Laparoscopic cholecystectomy versus mini-laparotomy cholecystectomy: a prospective, randomized, single-blind study

Preliminary Experience with Mini-Laparotomy Cholecystectomy in Jos

Background

Different techniques have been described for removing a diseased gall bladder; however, cholecystectomy via the laparoscopic approach is currently regarded as the gold standard. Laparoscopic surgery services are not widely available in low- and middle-income countries and mini-laparotomy cholecystectomy may be a suitable alternative in such circumstances. This technique achieves cholecystectomy with a smaller incision and affords the advantages of the laparoscopic approach.

Objective

We report our experience over a 2-year period of 24 consecutive patients from two hospitals who underwent mini-laparotomy cholecystectomy to highlight our outcomes with the procedure.

Materials and Methods

Data were obtained from the surgical theatre procedure register and medical records department of the hospital.

Results

During the study period, a total of 24 mini-laparotomy cholecystectomies were performed. Fourteen (58.3%) patients had a clinical diagnosis of calculous cholecystitis whereas 10 (41.7%) patients had symptomatic gallstones. There were four males (16.7%) and 20 females (83.3%) giving a male-to-female ratio of 1:5. The ages ranged from 18 to 68 years with a mean of 46.8 years (standard deviation (SD) = 12.7 years) and the mean operating time was 56.3 min (SD = 7.5 min) and ranged from 45 to 72 min. There was no conversion to the traditional large incision cholecystectomy. There were no intra-operative or post-operative complications and there was no mortality in the study. All the patients were discharged 48 h post-op.

Conclusion

Mini-laparotomy cholecystectomy offers the benefits of a minimally invasive procedure such as good cosmesis and short hospital stay. It has a relatively short operative time and a low incidence of complications and can be practised in a low-resource environment, where laparoscopic services are not available.

The ED50 and ED95 of esketamine for preventing early postoperative pain in patients undergoing laparoscopic cholecystectomy: a prospective, double-blinded trial

BACKGROUND

This study aims to estimate the safety, efficacy, and median effective dose (ED50) of esketamine for preventing early postoperative pain in patients undergoing laparoscopic cholecystectomy.

METHODS

54 patients undergoing laparoscopic cholecystectomy were prospectively randomized into two groups (group C and group E). Different doses of esketamine were intravenously administered before the skin incision in Group E. The patients in group C received the same dose of saline at the same time. General population characteristics were recorded. The median effective dose (ED50) and 95% effective dose (ED95) were calculated using Dixon's up-and-down method. Hemodynamic parameters were monitored, and pain intensity was assessed using a visual analog scale. We also recorded the condition of anesthesia recovery period and postoperative adverse reactions.

RESULTS

The ED50 of esketamine for preventing early postoperative pain was 0.301 mg/kg (95%CI: 0.265-0.342 mg/kg), and the ED95 was 0.379 mg/kg (95%CI: 0.340-0.618 mg/kg), calculated by probability unit regression. Heart rate (HR) was significantly lower in the esketamine group compared to the control at the skin incision (p < 0.05). The total VAS score at resting was significantly lower in the esketamine group compared to the control group during the awakening period (p < 0.05). There was no significant difference between the two groups regarding the incidence of adverse reactions (p > 0.05).

CONCLUSIONS

In this study, esketamine can prevent early postoperative pain effectively. The ED50 and ED95 of esketamine for controlling early postoperative pain were 0.301 mg/kg and 0.379 mg/kg, respectively.

TRIAL REGISTRATION

ChiCTR2200066663, 13/12/2022.

Management of cholelithiasis with choledocholithiasis: Endoscopic and surgical approaches

Gallstone disease and complications from gallstones are a common clinical problem. The clinical presentation ranges between being asymptomatic and recurrent attacks of biliary pain requiring elective or emergency treatment. Bile duct stones are a frequent condition associated with cholelithiasis. Amidst the total cholecystectomies performed every year for cholelithiasis, the presence of bile duct stones is 5%-15%; another small percentage of these will develop common bile duct stones after intervention. To avoid serious complications that can occur in choledocholithiasis, these stones should be removed. Unfortunately, there is no consensus on the ideal management strategy to perform such. For a long time, a direct open surgical approach to the bile duct was the only unique approach. With the advent of advanced endoscopic, radiologic, and minimally invasive surgical techniques, however, therapeutic choices have increased in number, and the management of this pathological situation has become multidisciplinary. To date, there is agreement on preoperative management and the need to treat cholelithiasis with choledocholithiasis, but a debate still exists on how to cure the two diseases at the same time. In the era of laparoscopy and mini-invasiveness, we can say that therapeutic approaches can be performed in two sessions or in one session. Comparison of these two approaches showed equivalent success rates, postoperative morbidity, stone clearance, mortality, conversion to other procedures, total surgery time, and failure rate, but the one-session treatment is characterized by a shorter hospital stay, and more cost benefits. The aim of this review article is to provide the reader with a general summary of gallbladder stone disease in association with the presence of common bile duct stones by discussing their epidemiology, clinical and diagnostic aspects, and possible treatments and their advantages and limitations.

Comparative outcomes of needlescopic, single-incision laparoscopic, standard laparoscopic, mini-laparotomy, and open cholecystectomy: A systematic review and network meta-analysis of 96 randomized controlled trials with 11,083 patients

BACKGROUND

Most randomized trials on minimally invasive cholecystectomy have been conducted with standard (3/4-port) laparoscopic or open cholecystectomy serving as the control group. However, there exists a dearth of head-to-head trials that directly compare different minimally invasive techniques for cholecystectomy (eg, single-incision laparoscopic cholecystectomy versus needlescopic cholecystectomy). Hence, it remains largely unknown how the different minimally invasive cholecystectomy techniques fare up against one another.

METHODS

To minimize selection and confounding biases, only randomized controlled trials were considered for inclusion. Perioperative outcomes were compared using frequentist network meta-analyses. The interpretation of the results was driven by treatment effects and surface under the cumulative ranking curve values. A sensitivity analysis was also undertaken focusing on a subgroup of randomized controlled trials, which recruited patients with only uncomplicated cholecystitis.

RESULTS

Ninety-six eligible randomized controlled trials comprising 11,083 patients were identified. Risk of intra-abdominal infection or abscess, bile duct injury, bile leak, and open conversion did not differ significantly between minimally invasive techniques. Needlescopic cholecystectomy was associated with the lowest rates of wound infection (surface under the cumulative ranking curve value = 0.977) with an odds ratio of 0.095 (95% confidence interval: 0.023-0.39), 0.32 (95% confidence interval: 0.11-0.98), 0.33 (95% confidence interval: 0.11-0.99), 0.36 (95% confidence interval: 0.14-0.98) compared to open cholecystectomy, single-incision laparoscopic cholecystectomy, mini-laparotomy, and standard laparoscopic cholecystectomy, respectively. Mini-laparotomy was associated with the shortest operative time (surface under the cumulative ranking curve value = 0.981) by a mean difference of 22.20 (95% confidence interval: 13.79-30.62), 12.17 (95% confidence interval: 1.80-22.54), 9.07 (95% confidence interval: 1.59-16.54), and 8.36 (95% confidence interval: -1.79 to 18.52) minutes when compared to single-incision laparoscopic cholecystectomy, needlescopic cholecystectomy, standard laparoscopic cholecystectomy, and open cholecystectomy, respectively. Needlescopic cholecystectomy appeared to be associated with the shortest hospitalization (surface under the cumulative ranking curve value = 0.717) and lowest postoperative pain (surface under the cumulative ranking curve value = 0.928).

