Small-incision (mini-laparotomy) versus laparoscopic cholecystectomy: a retrospective study in a university hospital

Minilaparotomy Cholecystectomy as a Day Surgery Procedure: A Prospective Clinical Pilot Study

Background and Aims:

In some studies minilaparotomy cholecystectomy (MC) has been shown to be as good as laparoscopic cholecystectomy (LC) in the surgical treatment of cholecystolithiasis. To our knowledge, the MC operation is rarely considered as a day surgery procedure.

Patients and Methods:

Thirty elective symptomatic non-complicated patients were included in the study during the end of the year 2004 to June 2005. The mean age of patients was 52 years (range 27–68), the mean body mass index 29 kg/m2 (range 19–41). Gallstones were confirmed with ultrasound and the pre-operative liver laboratory tests were normal in all patients. A five (+/-2) centimetre-long incision was used avoiding to split the rectus abdominis muscle. All patients were re-evaluated four weeks postoperatively with the follow-up letter.

Results:

The average operating time was 51 minutes (range 30–105 minutes). Day surgery was possible in 25 cases (83%). Five patients (17%) stayed over night at the hospital. There were four (13%) conversions to conventional cholecystectomy. The average postoperative sick leave was 16 days (range 14–30). Two patients returned to hospital. One patient had wound pain, but no complication was found, and the patient was not admitted. One patient had a wound infection and spent 6 days in the hospital. Twenty-nine (97%) patients were satisfied with the operation and were ready to recommend it for other patients.

Conclusions:

The results of this study support the suitability of MC as a day surgery procedure, but a prospective randomised trial is needed to evaluate the relative advantages of MC and LC.

The long-term results of distal gastrectomy by mini-laparotomy in early gastric cancer patients

INTRODUCTION

Radical distal gastrectomy by mini-laparotomy is an alternative surgical treatment modality with technical feasibility in early gastric cancer (EGC) patients. The aim of this study is to assess the oncologic feasibility of distal gastrectomy by mini-laparotomy in EGC patients through a long-term survival analysis based on the prospectively collected data.

PATIENTS AND METHODS

From January 2003 to November 2003, a total of 53 EGC patients who received distal gastrectomy by laparotomy were enrolled in this study. These patients were divided into two groups, that is, the mini-laparotomy group (ML, n = 22) and the conventional laparotomy group (CL, n = 31). A comparative long-term survival analysis was performed.

RESULTS

The hospital stay was significantly shorter in mini-laparotomy group (P = 0.002). However, there were no significant differences in the pathologic results such as the resection margin and the number of harvested lymph nodes. In long-term survival results, there were no significant differences in disease-free and overall survival rate of the patients according to the method of laparotomy.

CONCLUSIONS

Radical distal gastrectomy by mini-laparotomy in EGC patients would be also one of the minimally invasive surgical modality in oncologic aspect.

Mini-laparotomy cholecystectomy: Technique, outcomes: A prospective study

BACKGROUND

The last decades have been characterized by a rapid growth in minimally invasive techniques for acute and chronic cholecystitis. The aim of our study was to analyze 10 years of experience with the mini-laparotomy cholecystectomy.

METHODS

From 1994 to 2004, we performed 2295 mini-laparotomy cholecystectomies, including 1028 patients with acute and 1267 patients with chronic cholecystitis. There were 1780 women and 515 men. We utilized a special surgical tool kit with a system of circular and small hook-retractors incorporating an illuminator and long surgical instruments. Our surgical approach was carried out using a 3-5 cm longitudinal incision located immediately above the gallbladder with a muscle splitting technique.

RESULTS

The mean time of operation was 64.5+/-24.5 min and the conversion rate was 3.7%. Intraoperative complications occurred in 25 cases (1.1%), including 4 cases (0.17%) of biliary tract injury. Cholecystectomy was combined with intervention on the choledochus and the papilla of Vater in 133 patients with choledocholithiasis. Postoperative complications developed in 4.1%. Five hundred and five patients (22%) required opioid analgesics on the first postoperative day. The mortality rate was 0.17%. The mortalities involved patients who had severe concomitant diseases and required urgent surgery for acute cholecystitis. Patients operated for acute cholecystitis had significantly higher rates of postoperative complications (5.8% vs. 2.8%), need for opioids (25.5% vs. 19.2%) and mortality (0.39% vs. 0%).

CONCLUSIONS

Mini-laparotomy cholecystectomy is an alternative to laparoscopic approach in the surgical treatment of acute and chronic cholecystitis.

