181
Aust. N . Z . J . Surg. 1992,62, 181-187
LAPAROSCOPIC CHOLECYSTECTOMY GEORGEA. FIELDING Department of Surgery, Royal Brisbane Hospital, Brisbane, Queensland A consecutive series of 220 laparoscopic cholecystectomies(June 1990 to May 1991)is presented. These were the author's initial experience of the technique. Procedures were elective (205) and acute (15). including 3 gangrenous cholecystitis and 4 empyema. There were 166 females and 34 males, 12-75 years, weighing 44I15 kg. Forty-eight patients had prior abdominal surgery. Two hundred and eleven patients had successful laparoscopic cholecystectomies, 6 open cholecystectomies and 3 mini laparotomies to remove spilt stones. None of the last 120 cases were opened. Operating time ranged from 20min to 3h 20min. There were 4 serious complications: 2 bile leaks from the gall-bladder bed and 2 jejunal injuries (Veres needle and 5 mm trocar). Sixty-one patients were discharged the next day, 29 on day 2, 5 on day 3 , 4 on day 4,1 on day 5, I on day 22 and I on day 27. At two weeks follow-up all but 2 patients had fully recovered.
Key word: laparoscopic cholecystectomy.
Introduction
Methods
Laparoscopic cholecystectomy (LC) is a new approach to cholecystectomy developed initially in France by Mouret then taken up by Perissat and Dubois.'X2 It has been popularized in the United States of America by R e d d i ~ kAfter . ~ a slow introduction in 1987 and Reddick's introduction of the technique into the United States of America in 1988 and 1989, the procedure has now had widespread acceptance. The procedure is similar to that of the standard open cholecystectomy. However, recent developments in video technology, especially the development of the video chip that allows laparoscopy to be projected onto a video screen, and the development of long instruments for dissection and clipping, have meant that the procedure can be performed through four percutaneously placed ports. There are obvious advantages of LC over standard cholecystectomy. The major advantage to the patient is reduced pain, early discharge from hospital and early resumption of full activity, usually within a week. There are health cost implications both to the hospitals and to the community at large, due to both a shorter postoperative stay but especially the return to work and diminution of sick leave and social security payments to cover the patient during the normal recuperation after a standard cholecystectomy. This study is a report of the initial consecutive experience of 220 cases by one surgeon in Brisbane between June 1990 and S May 1991.
Data were collected on 220 patients in respect to sex, age, indications for surgery, pre-operative diagnosis, operative findings, duration of operation, postoperative hospital stay, postoperative complications and return to full activity postoperatively. In the early part of the experience, during the first 20 cases, a selection process was instituted. Patients who were overweight or had previous upper abdominal surgery were postponed until skills had improved. Patients with acute cholecystitis were done openly, and those with stones in the common bile duct were sent for ERCP. However, as comfort with the technique increased, it became evident that all patients should be offered the procedure. The only contraindication is pregnancy. All patients referred for consideration or presenting acutely were offered the procedure. None have declined it. Only two patients, not part of the 220 reviewed here, had open surgery, as they had stones in the common bile duct above a long distal tapered segment. The stones could not be removed and open cholecystectomy and exploration of the common bile duct were performed. Laparoscopic cholecystectomy is performed under general anaesthetic after a dose of broad spectrum antibiotics. The operations described in this study were performed using a variety of available equipment. Procedures were performed with a lOmm Panaview Wolff laparoscope, a Dyonics camera and video system (Richards) and Auto Suture disposable ports using two l0mm ports for the telescope and operative intervention and two Smm ports for grasping the gall-bladder. Instruments
Correspondence. Dr G. A. Fielding, Royal Brisbane Hospital, Herston Road, Herston, Qld 4029, Australia. Accepted for publication 21 July 1991
182
from Wissap, Storz Medical and Wolff were used for various parts of the procedure and the Auto Suture ligoclip applicator was used to clip the cystic artery and duct prior to division. Urinary catheters and nasogastric tubes were not used after the first 50 cases. Patients emptied their bladders prior to leaving the ward. A Veres needle was used to create a pneumoperitoneum employing C 0 2 with a normal gynaecological insufflator. A computerized insufflator was not available during the time of this study. The Veres needle was introduced after the urinary bladder had been emptied and the patient was placed in the Trendelenberg position. In the last 60 cases, the needle was inserted into the root of the umbilicus aiming to the left upper quadrant as described by Dubois.’ A vertical incision was made in the umbilicus, giving a nicer cosmetic result. The placement of the Veres needle within the peritoneal cavity was determined by a low intra-abdominal pressure at the commencement of insufflation. Once this was established, the pneumoperitoneum was created and determined to be sufficient by palpation of the abdomen and development of intra-abdominal pressure around 12 mmHg. The insufflation volumes ranged from 3 to 6 L . Once the pneumopentoneum was created a lOmm Auto Suture disposable port was inserted, usually infra-umbilically. If there had been a peri-umbilical incision, the Veres needle was introduced by an open technique and the port inserted to try and minimize the risk of small bowel injury due to adhesions. Alternatively, the lOmm sub-xiphoid port was inserted first, the telescope followed and the umbilicus was checked for adhesions. The umbilical port was inserted under direct vision and the telescope was then introduced so that subsequent ports were inserted under visual control. The technique used was that described by Reddick,3 where the fundus of the gall-bladder is grasped and the gall-bladder everted to allow placement of another grasping force upon the Hartmann’s pouch. Lateral distraction of the structures is used to expose Calot’s triangle exactly as in an open operation. A two handed dissection technique is used, relying on an assistant to hold the camera. This allows a real sense of feel for the tissues and it is possible to judge the amount of traction needed, the angle of retraction and depth of tissue under the forceps or hook. Calot’s triangle is then dissected, using a combination of diathermy hook, scissors and blunt spoon-bill forceps to expose the cystic duct passing from the gall-bladder to the junction with the common bile duct. The cystic artery is exposed at its division to anterior and posterior branches. An important technical step is to divide the posterior attachments of the gall-bladder to allow the gall-bladder to rise free from the liver at Hartmann’s pouch and facilitate complete exposure
FIELDING
of the Calot’s triangle. This is generally not done in the open operation and it was found that this step would truly facilitate the dissection. Two triangles can then be clearly defined: one between the cystic duct and artery, and another between the cystic artery and the liver. One develops an appreciation of anatomical variation of the cystic artery, which is frequently multiple. The aim is to have the gallbladder suspended from the liver by the cystic artery and the cystic duct down to the common bile duct. Operative cholangiography is not standard. However, if the patients had multiple small stones, if there was a suggestion of dilatation of the cystic or common bile duct or if the anatomy was at all difficult to determine, a cholangiogram was performed using a No. 5 ureteric catheter inserted either through the Storz cholangiocath instrument, through the suction tube or through an SPPS bottle airway. If the patients had been diagnosed with stones in the common bile duct pre-operatively, ERCP was performed and the duct was cleared prior to laparoscopic cholecystectomy. If the gastroenterologist was unable to remove the stones, an open cholecystectomy was performed. Once the cystic artery and duct were fully displayed they were divided between clips, using an Auto Suture disposable ligoclip applicator. The gallbladder was removed from the liver with a diathermy hook and scissors, achieving haemostasis at the gall-bladder bed as dissection progressed. The gall-bladder was left lying on top of the liver and irrigation and aspiration of blood was performed. The gall-bladder was then removed, usually through the upper sub-xiphoid port. There was no advantage in changing the telescope to bring the gall-bladder out through the umbilicus. Earlier on in the experience, in the event of the gall-bladder being entered and stones being spilt, the abdomen was opened through a small incision and the stones removed. However, a decision was soon made to remove stones where possible using grasping forceps and suction and to leave behind any small stones, that were unable to be removed. If there was a cascade of small stones through a hole in the gall-bladder, a rather daunting sight initially, this was dealt with by completing the procedure then turning the patient head down and right side down and filling the upper abdomen with saline. The stones almost invariably settled behind the liver. A sigmoidoscopy sucker with a 7.5mm adaptor was then used to suck out the stones. If there was no sign of any bleeding and the gall-bladder bed was perfectly dry, no drain was inserted. However if a decision to drain was made, a 3mm Redivac was inserted through the subcostal 5 mm port and placed at the gall-bladder bed with the tip of the Redivac lying up into the subphrenic space. Four very obese patients had an extra port inserted to
183
LAPAROSCOPICCHOLECYSTECTOMY
allow retraction of fatty omentum and transverse colon. Postoperatively, the patients were managed with intermittent narcotic analgesia as required. Rectal Indocid has been used recently and found very useful. Patients were free to take oral fluids, and eat as desired. Most drains were removed the day after operation but if they contained bile they were left until the drainage was reduced. Patients were discharged when they felt they could cope with leaving hospital free of any narcotic pain relief and when they had eaten a normal meal. Patients were followed up at two weeks and their feelings about the procedure were discussed. If all was well at that time no further follow-up appointment was made.
