Twenty years after Erich Muhe: Persisting controversies with the gold standard of laparoscopic cholecystectomy

Outcomes of Concurrent Ventral Hernia Repair and Cholecystectomy Compared to Ventral Hernia Repair Alone

Introduction It has been suggested that hernia repair with concomitant cholecystectomy increases the risk of postoperative complications due to potential mesh contamination. This study compares postoperative outcomes and complications between patients who underwent ventral hernia repair (VHR) with and without concomitant cholecystectomy (CCY). Methods Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database, from 2005 to 2019, we queried patients who underwent ventral hernia repairs using the current procedural terminology (CPT) codes 49652-49657 (laparoscopic) and 49560-49566 (open), with or without cholecystectomy. The ACS NSQIP is a prospective, systematic study of patients who underwent major general surgical procedures aggregating data from over 200 hospitals. Cases involving additional concomitant procedures were excluded. Primary outcomes of interest were 30-day mortality, length of stay, readmission, return to operating room (OR), and postoperative complications. The odds ratio for primary outcomes was calculated using multivariable binomial logistic regression to control for patient risk factors. Results In total, 167586 cases were identified, 165,758 ventral hernia repairs alone, and 1,828 ventral hernia repairs with concomitant cholecystectomy. There was no difference in 30-day mortality, length of stay, readmission, return to the operating room, or postoperative complications between groups. Patients who underwent simultaneous VHR/CCY when compared to those who had VHR alone, had no differences in the rate of surgical site infections (1.86% vs. 1.97%, P = 0.57) or sepsis (0.82% vs. 0.41%, P = 0.10).  Conclusion In a large national sample, there is no significant difference in postoperative outcomes, specifically infection-related complications, when comparing VHR along with concurrent VHR/CCY. Our findings suggest no increased risks for patients undergoing concurrent ventral hernia repair and cholecystectomy. Hence, surgeons might consider this combined approach to offer the best value-based care, especially when it could eliminate the need for a second operation and the risk of infection is low. Prospective studies with more procedural-specific information for hernia repairs and indications for cholecystectomy are needed however it is likely safe to perform both procedures during the same setting in cholecystectomy cases lacking signs of acute infection.

Advances in endoscopic surgery for small animal reproduction

Although endoscopic surgery entered its "golden era" in the mid-1980s, it is still advancing at a tremendous pace. Novel surgical techniques and devices are continuously developed and applied, and new indications (and/or contraindications) for the use of endoscopic surgery are routinely reported in the literature and subjected to systematic assessments. Although endoscopic surgery (laparoscopy in particular) has already become established as the gold standard in human medicine, it has yet to be proven as a viable alternative to open surgery in the field of veterinary medicine. The advantages of minimally invasive surgery include better intra-operative visualization, reduced postoperative pain, reduced scar formation and increased postoperative mobility. Therefore, it is reasonable to expect that the application of this will continue to expand. Small animal reproduction, a field within the broad discipline of veterinary medicine, has already recognized and begun to reap the benefits of endoscopic surgery. Herein, we retrospectively review the most recent successful novel applications of endoscopic surgery in the small animal reproduction system to provide small animal reproductive surgeons with important knowledge to help improve their own veterinarian medical practice.

Cicatrical cecal volvulus following laparoscopic cholecystectomy

Complications can arise from spilled gallstones during cholecystectomy. A surgeon should make every effort to avoid gallbladder perforation and spillage of stones during laparoscopic cholecystectomy.

Laparoscopic cholecystectomy is the procedure of choice for the treatment of symptomatic biliary disease. There is currently no agreement on the management of spilled gallstones, which commonly occurs during laparoscopic cholecystectomy and may produce significant morbidity. We present a case of spilled gallstones causing cicatrical cecal volvulus and also provide a review of pertinent literature.