Laparoscopic cholecystectomy after open cholecystostomy for gallbladder empyema: a case report

The case of a patient with gallbladder empyema initially drained through a minilaparotomy procedure under local anesthesia with a tube cholecystostomy is reported in this paper. Eight weeks later, the patient underwent an elective interval laparoscopic cholecystectomy. At laparoscopy, the gallbladder and the cholecystostomy tube were dissected free from the abdominal wall and the greater omentum, which was attached to the gallbladder. The tube was removed from the gallbladder fundus, and the operation was completed laparoscopically without any major problems.

Laparoscopic Cholecystectomy Without Intraoperative Cholangiography

BACKGROUND

The aim of this retrospective study was to evaluate the outcome of laparoscopic cholecystectomies (LCs) performed in our Academic Surgical Unit, and the impact of our policy not to perform intraoperative cholangiograms (IOCs) on the incidence of bile duct injuries (BDIs).

MATERIALS AND METHODS

Data was collected for the time period from 1992 (when the laparoscopic procedure was first introduced in our Unit) until 2005. During this time, 1851 patients underwent an LC. Patients with a history of jaundice, ultasonographic bile duct dilatation, bile duct stones, or deranged liver function tests were referred initially for an endoscopic retrograde cholangiopancreatography procedure. An IOC was not performed on any patient.

RESULTS

The conversion rate was 23.9% among the patients with acute cholecystitis and 1.6% among the patients with a noninflamed gallbladder. This difference was statistically significant. The morbidity reached 1.1%, as minor or major complications were present in 22 of 1851 patients. Complications consisted of BDI in 7 patients (0.37%). Six patients presented with minor BDI. Two of the BDIs occurred among the group of patients with acute cholecystitis, whereas the remaining 5 occurred in the group of patients with a noninflamed gallbladder. This distribution was not statistically significant.

CONCLUSIONS

The low BDI rate in our series allowed us to recommend an LC procedure without an IOC. Performing a cholangiogram either routinely or selectively is not wrong. However, adherence to a meticulous hemostatic technique, thorough knowledge of the anatomy, and a low threshold for conversion may also enable satisfactory results to be achieved.

Laparoscopic cholecystectomy versus mini-laparotomy cholecystectomy: a meta-analysis of randomised control trials

AIMS

To use meta-analytic techniques to compare peri-operative and short term post-operative outcomes for patients undergoing cholecystectomy via the laparoscopic or mini-open approach.

METHODS

Randomised control trials published between 1992 and 2005, cited in the literature of elective laparoscopic (LC) versus mini-open cholecystectomy (MoC) for symptomatic gallstone disease were included. End points evaluated were adverse events, operative and functional outcomes. A random effects meta-analytical model was used and between-study heterogeneity assessed. Subgroup analysis was performed to evaluate the difference in results for study size and quality and data reported from 2000.

RESULTS

Nine randomised studies of 2032 patients were included in the analysis. There was considerable variation in the size and type of incision used for MoC in the studies. There was a significantly longer operating time for the LC group, by 14.14 minutes (95% CI 2.08, 26.19; p < 0.0001). Length of stay was reduced in the LC group by 0.37 days (95% CI -0.53, -0.21; p < 0.0001), with no significant heterogeneity for either outcome. For all other operative and post-operative outcomes, there was no significant difference between the two groups.

CONCLUSION

MoC appeared to have similar outcomes compared to LC, however LC did reduce the length of hospital stay. MoC is a viable and safe option for healthcare providers without the financial resources for laparoscopic equipment and appropriately trained surgical teams.

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.

Non-randomised patients in a cholecystectomy trial: characteristics, procedures, and outcomes

Background

Laparoscopic cholecystectomy is now considered the first option for gallbladder surgery. However, 20% to 30% of cholecystectomies are completed as open operations often on elderly and fragile patients. The external validity of randomised trials comparing mini-laparotomy cholecystectomy and laparoscopic cholecystectomy has not been studied. The aim of this study is to analyse characteristics, procedures, and outcomes for all patients who underwent cholecystectomy without being included in such a trial.

Methods

Characteristics (age, sex, co-morbidity, and ASA-score), operation time, hospital stay, and mortality were compared for patients who underwent cholecystectomy outside and within a randomised controlled trial comparing mini-laparotomy and laparoscopic cholecystectomy.

Results

During the inclusion period 1719 patients underwent cholecystectomy. 726 patients were randomised and 724 of them completed the trial; 993 patients underwent cholecystectomy outside the trial. The non-randomised patients were older – and had more complications from gallstone disease, higher co-morbidity, and higher ASA – score when compared with trial patients. They were also more likely to undergo acute surgery and they had a longer postoperative hospital stay, with a median 3 versus 2 days (p < 0.001 for all comparisons). Standardised mortality ratio within 90 days of operation was 3.42 (mean) (95% CI 2.17 to 5.13) for non-randomised patients and 1.61 (mean) (95%CI 0.02 to 3.46) for trial patients. For non-randomised patients, operation time did not differ significantly between mini-laparotomy and open cholecystectomy in multivariate analysis. However, the operation for laparoscopic cholecystectomy lasted 20 minutes longer than open cholecystectomy. Hospital stay was significantly shorter for both mini-laparotomy and laparoscopic cholecystectomy compared to open cholecystectomy.