CONCLUSION

Perioperative outcomes differed across minimally invasive techniques and, in some instances, afforded superior outcomes compared to standard laparoscopic cholecystectomy. These findings suggest that there may be equipoise for exploring further the utility of novel minimally invasive techniques and potentially incorporating them into the general surgery training curriculum.

Does near-infrared fluorescent cholangiography with indocyanine green reduce bile duct injuries and conversions to open surgery during laparoscopic or robotic cholecystectomy? - A meta-analysis

BACKGROUND

Bile duct injury and conversion-to-open-surgery rates remain unacceptably high during laparoscopic and robotic cholecystectomy. In a recently published randomized clinical trial, using near-infrared fluorescent cholangiography with indocyanine green intraoperatively markedly enhanced biliary-structure visualization. Our systematic literature review compares bile duct injury and conversion-to-open-surgery rates in patients undergoing laparoscopic or robotic cholecystectomy with versus without near-infrared fluorescent cholangiography.

METHODS

A thorough PubMed search was conducted to identify randomized clinical trials and nonrandomized clinical trials with ≥100 patients. Because all near-infrared fluorescent cholangiography studies were published since 2013, only studies without near-infrared fluorescent cholangiography published since 2013 were included for comparison. Incidence estimates, weighted and unweighted for study size, were adjusted for acute versus chronic cholecystitis, and for robotic versus laparoscopic cholecystectomy and are reported as events/10,000 patients. All studies were assessed for bias risk and high-risk studies excluded.

RESULTS

In total, 4,990 abstracts were reviewed, identifying 5 near-infrared fluorescent cholangiography studies (3 laparoscopic cholecystectomy/2 robotic cholecystectomy; n = 1,603) and 11 not near-infrared fluorescent cholangiography studies (5 laparoscopic cholecystectomy/4 robotic cholecystectomy/2 both; n = 5,070) for analysis. Overall weighted rates for bile duct injury and conversion were 6 and 16/10,000 in near-infrared fluorescent cholangiography patients versus 25 and 271/10,000 in patients without near-infrared fluorescent cholangiography. Among patients undergoing laparoscopic cholecystectomy, bile duct injuries, and conversion rates among near-infrared fluorescent cholangiography versus patients without near-infrared fluorescent cholangiography were 0 and 23/10,000 versus 32 and 255/10,000, respectively. Bile duct injury rates were low with robotic cholecystectomy with and without near-infrared fluorescent cholangiography (12 and 8/10,000), but there was a marked reduction in conversions with near-infrared fluorescent cholangiography (12 vs 322/10,000).

CONCLUSION

Although large comparative trials remain necessary, preliminary analysis suggests that using near-infrared fluorescent cholangiography with indocyanine green intraoperatively sizably decreases bile duct injury and conversion-to-open-surgery rates relative to cholecystectomy under white light alone.

Twenty years of mini-laparoscopy in Brazil: What we have learned so far

The mini-laparoscopic cholecystectomy (MLC) was first performed in 1996, as the logical advancement of the conventional laparoscopic cholecystectomy. In Brazil, mini-laparoscopy was first performed in 1998, by Professors Peter Goh and Go Wakabaiashi, who performed a cholecystectomy using 3-mm instruments. The first study, with a considerable number of patients, was performed in Recife by Dr. Carvalho, and he reported that 719 patients were submitted to a MLC with a small rate of conversion for conventional laparoscopy. We discuss the development of mini-laparoscopy in Brazil for the past 20 years.

Applying the Delphi process for development of a hepatopancreaticobiliary robotic surgery training curriculum

BACKGROUND

Robotic hepatopancreaticobiliary (HPB) procedures are performed worldwide and establishing processes for safe adoption of this technology is essential for patient benefit. We report results of the Delphi process to define and optimize robotic training procedures for HPB surgeons.

METHODS

In 2019, a robotic HPB surgery panel with an interest in surgical training from the Americas and Europe was created and met. An e-consensus-finding exercise using the Delphi process was applied and consensus was defined as 80% agreement on each question. Iterations of anonymous voting continued over three rounds.

RESULTS

Members agreed on several points: there was need for a standardized robotic training curriculum for HPB surgery that considers experience of surgeons and based on a robotic hepatectomy includes a common approach for "basic robotic skills" training (e-learning module, including hardware description, patient selection, port placement, docking, troubleshooting, fundamentals of robotic surgery, team training and efficiency, and emergencies) and an "advanced technical skills curriculum" (e-learning, including patient selection information, cognitive skills, and recommended operative equipment lists). A modular approach to index procedures should be used with video demonstrations, port placement for index procedure, troubleshooting, and emergency scenario management information. Inexperienced surgeons should undergo training in basic robotic skills and console proficiency, transitioning to full procedure training of e-learning (video demonstration, simulation training, case observation, and final evaluation). Experienced surgeons should undergo basic training when using a new system (e-learning, dry lab, and operating room (OR) team training, virtual reality modules, and wet lab; case observations were unnecessary for basic training) and should complete the advanced index procedural robotic curriculum with assessment by wet lab, case observation, and OR team training.

CONCLUSIONS

Optimization and standardization of training and education of HPB surgeons in robotic procedures was agreed upon. Results are being incorporated into future curriculum for education in robotic surgery.

Mini-cholecystectomy versus laparoscopic cholecystectomy: a retrospective multicentric study among patients operated in some Eastern Libyan hospitals

Objectives

This study was conducted to analyze the difference between Mini-Cholecystectomy (MC) and Laparoscopic Cholecystectomy (LC) in terms of feasibility and postoperative outcomes to determine if MC could be accepted as a good alternative procedure to LC.

Material and Methods

A retrospective comparative study of 206 consecutively operated patients of chronic cholecystitis (138 LC and 68 MC), in Al-Jalaa, Ajdabiya and Almrg Teaching hospitals between January 2014 and December 2015 was performed. All cases within the two groups were balanced for age, sex, co-morbidities, ultrasound and intraoperative findings. Exclusion criteria were acute cholecystitis, preoperative jaundice, liver cirrhosis, suspicion of malignancy, previous upper abdominal surgery and pregnancy.

Results

Mean age of the patients in the study was around 37 years. Female patients represented 88.84%. Intraoperative complications occurred in about 2% of the patients with bleeding in three cases (one in MC, two in LC) and injury to the bile ducts occurred in one case who underwent LC. Operative duration was longer in LC (mean values 64 minutes for LC and 45 minutes for MC). Rate of conversion to classical cholecystectomy in LC was 5% while it was 0% in MC. Only one case of wound infection was registered in the LC group. Postoperative hospital stay was insignificantly longer for LC versus MC (1.97 days for MC and 2.63 days for LC).

Conclusion

Mini-cholecystectomy is a feasible technique, which can be considered as a good alternative method for gallbladder removal for surgeons who have no experience with laparoscopic techniques and in peripheral hospitals where LC is not available.

