup.

Safety and effectiveness of outpatient laparoscopic cholecystectomy in a teaching hospital: a prospective study of 110 consecutive patients

BACKGROUND

The aim of this study was to evaluate the safety and efficacy of outpatient laparoscopic cholecystectomy (OLC) in a day surgery unit in a teaching hospital. OLC was offered to patients with symptomatic cholelithiasis who met the following established inclusion criteria: ASA (American Society of Anesthesiology) physical status classification class I and II; age: 18 - 70 years; body mass index (BMI) < 30 kg/m2; patient acceptance and cooperation (informed consent); presence of a responsible adult to accompany the patient to his residency; patient residency in Athens. The primary study end-point was to evaluate success rates (patient discharge on the day of surgery), postoperative outcome (complications, re-admissions, morbidity and mortality) and patient satisfaction. A secondary endpoint was to evaluate its safe performance under appropriate supervision by higher surgical trainees (HSTs).

FINDINGS

110 consecutive patients, predominantly female (71%) and ASA I (89%) with a mean age 40.6 +/- 8.1 years underwent an OLC. Surgery was performed by a HST in 90 patients (81.8%). A mean postoperative pain score 3.3 (range 0-6) occurred in the majority of patients and no patient presented postoperative nausea or vomiting. Discharge on the day of surgery occurred in 95 cases (86%), while an overnight admission was required for 15 patients (14%). Re-admission following hospital discharge was necessary for 2 patients (1.8%) on day 2, due to persistent pain in the umbilical trocar site. The overall rate of major (trocar site bleeding) and minor morbidity was 15.5% (17 patients). At 1 week follow-up, 94 patients (85%) were satisfied with their experience undergoing OLC, with no difference between grades of operating surgeons.

CONCLUSIONS

This study confirmed that OLC is clinical effective and can be performed safely in a teaching hospital by supervised HSTs.

An Isolator System for minimally invasive surgery: the new design

BACKGROUND

The risk of obtaining a postsurgical infection depends highly on the air quality surrounding the exposed tissue, surgical instruments, and materials. Many isolators for open surgery have been invented to create a contained sterile volume around the exposed tissue. With the use of an isolator, a surgical procedure can be performed outside sterile environments. The goal of this study was to design an Isolator System (IS) for standard laparoscopic instruments while instrument movements are not restricted.

METHODS

The developed IS consists of a sleeve to protect the instrument shaft and tip and a special balloon to protect the incision and trocar tube. A coupling mechanism connected at the sleeve allows instrument changes without contamination of the isolated parts. Smoke tests were performed to show that outside air does not enter the new IS during a simulated laparoscopic procedure. Eight test runs and one baseline run inside a contained volume filled with thick smoke were performed to investigate whether smoke particles entered the Isolator System. Filters were used to identify smoke entering the Isolator System.

RESULTS

Seven filters showed no trace of smoke particles. In one test run, a part of the IS loosened and a small brown spot was visible. The filter from the baseline run was completely covered with a thick layer of particles, proving the effectiveness of the test. During all test runs, the isolated instrument was successfully locked on and unlocked from the isolated trocar. Instrument movements gave no complications. After removal of the isolated instrument, it took three novices an average of 3.1 (standard deviation (SD), 0.7) seconds to replace it correctly on the isolated trocar.

CONCLUSIONS

The designed IS for laparoscopy can increase sterility in environments where sterility cannot be guaranteed. The current design is developed for laparoscopy, but it can easily be adapted for other fields in minimally invasive surgery.

Should laparoscopic cholecystectomy be practiced in the developing world?: the experience of the first training program in Afghanistan

OBJECTIVE

We address the controversial issue of whether or not it is wise to perform and train laparoscopic cholecystectomy (LC) in a developing nation by reviewing the results of the first large series done in Afghanistan. Afghanistan has been devastated by 3 decades of war leaving it with deficiencies in training programs, medical technologies, and overall medical infrastructure that are among the worst in the developing world.

METHODS

We retrospectively reviewed 137 consecutive cholecystectomies, 102 laparoscopic and 35 open, performed by 4 senior and 3 junior surgeons trained at our hospital in Kabul from July 2005 until February 2008. Deaths, complications, conversion rate, operative time, and hospital length of stay were compared.

RESULTS

Unrecognized major operative injuries occurred in 4 LC patients, 3 bile leaks, and 1 duodenal perforation, although there were no such injuries in the open cholecystectomy group. Complication rates were much higher for patients operated on for acute cholecystitis for both surgeon groups. Even though junior surgeons converted to open cholecystectomy more frequently than senior surgeons, they had a higher major complication rate. Hospital length of stay was 28% shorter for the laparoscopic group.

CONCLUSIONS

The high rate of major unrecognized intraoperative complications during LC in our series underscores the difficulties inherent in performing and training LC in developing nations. Practical changes are suggested to make LC more efficient and safer in a developing world hospital.

Patient perception of natural orifice transluminal endoscopic surgery as a technique for cholecystectomy

BACKGROUND

Although the concept of natural orifice transluminal endoscopic surgery (NOTES) as a minimally invasive surgical technique is gaining increasing popularity, patient perception toward NOTES is unclear. Because cholecystectomy is the most common laparoscopic procedure, the concept of NOTES was examined in this context.

AIM

To evaluate patient perception of NOTES as a potential technique for a cholecystectomy.

PATIENTS

Those patients with an intact gallbladder who were undergoing an EUS or an ERCP for evaluation of abdominal pain, pancreatitis, or suspected choledocholithiasis.

SETTING

Tertiary-referral center.

DESIGN

Cross-sectional survey.

METHODS

One hundred patients were given a questionnaire that described the technique, the complication rates, and benefits of laparoscopic cholecystectomy (LC). The concept of NOTES was then described in detail, with possible orifices being the mouth, the rectum, and the vagina. Patients were queried about their preference for a cholecystectomy technique (LC vs NOTES), choice of orifice, and the risks that they were willing to undergo for NOTES.

RESULTS

Of the 100 patients, 78% preferred NOTES, and 22% preferred LC. The mean age of the patients was 45 years; 36% of patients were men, 70% were white, and 83% had undergone a prior endoscopy; no significant differences were observed between the NOTES and LC groups for these characteristics. In multivariable modeling, those with age </= 50 years (odds ratio [OR] 1.3, P = .61), female sex (OR 2.1, P = .14), and prior endoscopy experience (OR 2.2, P = .19) were more likely to prefer NOTES than an LC. There was no difference in preference for NOTES between whites and nonwhites (OR 1.0, P = .98). The most common reasons for NOTES preference were lack of external pain (99%) and scarring (89%). Among the patients who preferred NOTES, for both men (23/25 [92%]) and women (43/53 [81%]), the oral route was the preferred orifice. A decreasing trend of patient preference for NOTES was observed with increased procedural complications: patient preference was 100% if complications were <3%, 97% if complications were equal to 3%, 15% if complications were 6%, and 6% if complications were 9%.

LIMITATIONS

A selective cohort of patients was evaluated.

CONCLUSIONS

Patients preferred NOTES to laparoscopy as the technique for cholecystectomy as long as the complication rates were comparable with current standards of LC. The oral orifice appeared to be the preferred approach for most patients. Given this favorable perception, further innovations in NOTES-related technology and refinements in procedural technique are justified.