Results There were 220 patients in this initial report. Patients were referred from Brisbane and surrounding centres. All were referred with a preliminary diagnosis of biliary colic or cholecystitis. Patient details are listed in Table I . Table 1. Patient details No. patients Planned cases Acute cases Gender (M :F) Age (years) Weight (kg)
220 205 15 186:34 12-79 44-1 15
Results of radiology are listed in Table 2 . The two patients whose stones were unable to be removed are not part of this study and were the only two patients in the consecutive series of 222 referred patients to be offered open surgery. Table 2. Diagnosis of stones No. patients Ultrasound
Oral cholecystogram Acalculous chronic cholecystitis Pre-operative ERCP Stones not removed Stones removed No stones
203 I1
6
2 5 3
Of the 220 patients, only four were unable to have the cholecystectomy carried out (Table 3 ) . Very early in the experience, a posterior branch of the cystic artery was divided. Due to the very conservative approach early on, a mini laparotomy was performed, bleeding controlled and the gall-bladder removed. The second patient had damage to the
jejunum on insertion of one of the 5 mm disposable ports. This piece of jejunum had been tethered on to the abdominal wall and the port entered the side of the jejunum on insertion. A mini laparotomy was performed, the jejunum repaired and cholecystectomy carried out. Table 3. Reasons for converting to open surgery No. patients (n = 9)
Bleeding Trocar injury to jejunum Cardiac instability Equipment failure Spilt stones Large CBD stones, distal tapering of duct
1
1
I I 3 2
The third patient had a mini laparotomy to complete the cholecystectomy. She was an elderly lady who had been unstable with brachycardia on development of the pneumoperitoneum. This had resolved and cholecystectomy was proceeded with. She had a very friable gall-bladder which tore during removal from the liver. Her gall-bladder contained multiple small stones which cascaded into the abdomen and it was decided to open the abdomen, remove the stones and complete the cholecystectomy quickly. The fourth patient had technical problems with the cholangiogram catheter. An operative cholangiogram was thought essential in this case, so the abdomen was opened and cholecystectomy done. The plane between the gall-bladder and the liver is sometimes difficult to determine. The gall-bladder is occasionally entered, usually at the fundus, where it is embedded in the liver with severe chronic cholecystitis and stones spilt. Early on in the experience, three patients had a mini laparotomy performed to retrieve stones that were spilled from the gall-bladder. However, when this happened subsequently, the stones were removed by a combination of suction lavage and grasping forceps. None of the last I20 patients were opened. Eighteen of the first 100 patients had operative cholangiography, four to determine the anatomy and 14 because the cystic duct was dilated in the presence of small stones. Two patients had large common bile duct (CBD) stones and distal tapering of the common bile duct and were opened. A third had two small stones left, which were removed at ERCP. One case had to be opened due to technical difficulties which arose when the catheter was inserted. There were no stones in the duct. The remaining 15 had a normal cholangiogram. Numerous patients had short cystic ducts opening to the common duct. Some were very short and thick. Three patients had cystic to right hepatic ducts found at dissection, not
FIELDING
184
by cholangiography. In the subsequent 120 cases, cholangiography was not performed. Of the 220 patients, a total of nine patients underwent open operation. Three operations removed spilt stones and were probably unnecessary. No patients in the last consecutive 120 cases were opened. The operating times listed in Table 4 were from induction of anaesthetic to completion of the anaesthetic and ranged from 20 min to 3 h 20 min. Table 4. Operating time
Time
No. operation
2h
Three patients were incorrectly diagnosed with biliary colic. A 74 year old woman, was found to have carcinoma of the gall-bladder with multiple liver metastases that had been missed on ultrasound examination. The second patient was found to have a benign calcified liver cyst behind the gall-bladder in segment 4 and no gallstones. A 66 year old man was found, on histology, to have a carcinoma of the gall-bladder and no stones. He subsequently underwent successful wide resection of the gall-bladder bed, complete lymphatic clearance and bile duct resection. There were three severe postoperative complications. The first was a 65 year old man who underwent a successful laparoscopic cholecystectomy. On attempting to remove the gall-bladder, the gallbladder broke, showering stones into the peritoneal cavity. A mini laparoiomy was performed. The gallstones were removed, the gall-bladder bed was checked and a drain inserted. Thirty-six hours later he developed bile peritonitis. No obvious source of this was found and after a stormy postoperative course, he made a full recovery and was discharged on day 22. The second major complication was a 74 year old woman who had a previous abdominal hysterectomy through a lower left paramedian incision. On insertion of the Veress needle, a piece of jejunum that had been tethered up was entered and passed through. This was missed at the time of operation as it was caught up in adhesions and there was no free spill of bile at the time. The laparoscopic cholecystectomy was completed with apparent success. Thirty-six hours later the woman became septicaemic. Laparotomy was performed and she was found to have peritonitis. A small hole in the jejunum was found and repaired. Copious lavage of the peritoneal cavity was carried out. Debridement of fat around the area was completed and after a cnurse in intensive care she made a slow but steady recovery. She was discharged on day 27.