Predicting Conversion from Laparoscopic to Open Cholecystectomy: A Single Institution Retrospective Study

BACKGROUND

Laparoscopic cholecystectomy (LC) is the standard surgical treatment for benign gallbladder disease. Nevertheless, conversion to open cholecystectomy (OC) is needed in some cases. The aim of this study is to calculate our institutional conversion rate and to identify the variables that are implicated in increasing the risk of conversion (LC-OC).

MATERIALS AND METHODS

We carried out a retrospective study of all cases of LC performed at the American University of Beirut Medical Center between 2000 and 2015. Each (LC-OC) case was randomly matched to a laparoscopically completed case by the same consultant within the same year of practice, as the LC-OC case, in a 1:5 ratio. Forty-eight parameters were compared between the two study groups.

RESULTS

Forty-eight out of 4668 LC were converted to OC over the 15-year study period; the conversion rate in our study was 1.03%. The variables that were found to be most predictive of conversion were male gender, advanced age, prior history of laparotomy, especially in the setting of prior gunshot wound, a history of restrictive or constrictive lung disease and anemia (Hb < 9 g/dl). The most common intraoperative reasons for conversion were perceived difficult anatomy or obscured view secondary to severe adhesions or significant inflammation. Patients who were in the LC-OC arm had a longer length of hospital stay.

CONCLUSION

Advance age, male gender, significant comorbidities and history of prior laparotomies have a high risk of conversion. Patients with these risk factors should be counseled for the possibility of conversion to open surgery preoperatively. Further research is needed to determine whether these high risks patients should be operated on by surgeons with more extensive experience in minimal invasive surgery.

Comparison Between Outcomes of Laparoscopic Cholecystectomy in Patients With Liver Cirrhosis or With Normal Liver Function

Objective and Background:

The safety of laparoscopic cholecystectomy in patients with Child–Pugh A and B cirrhosis is well-established, but perioperative complications are frequently observed in patients with cirrhosis. Technical challenges of this operation in cirrhotic patients remain in need of resolution.

Methods:

Twenty-one patients preoperatively diagnosed as having cirrhosis underwent laparoscopic cholecystectomy mainly using the French approach and were retrospectively reviewed. Their clinicopathologic characteristics were compared with 74 continuous patients with gallstone but no cirrhosis who underwent laparoscopic cholecystectomy using the American approach.

Results:

Most cirrhotic patients (19/21, 90.5%) had a chronic liver disease such as hepatitis B/C, alcoholic hepatitis, or primary biliary cholangitis. On imaging, the Chilaiditi sign and gallbladder bed pocket score, previously proposed to be informative in these patients, were significantly higher in the cirrhosis group than in the no cirrhosis group. Although the Child–Pugh score was higher in patients with cirrhosis, the model for end-stage liver disease (MELD) score was similar for the 2 groups. There were no differences in the operation time or the amount of intraoperative blood transfused. Postoperative hospital stay and postoperative morbidity rates were significantly greater in the cirrhosis group, although severe complications with a Clavien–Dindo score ≥ IIIa occurred in only 1 patient in each group.

Conclusions:

The safety of laparoscopic cholecystectomy in cirrhotic patients was confirmed. Because the gallbladder is completely covered in patients with cirrhosis, the French style approach, which enables surgeons to more easily access the gallbladder pocket, is assumed to be one of the operative options.

Costs and quality of life of small-incision open cholecystectomy and laparoscopic cholecystectomy - an expertise-based randomised controlled trial

Background

Health care providers need solid evidence based data on cost differences between alternative surgical procedures for common surgical disorders. We aimed to compare small-incision open cholecystectomy (SIOC) and laparoscopic cholecystectomy (LC) concerning costs and health-related quality of life using data from an expertise-based randomised controlled trial.

Methods

Patients scheduled for cholecystectomy were assigned to undergo LC or SIOC performed by surgeons in two different expert groups. Total costs were calculated in USD. Reusable instruments were assumed for the cost analysis. Quality of life was measured using the EuroQol 5-D 3-L (EQ 5-D-3L), at five postoperative time points and calculated to Area Under Curve (AUC) for 1 year postoperatively. Two hospitals participated in the trial, which included both emergency and elective surgery.

Results

Of 477 patients that underwent a cholecystectomy during the study period, 355 (74.9%) were randomised and 323 analysed, 172 LC and 151 SIOC patients. Both direct and total costs were less for SIOC than for LC patients. The total costs were 5429 (4293–6932) USD for LC and 4636 (3905–5746) USD for SIOC, P = 0.001. The quality of life index did not differ between the LC and SIOC groups at any time. Median values (25th and 75th percentiles (p25-p75)) for AUC at 1 year were as follows: 349 (337–351) for LC and 349 (338–350) for SIOC.

Conclusions

In this expertise-based randomised controlled trial LC was a more costly procedure and quality of life did not differ after SIOC and LC. (ClinicalTrials.gov Identifier: NCT00370344, August 30, 2006).

Electronic supplementary material

The online version of this article (doi:10.1186/s12876-017-0601-1) contains supplementary material, which is available to authorized users.

Consequences of Lost Gallstones During Laparoscopic Cholecystectomy: A Review Article

BACKGROUND

Laparoscopic cholecystectomy (LC) has become a popular and widespread procedure for the treatment of gallstone disease. There is still an increasing concern about specific complications of LC due to gallbladder perforation and spillage of bile and stones. Although unretrieved intraperitoneal gallstones rarely become symptomatic, their infective complications may cause serious morbidities even after a long interval from LC.

METHODS

We performed a review of the literature on the diagnosis, prevention, consequences, and management of lost gallstones. All studies with a focus on lost gallstones or perforated gallbladder were analyzed to evaluate the postoperative complications.

RESULTS

Between 1991 and 2015, >250 cases of postoperative complications of spilled gallstones were reviewed in the surgical literature. The most common complications are intraperitoneal abscesses and fistulas. Confusing clinical pictures due to gallstones spreading in different locations makes diagnosis challenging. Even asymptomatic dropped gallstones may masquerade intraperitoneal neoplastic lesions.

CONCLUSIONS

Every effort should be made to prevent gallbladder perforation; otherwise, they should be retrieved immediately during laparoscopy. In cases with multiple large spilled stones or infected bile, conversion to open surgery can be considered. Documentation in operative notes and awareness of patients about lost gallstones are mandatory to early recognition and treatment of any complications.

Inflammatory response to surgical trauma in patients with minilaparotomy cholecystectomy versus laparoscopic cholecystectomy: a randomised multicentre study

OBJECTIVE

The aim of the study was to evaluate the inflammatory response to surgical trauma in minilaparotomy cholecystectomy (MC) compared to laparoscopic cholecystectomy (LC). Assessment of inflammatory response to surgical trauma in MC has not been addressed properly. Therefore, we investigated five interleukins (IL) and C-reactive protein (CRP) in MC versus LC group in a prospective randomised trial.

METHODS

Initially, 106 patients with non-complicated symptomatic gallstone disease were randomised into MC (n = 56) or LC (n = 50) groups. Plasma levels of five interleukins (IL-1β, IL-1ra, IL-6, IL-8, IL-10) and hs-CRP were measured at three time points; before operation (PRE), immediately after operation (POP1) and six hours after operation (POP2). The primary end-point of the study was to compare the plasma levels of five interleukins and CRP in LC versus MC group.

