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Laparoscopic
Cholecystectomy
n he article by Peters and colleagues, Safety and Efficacy of Laparoscopic Cholecystectomy: A Prospective Analysis of 100 Initial Patients, in this issue of Annals of Surgery is one of an increasing number of experiences evaluating this new treatment modality for cholelithiasis. There are approximately 500,000 cholecystectomies performed in this country annually. For decades nearly all these procedures have been performed through a right upper quadrant incision, and this has proved to be an exceedingly safe and effective means of managing cholelithiasis. The hospital mortality rate is less than 1%, morbidity rates are low, and long-term results are excellent, with most patients rendered asymptomatic after cholecystectomy. Despite the outstanding results obtained with standard cholecystectomy, during the past decade a variety of alternative treatment options have been introduced. Many have been pursued enthusiastically, with some encouraging results. None, however, has replaced standard cholecystectomy as the treatment of choice for most symptomatic patients with gallstones. The newest treatment modality to be introduced for the management of gallstone disease is laparoscopic cholecystectomy. Most surgeons in the United States first became aware of this alternative in 1989 at the Fall Meeting of the American College of Surgeons. Many surgeons greeted this procedure with skepticism, and some with total disdain, because it challenged one of our safest and most effective operative procedures. Nevertheless some surgeons were convinced early on of the procedure's potential and initiated programs in laparoscopic cholecystectomy. Many centers and institutions have now accumulated series comparable in size to the one reported by Peters and colleagues in this issue, with excellent results. The rapidity with which laparoscopic cholecystectomy is gaining acceptance is almost totally consumer driven. Surgeons and hospitals not performing laparoscopic cholecystectomy soon began to lose patients to those who were. Not unlike the changes that have occurred in the management of breast cancer, reluctant surgeons have been prodded by an informed, accepting patient population. Although both standard cholecystectomy and laparoscopic cholecystectomy require general anesthesia, the vast majority of patients undergoing the laparoscopic procedure are discharged the day after surgery, compared to a 2- or 3-day hospitalization following standard cholecystectomy. In addition most patients after laparoscopic cholecystectomy can return to work, participate in sports, and resume all activities by 1 week, and virtually all can by 2 weeks. Vacations do not need to be delayed, time off from work can be nearly eliminated, and the problem of an uncomfortable incision is avoided. In addition most patients think the cosmetic results of the four small incisions required for laparoscopic cholecystectomy are preferable to those of a right subcostal incision. Despite the rapid and widespread acceptance, early data suggest that some complications are more common after laparoscopic cholecystectomy when compared to standard cholecystectomy. Peters and coworkers report that there was one common duct injury among their 100 patients. Experience from several institutions suggest that the incidence of biliary tract injury, which is 1 in 1000 patients with standard cholecystectomy, is 1 in 100 with laparoscopic cholecystectomy. This incidence may decrease substantially once experience increases. However laparoscopic cholecystectomy, despite the beautiful magnified video display of the right upper quadrant, is done in the absence of threedimensional depth perception. The fact that the surgeon must perform the operative procedure with a two-dimensional perspective suggests that the incidence of common duct injury may remain higher with this procedure than with standard cholecystectomy. Other complications, such as clips becoming dislodged from the cystic duct resulting in bile ascites, also have occurred with an incidence much higher than after standard cholecystectomy. Cholangiography is more difficult to perform during laparoscopic cholecystectomy and its prevalence will undoubtedly decrease significantly from that during routine cholecystectomy. Whether this will result in a significant increase in the incidence of retained stones remains to be seen. Some institutions are beginning to perform common duct explorations during laparoscopic cholecystectomy by concurrently performing an endoscopic papillotomy and inserting a scope into the common duct from below. Whether this will provide improved results and decreased mortality and morbidity rates compared to standard cholecystectomy and common duct exploration is not known. It probably will be several years before the true morbidity rate for this procedure can be evaluated and compared to standard cholecystectomy. It is not yet clear what percentage of the 500,000 patients who undergo cholecystectomy each year are candidates
1
2
CAMERON AND GADACZ
Ann. Surg. January 1991
for the laparoscopic procedure. In our hospital approximately 80% of all patients undergoing cholecystectomy have the operation performed laparoscopically. This figure may even increase as experience is gained. Cholecystectomy is not the only operative procedure that can be performed laparoscopically. Inguinal herniorrhaphies, appendectomies, and highly selective vagotomies have all been performed through the laparoscope. Other laparoscopic procedures undoubtedly will follow. One prominent department of surgery in Germany has already established a Division of Laparoscopic Surgery. Currently many hospitals are debating who should be allowed to perform laparoscopic cholecystectomy. Credentialing for this procedure should be well defined, restricted to general surgeons experienced in biliary tract surgery, and should include formal instruction with hands-on animal work, laparoscopic experience, and a period of proctoring by a surgeon experienced with laparoscopic cholecystectomy. National organizations such as the Society for Surgery of the Alimentary Tract, the Society of American Gastrointestinal Endoscopic Surgeons, and the American College of Surgeons have published credentialing guidelines. In addition residency programs should begin to include this procedure in their training programs. It is healthy and appropriate for surgeons to treat with some skepticism new management innovations, particularly when treating a disease in which there is well-established effective surgical therapy that can be performed with low mortality and morbidity rates. This skepticism, however, should not interfere with the introduction of new procedures that clearly are beneficial. Some aspects of laparoscopic cholecystectomy are contrary to the basic tenants and principles that we learned during our surgical training. Surgery is forever changing, however, and laparoscopic surgery is undoubtedly here to stay. The wonder is not that it was introduced but why it took general surgeons so long, considering that gynecologists have performed abdominal procedures through the laparoscope for decades. Laparoscopic cholecystectomy is proving to be a new and exciting development for general surgery. Careful, cautious experience, such as that reported by Peters and his colleagues in this issue of Annals, should be encouraged and will help to clarify the indications, safety, and efficacy of this new surgical procedure. JOHN L. CAMERON, M.D., F.A.C.S THOMAS R. GADACZ, M.D., F.A.C.S. Baltimore, Maryland