The third patient, a 35 year old woman, had a bile leak which did not settle. Laparoscopy and redrainage did not help and at laparotomy she had bile leaking from a tiny duct of Luschka in the fundus area of the gall-bladder bed. Two patients drained bile from their Redivac for 24 h and then bile drainage ceased spontaneously. One patient developed severe pain in the first postoperative week. This was thought to have been due to injury to a subcostal nerve on insertion of the middle subcostal trocar as it was in the distribution of an intercostal nerve. Injection of the area with local anaesthetic and steroid led to resolution of the pain. It was interesting that 16 patients developed quite incapacitating nausea and vomiting to the extent that it delayed their discharge from hospital. This was despite liberal use of anti-emetics in the postoperative phase when nausea developed. This was not related in any way to the length or difficulty of the procedure. Time to discharge is listed in Table 5 . At least 20 patients could have been discharged on the day of the procedure but this was thought to be a little radical, so the patients were kept in overnight. Table 5. Discharge from hospital
Postoperative day
No. patients I56 48 7 14 1
10 22 27
1
I I
Reasons for stay
Nausea and vomiting Mini laparotomy Gangrenous GBlAntibiotics Bile leak, duct of Lushka Bile leak, peritonitis Jejunal injury
Fifteen patients were admitted with acute cholecystitis (Table 6). These cases were managed by aspiration of the gall-bladder and standard laparoscopic procedure was carried out. All required some enlargement of the subcostal port for removal of the thickened gall-bladder. One acute case had the gall-bladder posterior wall left as it was deeply recessed and thick. The patient went home the next day. A 55 year old man with primary biliary cirrhosis, portal hypertension and symptomatic gallstones also had the posterior wall of the gall-bladder left in siru, and was discharged the next day. A 20 year old woman with cystic fibrosis and an FEVl of 0.5L had the procedure under an epidural, with very brief general anaesthetic at the last minute to allow suction under the diaphragm. She suffered no respiratory embarrassment after the procedure.
185
LAPAROSCOPlC CHOLECYSTECTOMY
Table 6 . Acute cholecystitis No. patients (n = 15)
Gangrenous Em py erna Acute cholecystitis Discharge Day 1 Day 2 Day 3 Day 5
When the patients were seen at two weeks followup, all but two were well. One patient had persistent pain. Pre-operative ERCP had shown a patulous ampulla but no stone. Operative cholangiogram showed no stone and good flow. After 3 weeks of persistent attacks of pain, a repeat ERCP showed a stone at the ampulla. This was removed leading to a complete recovery. The second patient had long standing nausea but settled after 6 weeks. Four patients had infection of the subcostal ports through which the gall-bladder had been removed. This had been successfully treated by their local doctor. Five patients had some persistent nausea for at least a week. Apart from the 8 patients that had a laparotomy, all patients had resumed full activity within 2 weeks. This ranged from a meat worker who went back to work on the fourth postoperative day to numerous women who had a game of tennis within 1 week of discharge. This is in contrast to the seven patients who had a mini laparotomy, all of whom were still suffering some discomfort at the time of review, although this was less than it would have been after a standard Kocher or paramedian incision. All patients were pleased to have had their cholecystectomy performed by this technique.
Discussion There are two very cogent reasons for the widespread introduction of this technique. There is undoubted benefit to the individual patient in terms of pain and suffering and also the ability to return to full activity very quickly. The understanding of this by the population at large has led to an unprecedented demand for the procedure. Studies are in place to determine the true cost effectiveness of the procedure, but it will doubtless reduce bed stay and in particular reduce sickness benefits and sick leave requirements within the community at large. This paper reports the early consecutive experience of laparoscopic cholecystectomy by one surgeon at the Royal Brisbane Hospital. It demonstrates the evolution of the technique and illustrates the various problems that surgeons embarking on the pro-
cedure will encounter. This procedure will become the procedure of choice for cholecystectomy in Australia and most general surgeons, once adequately trained, will carry out the p r o ~ e d u r e . ~Laparos.~ copic cholecystectomy has developed purely because of the development of technology. General surgeons have been traditionally very circumspect in accepting new technology, but it has been widely taken up by surgeons in other spheres of medicine including gastroenterologists, urologists, ear nose and throat surgeons, ophthalmic surgeons and most recently the vascular surgeons, all of whom have changed their practice dramatically to accommodate the advantages offered by new technology. It would appear that most patients will be able to have their cholecystectomy performed via the laparoscope. Conversion to open cholecystectomy will occur in about 10% of early cases. Once the surgeon is competent and comfortable with the technique, this figure will drop, so that opening will be very uncommon. Opening is not a failure. It is a decision made in the best interests of the patient. Various objections, such as risk of common duct stones, adhesions, obesity and acute cases have been raised. The use of pre-operative ERCP, when the common bile duct stones are anticipated, will allow the selection of those patients who require duct clearance prior to the laparoscopic procedure. Furthermore, exploration via the cystic duct and direct exploration via an incision in the common duct, will reduce the need for this potentially hazardous procedure.' In this study, 19 patients had undergone a previous upper abdominal incision and it had no impact on the ability to carry out the procedure. Three patients suffered adhesions, but adhesolysis allowed full definition of the anatomy and removal of the gall-bladder. It would appear that most problems arise with insertion of the Veress needle in patients who have had lower abdominal incisions. After the injury to the bowel caused by the Veress needle in this series, a decision was made to modify the insertion, by using an open technique or inserting the needle well away from the scar and the sub-xiphoid port first. The other major concern has been whether this procedure is suitable for people who are overweight. In fact, if anything, this is the ideal group of patients for a laparoscopic cholecystectomy . They suffer minimal morbidity postoperatively in relation to their chest, are able to mobilize quickly and reduce the chances of deep vein thrombosis. All five patients in the study who weighed over 100 kg were able to be discharged from hospital the next day and two were back at work within 4 days. Acute cases, though more difficult, are readily dealt with as seen by the cases in this series. Modification of the technique of exposure is often required as the gallbladder will not always permit elevation. Liver
I86