RESULTS

The demographic variables and the surgical data were similar in the study groups. The patients in the MC group had higher elevation of the CRP mean values post-operatively (p = 0.01). However, the patients in the MC group had higher elevation of the IL-1ra mean values post-operatively, the mean pre-/post-operative IL-1ra values being 299/614 pg/ml in the MC group versus 379/439 pg/ml in the LC group (p = 0.003). There was no statistical significance in IL-6 mean values between the MC and LC groups pre- and post-operatively (POP1). However, the patients in the MC group had higher IL-6 mean values six hours post-operatively (POP2), the mean IL-6 values being 27.6 pg/ml in the MC group versus 14.8 pg/ml in the LC group (p = 0.037). In addition, the patients in the MC group had higher elevation of the IL-6 mean values post-operatively, the mean pre-/post-operative IL-6 values being 4.1/27.6 pg/ml in the MC group versus 3.8/14.8 pg/ml in the LC group (p = 0.04). There was no statistical significance in IL-8, IL-10, and IL-1β mean values between the MC and LC groups pre- and post-operatively.

CONCLUSION

Our results suggest that the inflammatory response in MC versus LC groups was similar based on the IL-8, IL-10, and IL-1β values. A new finding with possible clinical relevance in the present work is higher relative elevation of the IL-1ra and IL-6 mean values post-operatively in the MC group.

Iatrogenic common bile duct injuries: Increasing complexity in the laparoscopic era: A prospective cohort study

PURPOSE

Iatrogenic bile duct injury (BDI) is the most significant associated complication to laparoscopic cholecystectomy (LC). Little is known about the evolution of the pattern of BDI in the era of laparoscopy. The aim of the study is to assess the pattern of post-LC BDIs managed in a tertiary referral centre.

METHODS

Post-LC BDI referred over two decades were studied. Demographic data, type of BDI (classified using the Strasberg System), clinical symptoms, diagnostic investigations, timing of referral, post-referral management and morbidity were analysed. The pattern of injury, associated vascular injuries rate and their management were compared over two time periods (1992-2004,2005-2014).

RESULTS

78 BDIs were referred. During the second time period Strasberg A injuries decreased from 14% to 0 and Strasberg E1increased from 4% to 23%, the rate of associated vascular injury was six time higher (3.6% versus 22.7%), more patients had an attempted repair at the index hospital (16% versus 35%) sand fewer patients could be managed without surgical intervention at the referral hospital (28% versus 4%).

CONCLUSION

Complexity of referred BDIs and rate of associated vascular injuries have increased over time. These findings led to more patients managed requiring surgical intervention at the referral hospital.

A modified Delphi method toward multidisciplinary consensus on functional convalescence recommendations after abdominal surgery

Background

Evidence-based information on the resumption of daily activities following uncomplicated abdominal surgery is scarce and not yet standardized in medical guidelines. As a consequence, convalescence recommendations are generally not provided after surgery, leading to patients’ insecurity, needlessly delayed recovery and prolonged sick leave. The aim of this study was to generate consensus-based multidisciplinary convalescence recommendations, including advice on return to work, applicable for both patients and physicians.

Method

Using a modified Delphi method among a multidisciplinary panel of 13 experts consisting of surgeons, occupational physicians and general practitioners, detailed recommendations were developed for graded resumption of 34 activities after uncomplicated laparoscopic cholecystectomy, laparoscopic and open appendectomy, laparoscopic and open colectomy and laparoscopic and open inguinal hernia repair. A sample of occupational physicians, general practitioners and surgeons assessed the recommendations on feasibility in daily practice. The response of this group of care providers was discussed with the experts in the final Delphi questionnaire round.

Results

Out of initially 56 activities, the expert panel selected 34 relevant activities for which convalescence recommendations were developed. After four Delphi rounds, consensus was reached for all of the 34 activities for all the surgical procedures. A sample of occupational physicians, general practitioners and surgeons regarded the recommendations as feasible in daily practice.

Conclusion

Multidisciplinary convalescence recommendations regarding uncomplicated laparoscopic cholecystectomy, appendectomy (laparoscopic, open), colectomy (laparoscopic, open) and inguinal hernia repair (laparoscopic, open) were developed by a modified Delphi procedure. Further research is required to evaluate whether these recommendations are realistic and effective in daily practice.

Anesthesia for Endoscopy

Anesthesia for endoscopic surgery can be challenging depending on surgical manipulations and patient comorbidity. Anesthetists must understand the possible systemic changes and complications that are associated with endoscopic surgery. Pneumoperitoneum induces vasoconstriction, reduces cardiac output, and decreases functional residual capacity in the cardiopulmonary system. Both hypoventilation caused by the thoracoscopic procedure and CO2 insufflation increase Paco2. To prevent the problems associated with high Paco2, monitoring of end-tidal CO2 (ETco2) and capability of positive pressure ventilation are crucial. Sudden changes of ETco2 should be monitored closely. Endoscopic surgery should be a less invasive procedure; however, appropriate analgesia remains necessary.

Laparoscopic cholecystectomy versus minilaparotomy in cholelithiasis: systematic review and meta-analysis

Introduction

A introdução da técnica laparoscópica em 1985 foi um fator importante na colecistectomia por representar técnica menos invasiva, resultado estético melhor e menor risco cirúrgico comparado ao procedimento laparotômico.

Aim

To compare laparoscopic and minilaparotomy cholecystectomy in the treatment of cholelithiasis.

Methods

A systematic review of randomized clinical trials, which included studies from four databases (Medline, Embase, Cochrane and Lilacs) was performed. The keywords used were "Cholecystectomy", "Cholecystectomy, Laparoscopic" and "Laparotomy". The methodological quality of primary studies was assessed by the Grade system.

Results

Ten randomized controlled trials were included, totaling 2043 patients, 1020 in Laparoscopy group and 1023 in Minilaparotomy group. Laparoscopic cholecystectomy dispensed shorter length of hospital stay (p<0.00001) and return to work activities (p<0.00001) compared to minilaparotomy, and the minilaparotomy shorter operative time (p<0.00001) compared to laparoscopy. Laparoscopy decrease the risk of postoperative pain (NNT=7) and infectious complications (NNT=50). There was no statistical difference between the two groups regarding conversion (p=0,06) and surgical reinterventions (p=0,27), gall bladder's perforation (p=0,98), incidence of common bile duct injury (p=1.00), surgical site infection (p=0,52) and paralytic ileus (p=0,22).

Conclusion

In cholelithiasis, laparoscopic cholecystectomy is associated with a lower incidence of postoperative pain and infectious complications, as well as shorter length of hospital stay and time to return to work activities compared to minilaparotomy cholecystectomy.

New trends in colorectal surgery: Single port and natural orifice techniques

Single-incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) have rapidly gained pace worldwide, potentially replacing conventional laparoscopic surgery (CLS) as the preferred colorectal surgery technique. Currently available data mainly consist of retrospective series analyzed in four meta-analyses. Despite conflicting results and lack of an objective comparison, SILS appears to offer cosmetic advantages over CLS. However, due to conflicting results and marked heterogeneity, present data fail to show significant differences in terms of operative time, postoperative morbidity profiles, port-site complications rates, oncological appropriateness, duration of hospitalization or cost when comparing SILS with conventional laparoscopy for colorectal procedures. The application of “pure” NOTES in humans remains limited to case reports because of unresolved issues concerning the ideal access site, distant organ reach, spatial orientation and viscera closure. Alternatively, minilaparoscopy-assisted natural orifice surgery techniques are being developed. The transanal “down-to-up” total mesorectum excision has been derived for transanal endoscopic microsurgery (TEM) and represents the most encouraging NOTES-derived technique. Preliminary experiences demonstrate good oncological and functional short-term outcomes. Large-scale randomized controlled trials are now mandatory to confirm the long-term SILS results and validate transanal TEM for the application of NOTES in humans.