Outcomes of simultaneous laparoscopic cholecystectomy and ventral hernia repair compared to that of laparoscopic cholecystectomy alone

BACKGROUND

Although incidental hernias frequently are found and repaired during laparoscopic cholecystectomy (LC), the outcomes of simultaneous LC and laparoscopic ventral hernia repair (LVHR) have not been scrutinized. In this study we evaluated short-term outcome data comparing simultaneous LC and LVHR against LC alone.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database (2005-2009) was queried using primary procedure and secondary current procedural terminology (CPT(®)) codes for LC and LVHR. Outcomes analyzed included separate LC and LVHR and simultaneous laparoscopic cholecystectomy and ventral hernia repair (LC/LVHR). The 30 day clinical outcomes along with postoperative hospital length of stay (LOS) were assessed using the χ(2) test and analysis-of-variance test with p values < 0.01 set as significant. We also performed forward stepwise multivariable regression taking in to consideration over 50 ACS NSQIP risk factors to adjust for patient risk.

RESULTS

A total of 82,837 patients underwent LC and/or LVHR of which 357 (0.4%) underwent simultaneous LC/LVHR. Patients who underwent LC/LVHR were more likely to have surgical site infections, suffer sepsis or septic shock, and have pulmonary complications, including pneumonia, reintubation or prolonged ventilator requirements, than LC-alone patients. No difference was noted in 30 day mortality, rates of deep vein thrombosis/pulmonary embolism (DVT/PE), renal insufficiency, or stroke. After multivariable adjustment for over 50 ACS NSQIP risk factors, concurrent LC/LVHR continued to pose a higher risk for these outcomes relative to LC only.

CONCLUSIONS

Simultaneous LC/LVHR results in greater postoperative morbidity in terms of surgical site infections, sepsis, and pulmonary complications when compared to LC alone. In light of this increased short-term morbidity, consideration should be given toward performing LC and LVHR independently in patients requiring both procedures. Prospective studies with long-term follow-up are required to better understand the implications of simultaneous LC/LVHR.

Combined procedures with laparoscopic cholecystectomy

With advancement in laparoscopic surgery a number of surgical procedures can be performed combined with laparoscopic cholecystectomy in a single surgery. We evaluate the safety & efficacy of such surgeries. A retrospective review of all patients who had undergone combined procedures with laparoscopic cholecystectomy during January 2005 to June 2009 was performed. 3144 laparoscopic cholecystectomies were performed in the period from January 2005 to June 2009. Of these, 401 cases were combined with another procedure. The mean operative time was 80 min (range 50-270 min). The mean hospital stay was 3.2 days (range 1-5 days). The mean no. of days injectable analgesics was required was 2 days (range 1 day-4 days). Combined procedures provide patients with all the benefits of minimal invasive surgery and also give the benefit of single time anaesthesia without adding to post operative morbidity & hospital stay.

Initial experience with single-incision laparoscopic cholecystectomy

BACKGROUND

Single-incision laparoscopic surgery is now increasingly used as an approach for cholecystectomy, based on anecdotal reports of decreased pain, reduced need for hospitalization, and a better cosmetic result. This is a report of a single surgeon's (JKE) initial experience with single-incision laparoscopic cholecystectomy (SILC).

STUDY DESIGN

We collected concurrent data on 238 consecutive patients undergoing SILC by 1 surgeon in a community hospital over 12 months.

RESULTS

From June 2008 to June 2009, 238 consecutive patients underwent an attempted SILC for biliary colic or dyskinesia (75%) or acute cholecystitis (25%) by a single surgeon. Conversion to a standard laparoscopic cholecystectomy was necessary in 6 patients (2.5%) for inflammation or bleeding (n = 4) or short cystic duct (n = 2). Conversion to an open cholecystectomy was necessary in 1 patient (0.42%) for a short cystic duct. No injuries to the common bile duct occurred, the average operative time was 40 minutes, and 95% of patients (n = 226) were discharged home on the day of operation. Postoperative port site hematomas occurred in 3 patients (1.3%), and dehiscence of the umbilical skin incision in 2 (0.8%). No perioperative deaths occurred.

CONCLUSIONS

This initial experience with SILC documents that the results of the procedure are equivalent to those with the standard procedure using 4 widely-spaced ports when performed by an experienced laparoscopic surgeon. Randomized trials will be necessary to document the suggested benefits of decreased pain and shorter hospitalization.