retraction, as in the Dubois method, is often preferable, allowing exposure of Hartmann’s pouch which is then retracted. It is essential for the safe development of this technique that the importance of training is emphasized. The old dictum that patience is a virtue was never more true than when applied to learning this operation. Depending on experience, the surgeon must be prepared to allow up to 3 h to carry out the procedure. Operating time can be reduced to between 1 and 2 h if the surgeon performs the procedure with the help of a colleague experienced in the technique. Once the surgeon is comfortable with the technique, the operating time is very similar to that of an open cholecystectomy. The ability to do an operative cholangiogram is exactly the same as in an open procedure and the decision to do so, the choice of the surgeon. The author’s preference is to be selective. If multiple stones are present in the gall-bladder, the cystic duct is dilated and pre-operative ERCP has not been done, an operative cholangiogram is performed. The author’s practice has been to leave small stones for retrieval at ERCP and to remove stones greater than 1 cm, especially if the distal end of the common bile duct is narrow. Small stones probably pass anyway. This approach will evolve as equipment becomes available for common duct exploration via the laparoscope. Ideally, it would be good to avoid pre-operative ERCP which has its own complications. As always, availability of equipment is a stumbling block, but flexible choledochoscopes are already available and there has been a recent report of direct exploration of the common bile duct and closure over a T tube.‘ The key to safety is meticulous dissection of the two windows, between cystic duct and arteries, and cystic artery and liver, such that the gall-bladder is projecting freely from the liver. suspended by the cystic duct and arteries. The cystic duct is cleared from the gall-bladder to the T junction. Nothing is clipped until this is the case. Should bleeding occur it can almost always be left alone until the dissection is completed. The most common source of bleeding is the posterior branch of the cystic artery. or the posterior cystic artery that arises independently. Unless one is very aware of this when freeing around the back of the gall-bladder, this vessel may be divided. Suction and copious irrigation will help if bleeding occurs and gentle water dissection is very effective in itself. One should resist the urge to clip a bleeding vessel immediately as the common or right hepatic duct may be lurking very close by. If this dissection is done, operative cholangiography is not of benefit in determining the anatomy. With small cystic ducts it is awkward. and if the cystic duct breaks, it is even more difficult to retrieve the end of the cystic duct. A large collected
FIELDING
series has shown a bile duct injury rate of 0.5% in 1518 cases performed by 20 surgical groups. The incidence of bile duct injury in the first 13 patients in each group was 2.2% as compared with 0.1 YO in subsequent patients.’ Another American series showed two duct injuries in the first 100 cases but none in the subsequent 200 cases8 Careful dissection of the anatomy coupled with an experienced operator and especially an experienced assistant early on, should reduce the common duct injury rate to levels no greater than at open surgery. Laparoscopic surgery has the potential for instrumental damage to bowel and blood vessels. Both this series and a recent series of SO cases from Ireland found cases of jejunal injury from the Veress needle insertion.’ With previous surgery and adhesions it is bound to happen occasionally. This complication may be minimized by inserting the needle away from scars and putting the umbilical trocar under direct vision, usually using the sub-xiphoid port. Care and gentle insertion of the trocar should prevent vessel injury on insertion. Dubois reported diathermy injury to the common bile duct which led to delayed bile leak, and to the colon resulting in faecal fistula. However with new instruments that are fully insulated down to the tip and the use of blunt diathermy hooks, the chances of this happening are greatly reduced. It is vital that surgeons recognize the optimum time to abandon the procedure especially early on in their operation to maximize the safety of the procedure. Reddick described one death, from pulmonary embolus, and no visceral injuries in over 700 cases.” A large combined study found no deaths in I5 16 cases.’ One of the factors which may help reduce injury on insertion of the trocars is the use of disposable trocars that have a protective plastic sheath that immediately springs down to protect the bowel on insertion of the trocar. In this series there was one case of injury to the small bowel when the sheath failed to protrude adequately. The use of disposable trocars with a sheath at the umbilicus should be a safety advantage. Early on, certainly in the first SO cases, operating time was between 1 and 2 h. However, operating time reduced with experience. In this series 91 cases were completed in under I h. Operative cholangiography added only 5 min if using an image intensifier and IOmin if using flat films. Eventually, the procedure should take no longer than that for open surgery. The view obtdlned is superb and opening and closing times have been eliminated. If a constant theatre team is used, setting up flows smoothly and is done while waiting for insufflation to be completed. Operating time should not be used as an argument against this procedure. There is ongoing development of instrumentation that will allow further improvement of operative
“’
187
LAPAROSCOPIC CHOLECYSTECTOMY
techniques. Needle holders have now been developed and special laparoscopic sutures are available that will allow expansion of the technique to include exploration of common bile duct laparoscopically. However, normal curved 3/0, 4/0 and Y O sutures are readily used and one can use any suture via the laparoscope. Sutures that are less whippy and rigid are much easier to handle and using an extra forcep held by an assistant makes knot tying relatively simple. Once confidence comes with eye/hand coordination, suturing does not pose a major problem. This procedure will become the procedure of choice for biliary disease, providing it is performed safely and judiciously on a widespread basis. Most problems should arise in the early part of a surgeon’s experience. It is important to be stringent in the selection of patients for the procedure early on, to minimize the difficulties that present themselves to the surgeons (i.e., obese patients, adhesions, large stones and contracted scarred gall bladders). If this is done and the procedure establishes itself as a safe alternative to standard cholecystectomy and the financial implications of the procedure both for individual hospitals and for the community at large are determined, then laparoscopic cholecystectomy would appear to be the start of the new era of general surgery. Techniques learnt with this procedure have already been applied to Nissen fundoplication, gastrojejunostomy, vagotomy, highly selective vagotomy, oversewing of perforated duodenal ulcers. bowel resection, inguinal hernia repair, division of adhesions. Ripstein procedure, appendicectomy for acute appendicitis and excision of liver cysts. It is only a matter of time before these become part of the general surgeon’s armamentarium.
References 1 . PhRlSSAT 1.. COLLERD. R. & BELLIARD R. (1989) Gallstones: Laparoscopic treatment, intra-corporeal lithotripsy followed by cholecystostomy or cholecystectomy - a personal technique. Endoscopy 21,
373-4. 2. DUBOlS F . , ICARD P., BERTHELOT G . & LEVARD H. ( 1990) Coelioscopic cholecystectomy. Ann. Surg. 211, 60-2. 3 . RmDiCK E. J . 8r OLSEND. 0. (1989) Laparoscopic laser cholecystectomy: A comparison with mini-lap cholecystectomy. Surg. Endus. 3, 31-3. 4. No.rr1.t P. N.,WALER. J . &JOHNSON W. R. (1991) Percutaneous laparoscopic cholecystectomy: The first fifty. Aust. N . Z . J. Surg. 61, 254-60. 5 . JONES R . M., FLETCHER D. R., MACLELLAN D. J . , LOWEA. W. & HAKDY K . J. (1991) Laparoscopic cholecystectomy - the initial experience. Aust. N . Z . 1.Surg. 61, 261-7. 6. JACOBSM., V t R D t J A J . c. & GOLDSTEIN H.s. (1991) Laparoscopic choledocholithotomy . J. Laparuendurcupic Surg. 1, 79-82. 7. T H SourHhm ~ SURGEONS CLUB(1991) A prospective analysis of 15 18 laparoscopic cholecystectomies. N . EngI. J. Med. 324, 1073-8. X . ZUCKEK K. A , . BAILEY R. W . , GADACZ T . R. & IMBEMBCIA . ( 199 I ) Laparoscopic guided cholecystectomy. Am. J . Surg. 161. 36-44. 9. GKACE P. A , , QutKhSill A . e f u l . (1991) Reduced postoperative hospitalization after laparoxopic cholecystectomy. B r . J. Surg. 78, 160-2. 10. Dwsois F. (1990) In oral presentation, Sydney Hospital (unpubl.). 1 I WAYL. W. (1990) Changing therapy for gallstone disease. N . EngI. J . Med. 323, 1273-4. 12. NATHANSON L. K . , SHIMI S. & CUSCH~ERI A. (1991) Laparoscopic cholecystectomy: The Dundee technique. Br. J. Surg. 78. 155-9.