Single-session minimally invasive management of common bile duct stones

Up to 18% of patients submitted to cholecystectomy had concomitant common bile duct stones. To avoid serious complications, these stones should be removed. There is no consensus about the ideal management strategy for such patients. Traditionally, open surgery was offered but with the advent of endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC) minimally invasive approach had nearly replaced laparotomy because of its well-known advantages. Minimally invasive approach could be done in either two-session (preoperative ERCP followed by LC or LC followed by postoperative ERCP) or single-session (laparoscopic common bile duct exploration or LC with intraoperative ERCP). Most recent studies have found that both options are equivalent regarding safety and efficacy but the single-session approach is associated with shorter hospital stay, fewer procedures per patient, and less cost. Consequently, single-session option should be offered to patients with cholecysto-choledocholithiaisis provided that local resources and expertise do exist. However, the management strategy should be tailored according to many variables, such as available resources, experience, patient characteristics, clinical presentations, and surgical pathology.

A prospective, randomized multicenter study comparing conventional laparoscopic cholecystectomy versus minilaparotomy cholecystectomy with ultrasonic dissection as day surgery procedure--1-year outcome

OBJECTIVE

The long-term outcome between laparoscopic cholecystectomy (LC) and minilaparotomy cholecystectomy (MC) with ultrasonic dissection (UsD) technique has not been compared in randomized trials. Therefore, we investigated the outcome after conventional LC and MC with UsD in 78 patients (ClinicalTrials.gov Identifier: NCT0172340).

MATERIAL AND METHODS

Initially 88 patients with non-complicated symptomatic gallstone disease were randomized into MC (n = 44) or LC (n = 44) over a period of 2 years (2010-2012) and 78 of them (89%) were reached for a follow-up interview at 12 months after the surgery.

RESULTS

Baseline parameters were similar in the two groups, and 1/44 MCs and 2/44 LCs were converted to open laparotomy. The prevalence of chronic post-surgical pain (CPSP) one year after the procedure was quite similar in the two groups: 3/36 (8%) in the MC group and 2/42 (5%) in the LC group (p = 0.502). Residual abdominal symptoms were common, but the proportion was similar in both groups (28% in MC and 33% in LC group, p = 0.665). Both groups were very satisfied with the cosmetic outcome (numeric rating scale, p = 0.470). The Quality of life (QoL) improved 34/36 (94%) in the MC group and 33/42 (79%) in the LC group (p = 0.046) and all patients in both groups were satisfied with the operation overall.

CONCLUSION

Day-case MC and LC patients have a quite similar one-year outcome with no significant difference regarding residual abdominal symptoms, cosmetic satisfaction, QoL or CPSP.

Evaluation of the health-related quality of life for patients following laparoscopic cholecystectomy

PURPOSE

Laparoscopic cholecystectomy (LC) has become the standard procedure, and contributes to a shorter hospital stay. However, there have been no reports regarding when the patients can be discharged in terms of their health-related quality of life (HRQOL).

METHODS

The HRQOL was evaluated by using the SF-8 health survey (SF-8) 24-hour version in 127 consecutive patients treated from May 2007 to December 2008. The HRQOL and a visual analogue scale (VAS) score were assessed on the day before surgery and on postoperative day (POD) 1, POD2 and POD7.

RESULTS

All scores of the eight domains on POD1 were significantly decreased compared to the preoperative score (P < 0.05), and seven scores were still decreased on POD2, with the mental health (MH) domain showing an improvement. On POD7, the general health score improved to the preoperative level. The physical component summary 8 (PCS-8) was suppressed for all 7 days after LC. The mental health component summary 8 (MCS-8) was improved to the preoperative level on POD2, despite the significant suppression observed on POD1 (P < 0.05). The VAS score was higher in the low PCS-8 (PCS-8 < 42.4) and low MCS-8 (MCS-8 < 40.6) patients than in the high PCS-8 and high MCS-8 patients.

CONCLUSION

The HRQOL score demonstrated the improvement of the MCS-8 on POD2, which might suggest that a discharge of LC patients is appropriate on POD2 in terms of the patients' point of view.

Surgical treatment of subcostal incisional hernia with polypropylene mesh - analysis of late results

OBJECTIVE: To evaluate the results of subcostal incisional hernia repair using polypropylene mesh, the technical aspects of musculo-aponeurotic reconstruction, routine fixation of supra-aponeurotic mesh and follow-up for five years.METHODS: We conducted a retrospective study that assessed 24 patients undergoing subcostal incisional hernia repair with use of polypropylene mesh; 15 patients (62.5%) were female; ages ranged from 33 to 82, and 79.1% had comorbidities.RESULTS: Early complications: three cases (12.5%) of wound infection, three cases (12.5%) of seroma, one case (4.1%) of hematoma; and one case (4.1%) of wound dehiscence. Late complications occurred in one case (4.1%) of hernia recurrence attributed to technical failure in the fixation of the mesh and in one case (4.1%) of chronic pain. There were no cases of exposure or rejection of the mesh.CONCLUSION: The subcostal incisional hernia, though not very relevant, requires adequate surgical treatment. Its surgical correction involves rebuilding the muscle-aponeurotic defect, supra-aponeurotic fixation of polypropylene mesh, with less complexity and lower rates of complications and recurrences.

Mini-invasive surgery for colorectal cancer

Laparoscopic techniques have been extensively used for the surgical management of colorectal cancer during the last two decades. Accumulating data have demonstrated that laparoscopic colectomy is associated with better short-term outcomes and equivalent oncologic outcomes when compared with open surgery. However, some controversies regarding the oncologic quality of mini-invasive surgery for rectal cancer exist. Meanwhile, some progresses in colorectal surgery, such as robotic technology, single-incision laparoscopic surgery, natural orifice specimen extraction, and natural orifice transluminal endoscopic surgery, have been made in recent years. In this article, we review the published data and mainly focus on the current status and latest advances of mini-invasive surgery for colorectal cancer.

Endoscopic transluminal necrosectomy in necrotising pancreatitis: a systematic review

OBJECTIVE

We performed a systematic review to assess the outcome of endoscopic transluminal necrosectomy in necrotising pancreatitis with additional focus on indication, disease severity, and methodological quality of studies.

DESIGN

We searched the literature published between January 2005 and June 2013. Cohorts, including patients with (infected) necrotising pancreatitis, undergoing endoscopic necrosectomy were included. Indication, disease severity, and methodological quality were described. The main outcomes were mortality, major complications, number of endoscopic sessions, and definitive successful treatment with endoscopic necrosectomy alone.

RESULTS

After screening 581 papers, 14 studies, including 455 patients, fulfilled the eligibility criteria. All included studies were retrospective analyses except for one randomized, controlled trial. Overall methodological quality was moderate to low (mean 5, range 2-9). Less than 50 % of studies reported on pre-procedural severity of disease: mean APACHE-II score before intervention was 8; organ failure was present in 23 % of patients; and infected necrosis in 57 % of patients. On average, four (range 1-23) endoscopic interventions were performed per patient. With endoscopic necrosectomy alone, definitive successful treatment was achieved in 81 % of patients. Mortality was 6 % (28/460 patients) and complications occurred in 36 % of patients. Bleeding was the most common complication.