Conclusion

Non-randomised patients were older and more sick than trial patients. The assignment of healthier patients to trials comparing mini-laparotomy cholecystectomy and laparoscopic cholecystectomy limits the external validity of conclusions reached in such trials.

Open cholecystectomy for all patients in the era of laparoscopic surgery - a prospective cohort study

Background

Open cholecystectomy through a small incision is an alternative to laparoscopic cholecystectomy.

Methods

From 1 January 2002 through 31 December 2003, all operations upon the gallbladder in a district hospital with emergency admission and responsibility for surgical training were done as intended small-incision open cholecystectomy.

Results

182 women and 90 men with a median age of 56 (interquartile range 45 to 68 years) underwent cholecystectomy for symptomatic gallbladder disease, 170 as elective and 102 as emergency cases. Trainee surgeons assisted by consultants or registrars having passed an examination for open cholecystectomy performed surgery in 194 cases (71%). The common bile duct was explored in 52 patients. Total postoperative morbidity was six percent. Median postoperative stay was one day and mean total (pre- and postoperative) hospital stay 3.1 days. 32 operations (12%) were done as day surgery procedures. Nationally in Sweden in 2002, mean total hospital stay was 4.4 days, and 13% of all cholecystectomies were performed on an outpatient basis.

Conclusion

Open, small-incision cholecystectomy for all patients is compatible with short hospital stay, evidence-based gall-bladder surgery, and training of surgical residents.

Impact of treatment policies on patient outcomes and resource utilization in acute cholecystitis in Japanese hospitals

Background

Although currently available evidence predominantly recommends early laparoscopic cholecystectomy (LC) for the treatment of acute cholecystitis, this strategy has not been widely adopted in Japan. Herein, we describe a hospital-based study of patients with acute cholecystitis in 9 Japanese teaching hospitals in order to evaluate the impact of different institutional strategies in treating acute cholecystitis on overall patient outcomes and medical resource utilization.

Methods

From an administrative database and chart review, we identified 228 patients diagnosed with acute cholecystitis who underwent cholecystectomy between April 2001 and June 2003. In order to examine the relationship between hospitals' propensity to perform LC and patient outcomes and/or medical resource utilization, we divided the hospitals into three groups according to the observed to expected ratio of performing LC (LC propensity), and compared the postoperative complication rate, length of hospitalization (LOS), and medical charges.

Results

No hospital adopted the policy of early surgery, and the mean overall LOS among the subjects was 30.9 days. The use of laparoscopic surgery varied widely across the hospitals; the adjusted rates of LC to total cholecystectomies ranged from 9.5% to 77%. Although intra-operative complication rate was significantly higher among patients whom LC was initially attempted when compared to those whom OC was initially attempted (9.7% vs. 0%), there was no significant association between LC propensity and postoperative complication rates. Although the postoperative time to oral intake and postoperative LOS was significantly shorter in hospitals with high use of LC, the overall LOS did not differ among hospital groups with different LC propensities. Medical charges were not associated with LC propensity.

Conclusion

Under the prevailing policy of delayed surgery, in terms of the postoperative complication rate and medical resource utilization, our study did not show the superiority of LC in treating acute cholecystitis patients. The timing of surgery and discharge was mainly determined by the institutional policy in Japan, rather than by the clinical course of the patient; however, considering the substantially less postoperative pain and shorter recovery time of LC compared to OC, LC should be actively applied for the treatment of acute cholecystitis. If the policy of early surgery were universally applied, the advantage of LC over OC may be more clearly demonstrated.

Minilaparotomy cholecystectomy versus laparoscopic cholecystectomy: a randomized study with special reference to obesity

BACKGROUND

Minilaparotomy cholecystectomy (MC) has recently challenged the role of the laparoscopic approach (LC) for cholecystectomies. However, the situation is far from clear when operating times and recovery are evaluated.

METHODS

Altogether 157 patients with uncomplicated symptomatic gallstones were randomized into MC (n = 85) and LC (n = 72) groups. Both groups were similar in terms of age, body mass index, American Society of Anesthesiology (ASA) physical fitness classification, and operating surgeon.

RESULTS

The mean operating time was 55 +/- 19.5 min in the MC group and 79 +/- 27.0 min in the LC group (p < 0.0001). The postoperative hospital stay and length of sick leave did not differ between the two groups. There were no significant differences in postoperative pain, analgesic consumption, or postoperative pulmonary function between the groups. The body mass index did not influence operating time or patient recovery in either group. No major complications occurred in either groups.