Aust. N . Z . J . Surg. 1992,62, 181-187
LAPAROSCOPIC CHOLECYSTECTOMY GEORGEA. FIELDING Department of Surgery, Royal Brisbane Hospital, Brisbane, Queensland A consecutive series of 220 laparoscopic cholecystectomies(June 1990 to May 1991)is presented. These were the author's initial experience of the technique. Procedures were elective (205) and acute (15). including 3 gangrenous cholecystitis and 4 empyema. There were 166 females and 34 males, 12-75 years, weighing 44I15 kg. Forty-eight patients had prior abdominal surgery. Two hundred and eleven patients had successful laparoscopic cholecystectomies, 6 open cholecystectomies and 3 mini laparotomies to remove spilt stones. None of the last 120 cases were opened. Operating time ranged from 20min to 3h 20min. There were 4 serious complications: 2 bile leaks from the gall-bladder bed and 2 jejunal injuries (Veres needle and 5 mm trocar). Sixty-one patients were discharged the next day, 29 on day 2, 5 on day 3 , 4 on day 4,1 on day 5, I on day 22 and I on day 27. At two weeks follow-up all but 2 patients had fully recovered.
Key word: laparoscopic cholecystectomy.
Introduction
Methods
Laparoscopic cholecystectomy (LC) is a new approach to cholecystectomy developed initially in France by Mouret then taken up by Perissat and Dubois.'X2 It has been popularized in the United States of America by R e d d i ~ kAfter . ~ a slow introduction in 1987 and Reddick's introduction of the technique into the United States of America in 1988 and 1989, the procedure has now had widespread acceptance. The procedure is similar to that of the standard open cholecystectomy. However, recent developments in video technology, especially the development of the video chip that allows laparoscopy to be projected onto a video screen, and the development of long instruments for dissection and clipping, have meant that the procedure can be performed through four percutaneously placed ports. There are obvious advantages of LC over standard cholecystectomy. The major advantage to the patient is reduced pain, early discharge from hospital and early resumption of full activity, usually within a week. There are health cost implications both to the hospitals and to the community at large, due to both a shorter postoperative stay but especially the return to work and diminution of sick leave and social security payments to cover the patient during the normal recuperation after a standard cholecystectomy. This study is a report of the initial consecutive experience of 220 cases by one surgeon in Brisbane between June 1990 and S May 1991.
Data were collected on 220 patients in respect to sex, age, indications for surgery, pre-operative diagnosis, operative findings, duration of operation, postoperative hospital stay, postoperative complications and return to full activity postoperatively. In the early part of the experience, during the first 20 cases, a selection process was instituted. Patients who were overweight or had previous upper abdominal surgery were postponed until skills had improved. Patients with acute cholecystitis were done openly, and those with stones in the common bile duct were sent for ERCP. However, as comfort with the technique increased, it became evident that all patients should be offered the procedure. The only contraindication is pregnancy. All patients referred for consideration or presenting acutely were offered the procedure. None have declined it. Only two patients, not part of the 220 reviewed here, had open surgery, as they had stones in the common bile duct above a long distal tapered segment. The stones could not be removed and open cholecystectomy and exploration of the common bile duct were performed. Laparoscopic cholecystectomy is performed under general anaesthetic after a dose of broad spectrum antibiotics. The operations described in this study were performed using a variety of available equipment. Procedures were performed with a lOmm Panaview Wolff laparoscope, a Dyonics camera and video system (Richards) and Auto Suture disposable ports using two l0mm ports for the telescope and operative intervention and two Smm ports for grasping the gall-bladder. Instruments
Correspondence. Dr G. A. Fielding, Royal Brisbane Hospital, Herston Road, Herston, Qld 4029, Australia. Accepted for publication 21 July 1991
182
from Wissap, Storz Medical and Wolff were used for various parts of the procedure and the Auto Suture ligoclip applicator was used to clip the cystic artery and duct prior to division. Urinary catheters and nasogastric tubes were not used after the first 50 cases. Patients emptied their bladders prior to leaving the ward. A Veres needle was used to create a pneumoperitoneum employing C 0 2 with a normal gynaecological insufflator. A computerized insufflator was not available during the time of this study. The Veres needle was introduced after the urinary bladder had been emptied and the patient was placed in the Trendelenberg position. In the last 60 cases, the needle was inserted into the root of the umbilicus aiming to the left upper quadrant as described by Dubois.’ A vertical incision was made in the umbilicus, giving a nicer cosmetic result. The placement of the Veres needle within the peritoneal cavity was determined by a low intra-abdominal pressure at the commencement of insufflation. Once this was established, the pneumoperitoneum was created and determined to be sufficient by palpation of the abdomen and development of intra-abdominal pressure around 12 mmHg. The insufflation volumes ranged from 3 to 6 L . Once the pneumopentoneum was created a lOmm Auto Suture disposable port was inserted, usually infra-umbilically. If there had been a peri-umbilical incision, the Veres needle was introduced by an open technique and the port inserted to try and minimize the risk of small bowel injury due to adhesions. Alternatively, the lOmm sub-xiphoid port was inserted first, the telescope followed and the umbilicus was checked for adhesions. The umbilical port was inserted under direct vision and the telescope was then introduced so that subsequent ports were inserted under visual control. The technique used was that described by Reddick,3 where the fundus of the gall-bladder is grasped and the gall-bladder everted to allow placement of another grasping force upon the Hartmann’s pouch. Lateral distraction of the structures is used to expose Calot’s triangle exactly as in an open operation. A two handed dissection technique is used, relying on an assistant to hold the camera. This allows a real sense of feel for the tissues and it is possible to judge the amount of traction needed, the angle of retraction and depth of tissue under the forceps or hook. Calot’s triangle is then dissected, using a combination of diathermy hook, scissors and blunt spoon-bill forceps to expose the cystic duct passing from the gall-bladder to the junction with the common bile duct. The cystic artery is exposed at its division to anterior and posterior branches. An important technical step is to divide the posterior attachments of the gall-bladder to allow the gall-bladder to rise free from the liver at Hartmann’s pouch and facilitate complete exposure
FIELDING
of the Calot’s triangle. This is generally not done in the open operation and it was found that this step would truly facilitate the dissection. Two triangles can then be clearly defined: one between the cystic duct and artery, and another between the cystic artery and the liver. One develops an appreciation of anatomical variation of the cystic artery, which is frequently multiple. The aim is to have the gallbladder suspended from the liver by the cystic artery and the cystic duct down to the common bile duct. Operative cholangiography is not standard. However, if the patients had multiple small stones, if there was a suggestion of dilatation of the cystic or common bile duct or if the anatomy was at all difficult to determine, a cholangiogram was performed using a No. 5 ureteric catheter inserted either through the Storz cholangiocath instrument, through the suction tube or through an SPPS bottle airway. If the patients had been diagnosed with stones in the common bile duct pre-operatively, ERCP was performed and the duct was cleared prior to laparoscopic cholecystectomy. If the gastroenterologist was unable to remove the stones, an open cholecystectomy was performed. Once the cystic artery and duct were fully displayed they were divided between clips, using an Auto Suture disposable ligoclip applicator. The gallbladder was removed from the liver with a diathermy hook and scissors, achieving haemostasis at the gall-bladder bed as dissection progressed. The gall-bladder was left lying on top of the liver and irrigation and aspiration of blood was performed. The gall-bladder was then removed, usually through the upper sub-xiphoid port. There was no advantage in changing the telescope to bring the gall-bladder out through the umbilicus. Earlier on in the experience, in the event of the gall-bladder being entered and stones being spilt, the abdomen was opened through a small incision and the stones removed. However, a decision was soon made to remove stones where possible using grasping forceps and suction and to leave behind any small stones, that were unable to be removed. If there was a cascade of small stones through a hole in the gall-bladder, a rather daunting sight initially, this was dealt with by completing the procedure then turning the patient head down and right side down and filling the upper abdomen with saline. The stones almost invariably settled behind the liver. A sigmoidoscopy sucker with a 7.5mm adaptor was then used to suck out the stones. If there was no sign of any bleeding and the gall-bladder bed was perfectly dry, no drain was inserted. However if a decision to drain was made, a 3mm Redivac was inserted through the subcostal 5 mm port and placed at the gall-bladder bed with the tip of the Redivac lying up into the subphrenic space. Four very obese patients had an extra port inserted to
183
LAPAROSCOPICCHOLECYSTECTOMY
allow retraction of fatty omentum and transverse colon. Postoperatively, the patients were managed with intermittent narcotic analgesia as required. Rectal Indocid has been used recently and found very useful. Patients were free to take oral fluids, and eat as desired. Most drains were removed the day after operation but if they contained bile they were left until the drainage was reduced. Patients were discharged when they felt they could cope with leaving hospital free of any narcotic pain relief and when they had eaten a normal meal. Patients were followed up at two weeks and their feelings about the procedure were discussed. If all was well at that time no further follow-up appointment was made.