CONCLUSIONS

Endoscopic transluminal necrosectomy is an effective treatment for the majority of patients with necrotising pancreatitis with acceptable mortality and complication rates. It should be noted that methodological quality of the available studies is limited and that the combined patient population of endoscopically treated patients is only moderately ill.

[Not Available]

OBJECTIVE

To deteremine the incidence, nature and management of extra-biliary complications of laparoscopic cholecystectomy.

MATERIALS AND METHODS

This study presents a retrospective analysis of extra-biliary complications occuring during 1046 laparoscopic cholecystectomies performed from August 2003 to December 2006. The study population included all the patients with symptomatic gallstone disease in whom laparoscopic cholecystectomy was performed. The extra-biliary complications were divided into two distinct categories: (i) Procedure related and (ii) Access related.

RESULTS

The incidence of access-related complications was 3.77% and that of procedure-related complications was 6.02%. Port-site bleeding was troublesome at times and demanded a re-do laparoscopy or conversion. Small bowel laceration occurred in two patients where access was achieved by closed technique. Five cases of duodenal and two of colonic perforations were the major complications encountered during dissection in the area of Calot's triangle. In 21 (2%) patients the procedure was converted to open surgery due to different complications. Biliary complications occurred in 2.6% patients in the current series.

CONCLUSION

Major extra-biliary complications are as frequent as the biliary complications and can be life-threatening. An early diagnosis is critical to their management.

Expertise-based randomized clinical trial of laparoscopic versus small-incision open cholecystectomy

Background

Several randomized clinical trials have compared laparoscopic cholecystectomy (LC) and small-incision open cholecystectomy (SIOC). Most have had wide exclusion criteria and none was expertise-based. The aim of this expertise-based randomized trial was to compare healthcare costs, quality of life (QoL), pain and clinical outcomes after LC and SIOC.

Methods

Patients scheduled for cholecystectomy were randomized to treatment by one of two teams of surgeons with a preference for either LC or SIOC. Each team performed their specific method (SIOC or LC) as a first-choice operation, but converted to open cholecystectomy and common bile duct exploration when necessary. Intraoperative cholangiography was carried out routinely. The intention was to include all patients undergoing cholecystectomy, including emergency operations and procedures involving surgical training for residents.

Results

Some 74·9 per cent of all patients undergoing cholecystectomy were included. Of 355 patients randomized, 333 were analysed. Self-estimated QoL scores in 258 patients, analysed by the area under the curve method, were significantly lower in the SIOC group at 1 month after surgery: median 2326 (95 per cent confidence interval 2187 to 2391) compared with 2411 (2334 to 2502) for the LC group (P = 0·030). The mean(s.d.) duration of operation was shorter for SIOC: 97(41) versus 120(48) min (P &lt; 0·001). There were no significant differences between the groups in conversion rate, pain, complications, length of hospital stay or readmissions.

Conclusion

SIOC had comparable surgical results but slightly worse short-term QoL compared with LC. Registration number: NCT00370344 (http://www.clinicaltrials.gov).

Prevention and treatment of bile duct injuries during laparoscopic cholecystectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES)

BACKGROUND

Laparoscopic cholecystectomy is one of the most common surgical procedures in Europe (and the world) and has become the standard procedure for the management of symptomatic cholelithiasis or acute cholecystitis in patients without specific contraindications. Bile duct injuries (BDI) are rare but serious complications that can occur during a laparoscopic cholecystectomy. Prevention and management of BDI has given rise to a host of publications but very few recommendations, especially in Europe.

METHODS

A systematic research of the literature was performed. An international expert panel was invited to appraise the current literature and to develop evidence-based recommendations. Statements and recommendations were drafted after a consensus development conference in May 2011, followed by presentation and discussion at the annual congress of the EAES held in Torino in June 2011. Finally, full guidelines were consented and adopted by the expert panel via e-mail and web conference.

RESULTS

A total of 1,765 publications were identified through the systematic literature search and additional submission by panellists; 671 publications were selected as potentially relevant. Only 46 publications fulfilled minimal methodological criteria to support Clinical Practice Guidelines recommendations. Because the level of evidence was low for most of the studies, most statements or recommendations had to be based on consensus of opinion among the panel members. A total of 15 statements and recommendations were developed covering the following topics: classification of injuries, epidemiology, prevention, diagnosis, and management of BDI.

CONCLUSIONS

Because BDI is a rare event, it is difficult to generate evidence for prevention, diagnosis, or the management of BDI from clinical studies. Nevertheless, the panel has formulated recommendations. Due to the currently limited evidence, a European registry should be considered to collect and analyze more valid data on BDI upon which recommendations can be based.

Contributing factors to postoperative length of stay in laparoscopic cholecystectomy

This study indicates that patients undergoing laparoscopic cholecystectomy have discernable characteristics that can contribute in a major way to postoperative length of stay.

Background:

Laparoscopic cholecystectomy for gallbladder disease is a common surgical procedure performed in hospitals throughout the world. This study evaluates the major factors that contribute to postoperative length of stay for patients undergoing laparoscopic cholecystectomy.

Methods:

We analyzed data for patients undergoing laparoscopic cholecystectomy in a 5-hospital community health system from December 1, 2008 to January 31, 2009. The natural logarithm of postoperative length of stay was modeled to evaluate significant factors and contributions.

Results:

Included in the analysis were 232 patients. Three preoperative patient factors were significant contributors: body mass index was associated with decreased postoperative length of stay, while white blood cell count and the presence of biliary pancreatitis were associated with increased postoperative length of stay. The operative factors of fluids administered and ASA class were significant contributors to increased postoperative length of stay, with an increasing contribution with a higher ASA class. The utilization factor of nonelective status was a significant contributor to increased postoperative length of stay.

Conclusion:

Several factors were major contributors to postoperative length of stay, with ASA class and nonelective status having the most significant increased contribution. Efforts to optimize efficient elective care delivery for patients with symptomatic gallbladder disease may demonstrate a benefit of decreased hospital utilization.

Evaluating systemic stress response in single port vs. multi-port laparoscopic cholecystectomy

BACKGROUND AND AIMS

Acute-phase proteins and inflammatory cytokines mediate measurable responses to surgical trauma, which are proportional to the extent of tissue injury and correlate with post-operative outcome. By comparing systemic stress following multi-port (LC) and single-incision laparoscopic cholecystectomy (SILC), we aim to determine whether reduced incision size induces a reduced stress response.

METHODS

Thirty-five consecutive patients were included, 11 underwent SILC (mean ± SEM; age 44.8 ± 3.88 year; BMI 27 ± 1.44 kg/m(2)) and 24 underwent LC (56.17 ± 2.80 year; 31.72 ± 1.07 kg/m(2), p < 0.05). Primary endpoint measures included levels of interleukin-6 and C-reactive protein measured pre- and post-operatively. Length-of-stay (LOS) and postoperative morbidity were secondary endpoints.

RESULTS

No statistically significant differences were found between SILC and LC for interleukin-6 and C-reactive protein levels, LOS and duration of surgery. There was also no correlation between systemic stress response and operative parameters. There were no intra-operative complications.

