Laparoscopic cholecystectomy

Randomised, prospective, single-blind comparison of laparoscopic versus small-incision cholecystectomy

BACKGROUND

We report a prospective randomised comparison between laparoscopic and small-incision cholecystectomy in 200 patients which was designed to eliminate bias for or against either technique.

METHODS

Patients were randomised in the operating theatre and anaesthetic technique and pain-control methods were standardised. Four experienced surgeons did both types of procedure. Identical wound dressings were applied in both groups so that carers could be kept blind to the type of operation.

FINDINGS

There was no significant difference between the groups for age, sex, body mass index, and American Society of Anaesthesiologists grade. Laparoscopic cholecystectomy took significantly longer than small-incision cholecystectomy (median 65 [range 27-140] min vs 40 [18-142] min, p<0.001). The operating time included operative cholangiography which was attempted in all patients. We found no significant difference between the groups for hospital stay (postoperative nights in hospital, median 3-0 [1-17] nights for laparoscopic vs 3-0 [1-14] nights for small-incision, p=0.74), time back to work for employed persons (median 5-0 weeks vs 4.0 weeks; p=0.39), and time to full activity (median 3-0 weeks vs 3.0 weeks; p=0.15).

INTERPRETATION

Laparoscopic cholecystectomy takes longer to do than small-incision cholecystectomy and does not have any significant advantages in terms of hospital stay or postoperative recovery.

Randomized trial of laparoscopic cholecystectomy and mini-cholecystectomy

Three hundred and ten patients having elective cholecystectomy were randomized to either laparoscopic cholecystectomy or mini-cholecystectomy. There were 155 patients in each group. Conversion to open cholecystectomy was significantly more common with laparoscopic cholecystectomy (13 versus 4 per cent) and complications were significantly more frequent with laparoscopic cholecystectomy (9 versus 3 per cent). If laparoscopic cholecystectomy was successful, hospital stay was significantly shorter than for mini-cholecystectomy (2 versus 3 days respectively), but overall the hospital stay was not significantly different. Postoperative analgesia requirements were reduced and return to normal activities and to work were faster after laparoscopic cholecystectomy. There was no significant cost difference between the two procedures.

Unexpected difficulties in randomizing patients in a surgical trial: a prospective study comparing extracorporeal shock wave lithotripsy with open cholecystectomy

Shortly after extracorporeal shock wave lithotripsy (ESWL) was introduced as a promising new treatment modality for gallstone disease, a randomized controlled study was performed to assess the cost-effectiveness of ESWL compared to open cholecystectomy, the gold standard. During the performance of this study it was found that during a 3-year intake period only 8.3% (37 of 448) of the patients could be entered into the trial. Three factors were identified that hampered patient accrual: (1) restricted eligibility for ESWL (and thus for the study), which could not have been predicted on the data provided in the literature; (2) the introduction of laparoscopic cholecystectomy; and (3) strong patient preference, inhibiting randomization. All three mechanisms could not have been predicted during the design phase of the study. It is concluded that it is not always feasible to conduct a randomized study in surgery due to unforeseen circumstances. Entering patients into surgical trials is difficult in quickly evolving fields of surgery, such as the management of gallstone disease. Acquiring informed consent is also difficult when treatment characteristics are divergent. A randomized controlled study on the effects of laparoscopic cholecystectomy will therefore probably never be performed.