Results There were 220 patients in this initial report. Patients were referred from Brisbane and surrounding centres. All were referred with a preliminary diagnosis of biliary colic or cholecystitis. Patient details are listed in Table I . Table 1. Patient details No. patients Planned cases Acute cases Gender (M :F) Age (years) Weight (kg)
220 205 15 186:34 12-79 44-1 15
Results of radiology are listed in Table 2 . The two patients whose stones were unable to be removed are not part of this study and were the only two patients in the consecutive series of 222 referred patients to be offered open surgery. Table 2. Diagnosis of stones No. patients Ultrasound
Oral cholecystogram Acalculous chronic cholecystitis Pre-operative ERCP Stones not removed Stones removed No stones
203 I1
6
2 5 3
Of the 220 patients, only four were unable to have the cholecystectomy carried out (Table 3 ) . Very early in the experience, a posterior branch of the cystic artery was divided. Due to the very conservative approach early on, a mini laparotomy was performed, bleeding controlled and the gall-bladder removed. The second patient had damage to the
jejunum on insertion of one of the 5 mm disposable ports. This piece of jejunum had been tethered on to the abdominal wall and the port entered the side of the jejunum on insertion. A mini laparotomy was performed, the jejunum repaired and cholecystectomy carried out. Table 3. Reasons for converting to open surgery No. patients (n = 9)
Bleeding Trocar injury to jejunum Cardiac instability Equipment failure Spilt stones Large CBD stones, distal tapering of duct
1
1
I I 3 2
The third patient had a mini laparotomy to complete the cholecystectomy. She was an elderly lady who had been unstable with brachycardia on development of the pneumoperitoneum. This had resolved and cholecystectomy was proceeded with. She had a very friable gall-bladder which tore during removal from the liver. Her gall-bladder contained multiple small stones which cascaded into the abdomen and it was decided to open the abdomen, remove the stones and complete the cholecystectomy quickly. The fourth patient had technical problems with the cholangiogram catheter. An operative cholangiogram was thought essential in this case, so the abdomen was opened and cholecystectomy done. The plane between the gall-bladder and the liver is sometimes difficult to determine. The gall-bladder is occasionally entered, usually at the fundus, where it is embedded in the liver with severe chronic cholecystitis and stones spilt. Early on in the experience, three patients had a mini laparotomy performed to retrieve stones that were spilled from the gall-bladder. However, when this happened subsequently, the stones were removed by a combination of suction lavage and grasping forceps. None of the last I20 patients were opened. Eighteen of the first 100 patients had operative cholangiography, four to determine the anatomy and 14 because the cystic duct was dilated in the presence of small stones. Two patients had large common bile duct (CBD) stones and distal tapering of the common bile duct and were opened. A third had two small stones left, which were removed at ERCP. One case had to be opened due to technical difficulties which arose when the catheter was inserted. There were no stones in the duct. The remaining 15 had a normal cholangiogram. Numerous patients had short cystic ducts opening to the common duct. Some were very short and thick. Three patients had cystic to right hepatic ducts found at dissection, not
FIELDING
184
by cholangiography. In the subsequent 120 cases, cholangiography was not performed. Of the 220 patients, a total of nine patients underwent open operation. Three operations removed spilt stones and were probably unnecessary. No patients in the last consecutive 120 cases were opened. The operating times listed in Table 4 were from induction of anaesthetic to completion of the anaesthetic and ranged from 20 min to 3 h 20 min. Table 4. Operating time
Time
No. operation
2h
Three patients were incorrectly diagnosed with biliary colic. A 74 year old woman, was found to have carcinoma of the gall-bladder with multiple liver metastases that had been missed on ultrasound examination. The second patient was found to have a benign calcified liver cyst behind the gall-bladder in segment 4 and no gallstones. A 66 year old man was found, on histology, to have a carcinoma of the gall-bladder and no stones. He subsequently underwent successful wide resection of the gall-bladder bed, complete lymphatic clearance and bile duct resection. There were three severe postoperative complications. The first was a 65 year old man who underwent a successful laparoscopic cholecystectomy. On attempting to remove the gall-bladder, the gallbladder broke, showering stones into the peritoneal cavity. A mini laparoiomy was performed. The gallstones were removed, the gall-bladder bed was checked and a drain inserted. Thirty-six hours later he developed bile peritonitis. No obvious source of this was found and after a stormy postoperative course, he made a full recovery and was discharged on day 22. The second major complication was a 74 year old woman who had a previous abdominal hysterectomy through a lower left paramedian incision. On insertion of the Veress needle, a piece of jejunum that had been tethered up was entered and passed through. This was missed at the time of operation as it was caught up in adhesions and there was no free spill of bile at the time. The laparoscopic cholecystectomy was completed with apparent success. Thirty-six hours later the woman became septicaemic. Laparotomy was performed and she was found to have peritonitis. A small hole in the jejunum was found and repaired. Copious lavage of the peritoneal cavity was carried out. Debridement of fat around the area was completed and after a cnurse in intensive care she made a slow but steady recovery. She was discharged on day 27.