CONCLUSION

SILC appears to be a safe, feasible technique with potential advantages of cosmesis, reduced incisional pain, and well-being recommending its use. These data indicate no difference in systemic stress and morbidity between SILC and LC. A larger, multi-centred, randomised prospective trial is warranted to further investigate and confirm this finding.

Needlescopic clipless cholecystectomy as an efficient, safe, and cost-effective alternative with diminutive scars: the first 1000 cases

BACKGROUND

The advent of natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopic surgery (SILS), surgery without skin scarring, is now challenging every surgeon to improve the esthetic results for patients. Minilaparoscopic cholecystectomy (MLC) represents a refinement in laparoscopic surgery, potentially as cosmetically effective as NOTES. Nevertheless, because of the increased cost and difficulty in managing the equipment, it has not been widely accepted among surgeons.

OBJECTIVE

To report modifications of the minilaparoscopic technique that make it possible to conduct needlescopic procedures safely and effectively, thereby, considerably reducing costs and promoting the dissemination of this operation.

METHOD

One thousand consecutive patients who underwent MLC were analyzed, from January 2000 to May 2009 (78.7% women; average age 45.9 y).

SURGICAL TECHNIQUE

after performing the pneumoperitoneum at the umbilical site, 4 trocars were inserted; 2 of 2 mm, 1 of 3 mm, and 1 of 10 mm in diameter, through which a laparoscope was inserted. Neither the 3-mm laparoscope, nor clips, nor manufactured endobags were used. The cystic artery was safely sealed by electrocautery near the gallbladder neck and the cystic duct was sealed with surgical knots. Removal of the gallbladder was carried out, in an adapted bag made with a glove wrist, through the 10-mm umbilical site.

RESULTS

The operative time was 43 minutes. The average hospital stay was 16 hours. There was no conversion to open surgery; 2.8% of patients underwent conversion to standard (5 mm) laparoscopic cholecystectomy because of difficulties with the procedure; there were 1.9% minor umbilical site infections and 1.0% umbilical herniations. There was no mortality; no bowel injury, no bile duct injury, and no postoperative hemorrhage, only 1 patient with Luschka's duct bile leakage needed a reoperation.

CONCLUSIONS

The MLC technique shows no differences in risks as compared with other laparoscopic cholecystectomy procedures. It also entails a considerable reduction in cost, and, as it does not use the 3-mm laparoscope or disposable materials, it is possible to perform MLC on a larger number of patients. Owing to the near invisibility of scars, MLC may also be considered as cosmetically effective as NOTES and SILS.

What necessitates the conversion to open cholecystectomy? A retrospective analysis of 5164 consecutive laparoscopic operations

OBJECTIVE

Laparoscopic cholecystectomy (LC) has become the gold standard for the surgical treatment of gallbladder disease, but conversion to open cholecystectomy is still inevitable in certain cases. Knowledge of the rate and impact of the underlying reasons for conversion could help surgeons during preoperative assessment and improve the informed consent of patients. We decided to review the rate and causes of conversion from laparoscopic to open cholecystectomy.

METHOD

This study included all laparoscopic cholecystectomies due to gallstone disease undertaken from May 1999 to June 2010. The exclusion criteria were malignancy and/or existence of gallbladder polyps detected pathologically. Patient demographics, indications for cholecystectomy, concomitant diseases, and histories of previous abdominal surgery were collected. The rate of conversion to open cholecystectomy, the underlying reasons for conversion, and postoperative complications were also analyzed.

RESULTS

Of 5382 patients for whom LC was attempted, 5164 were included this study. The overall rate of conversion to open cholecystectomy was 3.16% (163 patients). There were 84 male and 79 female patients; the mean age was 52.04 years (range: 26-85). The conversion rates in male and female patients were 5.6% and 2.2%, respectively (p < 0.001). The most common reasons for conversion were severe adhesions caused by tissue inflammation (97 patients) and fibrosis of Calot's triangle (12 patients). The overall postoperative morbidity rate was found to be 16.3% in patients who were converted to open surgery.

CONCLUSION

Male gender was found to be the only statistically significant risk factor for conversion in our series. LC can be safely performed with a conversion rate of less than 5% in all patient groups.

Delayed assessment and eager adoption of laparoscopic cholecystectomy: Implications for developing surgical technologies

Despite the prevailing emphasis in the medical literature on establishing evidence, many changes in the practice of surgery have not been achieved using proper evidence-based assessment. This paper examines the adoption of laparoscopic cholecystectomy (LC) into regular use for the treatment of cholecystitis and the process of its acceptance, focusing on the limited role of technology assessment in its appraisal. A review of the published medical literature concerning LC was performed. Approximately 3000 studies of LC have been conducted since 1985, and there have been nearly 8500 publications to date. As LC was adopted enthusiastically into practice, the results of outcome studies generally showed that it compared favorably with the traditional, open cholecystectomy with regard to mortality, complications, and length of hospital stay. However, despite the rapid general agreement on surgical technique, efficacy, and appropriateness, there remained lingering doubts about safety, outcomes, and cost of the procedure that suggested that essential research questions were ignored even as the procedure became standard. Using LC as a case study, there are important lessons to be learned about the need for important guidelines for surgical innovation and the adoption of minimally invasive surgical techniques into current clinical and surgical practice. We highlight one recent example, natural orifice transluminal endoscopic surgery and how necessary it is to properly evaluate this new technology before it is accepted as a safe and effective surgical option.

Early laparoscopic cholecystectomy improves outcomes after endoscopic sphincterotomy for choledochocystolithiasis

BACKGROUND & AIMS

Patients with choledochocystolithiasis generally undergo endoscopic sphincterotomy (ES) followed by laparoscopic cholecystectomy (LC). However, many patients receive this surgery 6-8 weeks after ES. There is a high conversion rate of elective LC after ES, and patients can develop recurrent biliary events during the waiting period. We investigated whether the timing of surgery influences outcome.

METHODS

We performed a randomized trial of patients with choledochocystolithiasis who underwent successful ES. Patients were randomly assigned to groups that received early LC (within 72 hours after ES, n = 49) or delayed LC (after 6-8 weeks, n = 47), based on an expected difference in conversion rate of 25% vs 5%, respectively. Conversion rate, biliary events during follow-up, duration and difficulty of surgeries, postoperative morbidity, and hospital stay were scored. Intention-to-treat analyses were performed.

RESULTS

Groups were comparable in age, sex, and comorbidity. There was no difference between groups in conversion rate (4.3% in early vs 8.7% in delayed group) nor were there differences in operating times and/or difficulties or hospital stays. During the waiting period for LC, 17 patients in the delayed group (36.2%) developed recurrent biliary events compared with 1 patient in the early group (P < .001).

CONCLUSIONS

In a randomized trial to evaluate timing of LC after ES, recurrent biliary events occurred in 36.2% of patients whose LC was delayed for 6-8 weeks. Early LC (within 72 hours) appears to be safe and might prevent the majority of biliary events in this period following sphincterotomy.

[Laparoscopic transumbilical cholecystectomy. Results with the gel device and literature review]

INTRODUCTION

The appearance of single transumbilical incision surgery has opened a new era in the minimally invasive approach of cholecystectomy. Specific ports for this technique have made it easier to perform. We report our initial experience, from July 2008 to June 2009 and give an updated bibliographic review.