CONCLUSION

The MC procedure seems to be a faster technique than the LC approach for noncomplicated gallstone disease, with no difference in recovery times. The MC procedure also seems to be suitable for the obese patient.

Gallstone disease: Surgical aspects of symptomatic cholecystolithiasis and acute cholecystitis

Indications for cholecystectomy are limited to clearly symptomatic gallstones. Relatively high failure rates of pain relief are probably caused by incorrect selection of patients for the operation. Contraindications for (laparoscopic) cholecystectomy are related to anaesthesiological considerations. Laparoscopic cholecystectomy was accepted by consensus as the gold standard within 5 years of its introduction. Nevertheless, both the classical open and small-incision cholecystectomies are safe alternatives, and superiority of any one of the three techniques over the others has not been proven. Primary outcome measures (mortality, complications, and symptom relief) seem to be equal for the three techniques. Acute cholecystitis is a complication of gallstones. Generally it is recommended that early cholecystectomy be performed, as delayed cholecystectomy is associated with longer total hospital stay and convalescence due to recurrent cholecystitis episodes. Cholecystostomy is an alternative technique for patients unfit for general anaesthesia. Reported complication and conversion rates in cholecystectomy for acute cholecystitis vary, but are higher than for symptomatic cholecystolithiasis. New developments--such as robot-assisted surgery--are expected to have a significant impact in the near future.

Duration, complications, stress, and pain of open ovariohysterectomy versus a simple method of laparoscopic-assisted ovariohysterectomy in dogs

OBJECTIVE

To describe a simple method of laparoscopic-assisted ovariohysterectomy (LAOHE) and compare duration of surgery, complications, measures of surgical stress, and postoperative pain with open ovariohysterectomy (OHE) in dogs.

DESIGN

Randomized, prospective clinical trial.

ANIMALS

20 healthy sexually intact female dogs weighing >10 kg (22 lb).

PROCEDURES

Dogs were randomly allocated to receive conventional OHE or LAOHE. Intraoperative complications, anesthetic complications, total anesthesia time, and total surgery time were recorded. Serum cortisol and glucose concentrations, temperature, heart rate, and respiratory rate were measured preoperatively and 1, 2, 4, 6, 12, and 24 hours postoperatively. Pain scores were assigned by a nonblinded observer at 1, 2, 4, 6, 12, and 24 hours postoperatively. Duration of surgery, pain scores, objective measures of surgical stress, anesthetic complications, and surgical complications were compared between OHE and LAOHE.

RESULTS

Age, weight, PCV, and duration of surgery did not differ between treatment groups. Nine of 10 dogs in the OHE group required additional pain medication on the basis of pain scores, whereas none of the dogs in the LAOHE group did. Blood glucose concentrations were significantly increased from preoperative concentrations in the OHE group at 1, 2, 4, and 6 hours postoperatively and at 1 hour postoperatively in the LAOHE group. Cortisol concentrations were significantly increased at 1 and 2 hours postoperatively in the OHE group.

CONCLUSIONS AND CLINICAL RELEVANCE

LAOHE caused less pain and surgical stress than OHE and may be more appropriate for an outpatient setting.

Current status of laparoscopic therapy of cholecystolithiasis and common bile duct stones

BACKGROUND

Laparoscopic cholecystectomy (LC) is the standard operation for gallstone disease. The aim of this review was to scrutinize the advantages and benefits of this minimal invasive technique compared to the conventional operation according to the available literature. Regarding the evidence-based medicine criteria, the current status of laparoscopy in the treatment of cholecystolithiasis, cholecystitis and common bile duct stones has been worked out.

METHODS

A Medline, PubMed, Cochrane search.

RESULTS

Ten randomized controlled trials (RCTs) are available comparing laparoscopic versus open cholecystectomy. The superiority of LC in less postoperative pain, shorter recovery and hospital stay is stated. Operation time was longer in the first years of LC. 3 RCTs deal with acute cholecystitis: one paper could not find any significant advantage of LC over conventional cholecystectomy, the other two found benefits in recovery, hospital stay and postoperative pain. The range of conversion is between 5 and 7% in elective cases and increases up to 27% for acute cholecystitis. With a rate of more than 90% in Europe, the standard procedure for common bile duct stones is 'therapeutic splitting' with endoscopy and retrograde cholangiopancreatography preoperatively followed by LC. Laparoscopic bile duct clearance is effective and safe in experienced hands, however, the only proven benefit is a slightly shorter hospital stay.

CONCLUSION

The laparoscopic approach is preferred in elective cholecystectomy and acute cholecystitis. The minimal invasive technique has proven to be effective, gentle and safe. The main benefits are evident within the first postoperative days.