The third patient, a 35 year old woman, had a bile leak which did not settle. Laparoscopy and redrainage did not help and at laparotomy she had bile leaking from a tiny duct of Luschka in the fundus area of the gall-bladder bed. Two patients drained bile from their Redivac for 24 h and then bile drainage ceased spontaneously. One patient developed severe pain in the first postoperative week. This was thought to have been due to injury to a subcostal nerve on insertion of the middle subcostal trocar as it was in the distribution of an intercostal nerve. Injection of the area with local anaesthetic and steroid led to resolution of the pain. It was interesting that 16 patients developed quite incapacitating nausea and vomiting to the extent that it delayed their discharge from hospital. This was despite liberal use of anti-emetics in the postoperative phase when nausea developed. This was not related in any way to the length or difficulty of the procedure. Time to discharge is listed in Table 5 . At least 20 patients could have been discharged on the day of the procedure but this was thought to be a little radical, so the patients were kept in overnight. Table 5. Discharge from hospital
Postoperative day
No. patients I56 48 7 14 1
10 22 27
1
I I
Reasons for stay
Nausea and vomiting Mini laparotomy Gangrenous GBlAntibiotics Bile leak, duct of Lushka Bile leak, peritonitis Jejunal injury
Fifteen patients were admitted with acute cholecystitis (Table 6). These cases were managed by aspiration of the gall-bladder and standard laparoscopic procedure was carried out. All required some enlargement of the subcostal port for removal of the thickened gall-bladder. One acute case had the gall-bladder posterior wall left as it was deeply recessed and thick. The patient went home the next day. A 55 year old man with primary biliary cirrhosis, portal hypertension and symptomatic gallstones also had the posterior wall of the gall-bladder left in siru, and was discharged the next day. A 20 year old woman with cystic fibrosis and an FEVl of 0.5L had the procedure under an epidural, with very brief general anaesthetic at the last minute to allow suction under the diaphragm. She suffered no respiratory embarrassment after the procedure.
185
LAPAROSCOPlC CHOLECYSTECTOMY
Table 6 . Acute cholecystitis No. patients (n = 15)
Gangrenous Em py erna Acute cholecystitis Discharge Day 1 Day 2 Day 3 Day 5
When the patients were seen at two weeks followup, all but two were well. One patient had persistent pain. Pre-operative ERCP had shown a patulous ampulla but no stone. Operative cholangiogram showed no stone and good flow. After 3 weeks of persistent attacks of pain, a repeat ERCP showed a stone at the ampulla. This was removed leading to a complete recovery. The second patient had long standing nausea but settled after 6 weeks. Four patients had infection of the subcostal ports through which the gall-bladder had been removed. This had been successfully treated by their local doctor. Five patients had some persistent nausea for at least a week. Apart from the 8 patients that had a laparotomy, all patients had resumed full activity within 2 weeks. This ranged from a meat worker who went back to work on the fourth postoperative day to numerous women who had a game of tennis within 1 week of discharge. This is in contrast to the seven patients who had a mini laparotomy, all of whom were still suffering some discomfort at the time of review, although this was less than it would have been after a standard Kocher or paramedian incision. All patients were pleased to have had their cholecystectomy performed by this technique.
Discussion There are two very cogent reasons for the widespread introduction of this technique. There is undoubted benefit to the individual patient in terms of pain and suffering and also the ability to return to full activity very quickly. The understanding of this by the population at large has led to an unprecedented demand for the procedure. Studies are in place to determine the true cost effectiveness of the procedure, but it will doubtless reduce bed stay and in particular reduce sickness benefits and sick leave requirements within the community at large. This paper reports the early consecutive experience of laparoscopic cholecystectomy by one surgeon at the Royal Brisbane Hospital. It demonstrates the evolution of the technique and illustrates the various problems that surgeons embarking on the pro-
cedure will encounter. This procedure will become the procedure of choice for cholecystectomy in Australia and most general surgeons, once adequately trained, will carry out the p r o ~ e d u r e . ~Laparos.~ copic cholecystectomy has developed purely because of the development of technology. General surgeons have been traditionally very circumspect in accepting new technology, but it has been widely taken up by surgeons in other spheres of medicine including gastroenterologists, urologists, ear nose and throat surgeons, ophthalmic surgeons and most recently the vascular surgeons, all of whom have changed their practice dramatically to accommodate the advantages offered by new technology. It would appear that most patients will be able to have their cholecystectomy performed via the laparoscope. Conversion to open cholecystectomy will occur in about 10% of early cases. Once the surgeon is competent and comfortable with the technique, this figure will drop, so that opening will be very uncommon. Opening is not a failure. It is a decision made in the best interests of the patient. Various objections, such as risk of common duct stones, adhesions, obesity and acute cases have been raised. The use of pre-operative ERCP, when the common bile duct stones are anticipated, will allow the selection of those patients who require duct clearance prior to the laparoscopic procedure. Furthermore, exploration via the cystic duct and direct exploration via an incision in the common duct, will reduce the need for this potentially hazardous procedure.' In this study, 19 patients had undergone a previous upper abdominal incision and it had no impact on the ability to carry out the procedure. Three patients suffered adhesions, but adhesolysis allowed full definition of the anatomy and removal of the gall-bladder. It would appear that most problems arise with insertion of the Veress needle in patients who have had lower abdominal incisions. After the injury to the bowel caused by the Veress needle in this series, a decision was made to modify the insertion, by using an open technique or inserting the needle well away from the scar and the sub-xiphoid port first. The other major concern has been whether this procedure is suitable for people who are overweight. In fact, if anything, this is the ideal group of patients for a laparoscopic cholecystectomy . They suffer minimal morbidity postoperatively in relation to their chest, are able to mobilize quickly and reduce the chances of deep vein thrombosis. All five patients in the study who weighed over 100 kg were able to be discharged from hospital the next day and two were back at work within 4 days. Acute cases, though more difficult, are readily dealt with as seen by the cases in this series. Modification of the technique of exposure is often required as the gallbladder will not always permit elevation. Liver
I86