PATIENTS AND METHODS

A prospective, longitudinal and interventional study that included 30 patients with symptomatic cholelithiasis, from 10 July 2008 to 30 June 2009, on whom a single transumbilical incision laparoscopic cholecystectomy was performed (LESS technique), without other minilaparoscopic ports or traction stitches. A gel port was used for all surgeries (R-Port, Tri-Port), as well as straight and roticulating laparoscopic graspers. Surgical time, analgesia requirements, postoperative hospital stay, conversions and complications were registered.

RESULTS

The median age was 34.8 years (range, from 21 to 53), with a BMI between 21 kg/m(2) and 39.5 kg/m(2) (mean 25.8 kg/m(2)). Surgical time was 65.1 minutes (ranging from 40 to 150) and postoperative length stay was less than 24 hours. Postoperative pain was measured with the VAS scale, giving a low score. Up to now, two wound infections and a bile leak have been observed.

CONCLUSIONS

LESS cholecystectomy is a safe and feasible technique performed by experienced surgeons in minimally invasive surgery, and requires a greater learning curve than that of the conventional laparoscopic cholecystectomy.

Reported effects in randomized controlled trials were compared with those of nonrandomized trials in cholecystectomy

OBJECTIVES

Because external validity of randomized controlled trials (RCTs) may be insufficient, the performance of nonrandomized controlled trials (nRCTs) is increasingly debated. RCTs and nRCTs were compared using the example of laparoscopic vs. open cholecystectomy (LC vs. OC).

STUDY DESIGN AND SETTING

RCTs and nRCTs comparing LC and OC were identified by searching PubMed. To assess internal and external validity of the studies, patient characteristics, relative risks, and mean differences of RCTs and nRCTs were compared by meta-analytic techniques.

RESULTS

In total, 162 studies were analyzed (136 nRCTs and 26 RCTs). Significant discrepancies between RCT- and nRCT-based results were revealed for 3 of 15 variables: overall complications (P<0.021), wound infections (P<0.014), and length of hospital stay (P<0.005). In RCTs and in nRCTs, length of hospital stay and return to work were significantly reduced when using LC compared with OC. The results of nRCTs were more often heterogeneous among themselves (11 of 15) as compared with RCTs (4 of 15).

CONCLUSION

The results of RCTs and nRCTs differ significantly in at least 20% of the variables. External validities of RCTs and nRCTs in LC vs. OC appear to be similar. Between-study heterogeneity was larger in nRCTs than in RCTs of cholecystectomy.

Cost-minimization analysis in a blind randomized trial on small-incision versus laparoscopic cholecystectomy from a societal perspective: sick leave outweighs efforts in hospital savings

Background

After its introduction, laparoscopic cholecystectomy rapidly expanded around the world and was accepted the procedure of choice by consensus. However, analysis of evidence shows no difference regarding primary outcome measures between laparoscopic and small-incision cholecystectomy. In absence of clear clinical benefit it may be interesting to focus on the resource use associated with the available techniques, a secondary outcome measure. This study focuses on a difference in costs between laparoscopic and small-incision cholecystectomy from a societal perspective with emphasis on internal validity and generalisability

Methods

A blinded randomized single-centre trial was conducted in a general teaching hospital in The Netherlands. Patients with reasonable to good health diagnosed with symptomatic cholecystolithiasis scheduled for cholecystectomy were included. Patients were randomized between laparoscopic and small-incision cholecystectomy. Total costs were analyzed from a societal perspective.

Results

Operative costs were higher in the laparoscopic group using reusable laparoscopic instruments (difference 203 euro; 95% confidence interval 147 to 259 euro). There were no significant differences in the other direct cost categories (outpatient clinic and admittance related costs), indirect costs, and total costs. More than 60% of costs in employed patients were caused by sick leave.

Conclusion

Based on differences in costs, small-incision cholecystectomy seems to be the preferred operative technique over the laparoscopic technique both from a hospital and societal cost perspective. Sick leave associated with convalescence after cholecystectomy in employed patients results in considerable costs to society.

Trial registration

ISRCTN Register, number ISRCTN67485658.

The accordion severity grading system of surgical complications

BACKGROUND

A severity grading system is essential to reporting surgical complications. In 1992, we presented such a system (T92). Its use and that of systems derived from it have increased exponentially. Our purpose was to determine how well T92 and its modifications have functioned as a severity grading system and to develop an improved system for reporting complications.

METHODS

129 articles were studied in detail. Twenty variables were searched for in each article with particular emphasis on type of study, substitution of qualitative terms for grades, grade compression, and cut-points if grade compression was used. We also determined relative distribution of complications and manner of presentation of complications.

RESULTS

T92 and derivative classifications have received wide use in surgical studies ranging from small studies with few complications to large studies of complex operations that describe many complications. There is a strong tendency to contract classifications and to substitute terms with self evident meaning for the numerical grades. Complications are presented in a large variety of tabular forms some of which are much easier to follow than others.

CONCLUSIONS

Current methods for reporting the severity of complications incompletely fulfill the needs of authors of surgical studies. A new system-the Accordion Severity Grading System-is presented. The Accordion system can be used more readily for small as well as large studies. It introduces standard definition of simple quantitative terms and presents a standard tabular reporting system. This system should bring the field closer to a common severity grading method for surgical complications.

Primary access-related complications in laparoscopic cholecystectomy via the closed technique: experience of a single surgical team over more than 15 years

BACKGROUND

Laparoscopic cholecystectomy (LC), a common laparoscopic procedure, is a relatively safe invasive procedure, but complications can occur at every step, starting from creation of the pneumoperitoneum. Several studies have investigated procedure-related complications, but the primary access- or trocar-related complications generally are underreported, and their true incidence may be higher than studies show. Major vascular or visceral injury resulting from blind access to the abdominal cavity, although rare, has been reported. Of the two methods for creating pneumoperitoneum, the open access technique is reported to have the lower incidence of these injuries. The authors report their experience with the closed method and show that if performed with proper technique, it can be as rapid and safe as other techniques. However, injuries still happen, and the search for the predisposing factors must be continued.

METHODS

Between January 1992 and December 2007, a retrospective study examined 15,260 cases of LC performed for symptomatic gallstone disease in the authors' institution by a single team of surgeons. The primary access-related injuries in these cases were retrospectively analyzed.

RESULTS

In 15,260 cases of LC, 63 cases of primary access-related complications were identified, for an overall incidence of 0.41%. Major injuries in 11 cases included major vascular and visceral injuries, and minor injuries in 52 cases included omental and subcutaneous emphysema. For the closed method, the findings showed an overall incidence of 0.14% for primary access-related vascular injuries and 0.07% for visceral injuries.

CONCLUSION

Primary access-related complications during LC are common and can prove to be fatal if not identified early. The incidence of these injuries with closed methods is no greater than with open methods. No evidence suggests abandonment of the closed-entry method in laparoscopy.

Open cholecystectomy

Open cholecystectomy is employed most commonly when severe inflammation precludes identification of critical anatomy during laparoscopic cholecystectomy. Several other situations, however, still require a laparotomy to remove the gallbladder. A current challenge is to teach young surgeons how to safely manage complex gallbladder disease, when there is minimal experience with open biliary surgery during residency.