retraction, as in the Dubois method, is often preferable, allowing exposure of Hartmann’s pouch which is then retracted. It is essential for the safe development of this technique that the importance of training is emphasized. The old dictum that patience is a virtue was never more true than when applied to learning this operation. Depending on experience, the surgeon must be prepared to allow up to 3 h to carry out the procedure. Operating time can be reduced to between 1 and 2 h if the surgeon performs the procedure with the help of a colleague experienced in the technique. Once the surgeon is comfortable with the technique, the operating time is very similar to that of an open cholecystectomy. The ability to do an operative cholangiogram is exactly the same as in an open procedure and the decision to do so, the choice of the surgeon. The author’s preference is to be selective. If multiple stones are present in the gall-bladder, the cystic duct is dilated and pre-operative ERCP has not been done, an operative cholangiogram is performed. The author’s practice has been to leave small stones for retrieval at ERCP and to remove stones greater than 1 cm, especially if the distal end of the common bile duct is narrow. Small stones probably pass anyway. This approach will evolve as equipment becomes available for common duct exploration via the laparoscope. Ideally, it would be good to avoid pre-operative ERCP which has its own complications. As always, availability of equipment is a stumbling block, but flexible choledochoscopes are already available and there has been a recent report of direct exploration of the common bile duct and closure over a T tube.‘ The key to safety is meticulous dissection of the two windows, between cystic duct and arteries, and cystic artery and liver, such that the gall-bladder is projecting freely from the liver. suspended by the cystic duct and arteries. The cystic duct is cleared from the gall-bladder to the T junction. Nothing is clipped until this is the case. Should bleeding occur it can almost always be left alone until the dissection is completed. The most common source of bleeding is the posterior branch of the cystic artery. or the posterior cystic artery that arises independently. Unless one is very aware of this when freeing around the back of the gall-bladder, this vessel may be divided. Suction and copious irrigation will help if bleeding occurs and gentle water dissection is very effective in itself. One should resist the urge to clip a bleeding vessel immediately as the common or right hepatic duct may be lurking very close by. If this dissection is done, operative cholangiography is not of benefit in determining the anatomy. With small cystic ducts it is awkward. and if the cystic duct breaks, it is even more difficult to retrieve the end of the cystic duct. A large collected
FIELDING
series has shown a bile duct injury rate of 0.5% in 1518 cases performed by 20 surgical groups. The incidence of bile duct injury in the first 13 patients in each group was 2.2% as compared with 0.1 YO in subsequent patients.’ Another American series showed two duct injuries in the first 100 cases but none in the subsequent 200 cases8 Careful dissection of the anatomy coupled with an experienced operator and especially an experienced assistant early on, should reduce the common duct injury rate to levels no greater than at open surgery. Laparoscopic surgery has the potential for instrumental damage to bowel and blood vessels. Both this series and a recent series of SO cases from Ireland found cases of jejunal injury from the Veress needle insertion.’ With previous surgery and adhesions it is bound to happen occasionally. This complication may be minimized by inserting the needle away from scars and putting the umbilical trocar under direct vision, usually using the sub-xiphoid port. Care and gentle insertion of the trocar should prevent vessel injury on insertion. Dubois reported diathermy injury to the common bile duct which led to delayed bile leak, and to the colon resulting in faecal fistula. However with new instruments that are fully insulated down to the tip and the use of blunt diathermy hooks, the chances of this happening are greatly reduced. It is vital that surgeons recognize the optimum time to abandon the procedure especially early on in their operation to maximize the safety of the procedure. Reddick described one death, from pulmonary embolus, and no visceral injuries in over 700 cases.” A large combined study found no deaths in I5 16 cases.’ One of the factors which may help reduce injury on insertion of the trocars is the use of disposable trocars that have a protective plastic sheath that immediately springs down to protect the bowel on insertion of the trocar. In this series there was one case of injury to the small bowel when the sheath failed to protrude adequately. The use of disposable trocars with a sheath at the umbilicus should be a safety advantage. Early on, certainly in the first SO cases, operating time was between 1 and 2 h. However, operating time reduced with experience. In this series 91 cases were completed in under I h. Operative cholangiography added only 5 min if using an image intensifier and IOmin if using flat films. Eventually, the procedure should take no longer than that for open surgery. The view obtdlned is superb and opening and closing times have been eliminated. If a constant theatre team is used, setting up flows smoothly and is done while waiting for insufflation to be completed. Operating time should not be used as an argument against this procedure. There is ongoing development of instrumentation that will allow further improvement of operative
“’
187
LAPAROSCOPIC CHOLECYSTECTOMY
techniques. Needle holders have now been developed and special laparoscopic sutures are available that will allow expansion of the technique to include exploration of common bile duct laparoscopically. However, normal curved 3/0, 4/0 and Y O sutures are readily used and one can use any suture via the laparoscope. Sutures that are less whippy and rigid are much easier to handle and using an extra forcep held by an assistant makes knot tying relatively simple. Once confidence comes with eye/hand coordination, suturing does not pose a major problem. This procedure will become the procedure of choice for biliary disease, providing it is performed safely and judiciously on a widespread basis. Most problems should arise in the early part of a surgeon’s experience. It is important to be stringent in the selection of patients for the procedure early on, to minimize the difficulties that present themselves to the surgeons (i.e., obese patients, adhesions, large stones and contracted scarred gall bladders). If this is done and the procedure establishes itself as a safe alternative to standard cholecystectomy and the financial implications of the procedure both for individual hospitals and for the community at large are determined, then laparoscopic cholecystectomy would appear to be the start of the new era of general surgery. Techniques learnt with this procedure have already been applied to Nissen fundoplication, gastrojejunostomy, vagotomy, highly selective vagotomy, oversewing of perforated duodenal ulcers. bowel resection, inguinal hernia repair, division of adhesions. Ripstein procedure, appendicectomy for acute appendicitis and excision of liver cysts. It is only a matter of time before these become part of the general surgeon’s armamentarium.
References 1 . PhRlSSAT 1.. COLLERD. R. & BELLIARD R. (1989) Gallstones: Laparoscopic treatment, intra-corporeal lithotripsy followed by cholecystostomy or cholecystectomy - a personal technique. Endoscopy 21,
373-4. 2. DUBOlS F . , ICARD P., BERTHELOT G . & LEVARD H. ( 1990) Coelioscopic cholecystectomy. Ann. Surg. 211, 60-2. 3 . RmDiCK E. J . 8r OLSEND. 0. (1989) Laparoscopic laser cholecystectomy: A comparison with mini-lap cholecystectomy. Surg. Endus. 3, 31-3. 4. No.rr1.t P. N.,WALER. J . &JOHNSON W. R. (1991) Percutaneous laparoscopic cholecystectomy: The first fifty. Aust. N . Z . J. Surg. 61, 254-60. 5 . JONES R . M., FLETCHER D. R., MACLELLAN D. J . , LOWEA. W. & HAKDY K . J. (1991) Laparoscopic cholecystectomy - the initial experience. Aust. N . Z . 1.Surg. 61, 261-7. 6. JACOBSM., V t R D t J A J . c. & GOLDSTEIN H.s. (1991) Laparoscopic choledocholithotomy . J. Laparuendurcupic Surg. 1, 79-82. 7. T H SourHhm ~ SURGEONS CLUB(1991) A prospective analysis of 15 18 laparoscopic cholecystectomies. N . EngI. J. Med. 324, 1073-8. X . ZUCKEK K. A , . BAILEY R. W . , GADACZ T . R. & IMBEMBCIA . ( 199 I ) Laparoscopic guided cholecystectomy. Am. J . Surg. 161. 36-44. 9. GKACE P. A , , QutKhSill A . e f u l . (1991) Reduced postoperative hospitalization after laparoxopic cholecystectomy. B r . J. Surg. 78, 160-2. 10. Dwsois F. (1990) In oral presentation, Sydney Hospital (unpubl.). 1 I WAYL. W. (1990) Changing therapy for gallstone disease. N . EngI. J . Med. 323, 1273-4. 12. NATHANSON L. K . , SHIMI S. & CUSCH~ERI A. (1991) Laparoscopic cholecystectomy: The Dundee technique. Br. J. Surg. 78. 155-9.