Laparoscopic
Cholecystectomy
n he article by Peters and colleagues, Safety and Efficacy of Laparoscopic Cholecystectomy: A Prospective Analysis of 100 Initial Patients, in this issue of Annals of Surgery is one of an increasing number of experiences evaluating this new treatment modality for cholelithiasis. There are approximately 500,000 cholecystectomies performed in this country annually. For decades nearly all these procedures have been performed through a right upper quadrant incision, and this has proved to be an exceedingly safe and effective means of managing cholelithiasis. The hospital mortality rate is less than 1%, morbidity rates are low, and long-term results are excellent, with most patients rendered asymptomatic after cholecystectomy. Despite the outstanding results obtained with standard cholecystectomy, during the past decade a variety of alternative treatment options have been introduced. Many have been pursued enthusiastically, with some encouraging results. None, however, has replaced standard cholecystectomy as the treatment of choice for most symptomatic patients with gallstones. The newest treatment modality to be introduced for the management of gallstone disease is laparoscopic cholecystectomy. Most surgeons in the United States first became aware of this alternative in 1989 at the Fall Meeting of the American College of Surgeons. Many surgeons greeted this procedure with skepticism, and some with total disdain, because it challenged one of our safest and most effective operative procedures. Nevertheless some surgeons were convinced early on of the procedure's potential and initiated programs in laparoscopic cholecystectomy. Many centers and institutions have now accumulated series comparable in size to the one reported by Peters and colleagues in this issue, with excellent results. The rapidity with which laparoscopic cholecystectomy is gaining acceptance is almost totally consumer driven. Surgeons and hospitals not performing laparoscopic cholecystectomy soon began to lose patients to those who were. Not unlike the changes that have occurred in the management of breast cancer, reluctant surgeons have been prodded by an informed, accepting patient population. Although both standard cholecystectomy and laparoscopic cholecystectomy require general anesthesia, the vast majority of patients undergoing the laparoscopic procedure are discharged the day after surgery, compared to a 2- or 3-day hospitalization following standard cholecystectomy. In addition most patients after laparoscopic cholecystectomy can return to work, participate in sports, and resume all activities by 1 week, and virtually all can by 2 weeks. Vacations do not need to be delayed, time off from work can be nearly eliminated, and the problem of an uncomfortable incision is avoided. In addition most patients think the cosmetic results of the four small incisions required for laparoscopic cholecystectomy are preferable to those of a right subcostal incision. Despite the rapid and widespread acceptance, early data suggest that some complications are more common after laparoscopic cholecystectomy when compared to standard cholecystectomy. Peters and coworkers report that there was one common duct injury among their 100 patients. Experience from several institutions suggest that the incidence of biliary tract injury, which is 1 in 1000 patients with standard cholecystectomy, is 1 in 100 with laparoscopic cholecystectomy. This incidence may decrease substantially once experience increases. However laparoscopic cholecystectomy, despite the beautiful magnified video display of the right upper quadrant, is done in the absence of threedimensional depth perception. The fact that the surgeon must perform the operative procedure with a two-dimensional perspective suggests that the incidence of common duct injury may remain higher with this procedure than with standard cholecystectomy. Other complications, such as clips becoming dislodged from the cystic duct resulting in bile ascites, also have occurred with an incidence much higher than after standard cholecystectomy. Cholangiography is more difficult to perform during laparoscopic cholecystectomy and its prevalence will undoubtedly decrease significantly from that during routine cholecystectomy. Whether this will result in a significant increase in the incidence of retained stones remains to be seen. Some institutions are beginning to perform common duct explorations during laparoscopic cholecystectomy by concurrently performing an endoscopic papillotomy and inserting a scope into the common duct from below. Whether this will provide improved results and decreased mortality and morbidity rates compared to standard cholecystectomy and common duct exploration is not known. It probably will be several years before the true morbidity rate for this procedure can be evaluated and compared to standard cholecystectomy. It is not yet clear what percentage of the 500,000 patients who undergo cholecystectomy each year are candidates
1
2
CAMERON AND GADACZ
Ann. Surg. January 1991
for the laparoscopic procedure. In our hospital approximately 80% of all patients undergoing cholecystectomy have the operation performed laparoscopically. This figure may even increase as experience is gained. Cholecystectomy is not the only operative procedure that can be performed laparoscopically. Inguinal herniorrhaphies, appendectomies, and highly selective vagotomies have all been performed through the laparoscope. Other laparoscopic procedures undoubtedly will follow. One prominent department of surgery in Germany has already established a Division of Laparoscopic Surgery. Currently many hospitals are debating who should be allowed to perform laparoscopic cholecystectomy. Credentialing for this procedure should be well defined, restricted to general surgeons experienced in biliary tract surgery, and should include formal instruction with hands-on animal work, laparoscopic experience, and a period of proctoring by a surgeon experienced with laparoscopic cholecystectomy. National organizations such as the Society for Surgery of the Alimentary Tract, the Society of American Gastrointestinal Endoscopic Surgeons, and the American College of Surgeons have published credentialing guidelines. In addition residency programs should begin to include this procedure in their training programs. It is healthy and appropriate for surgeons to treat with some skepticism new management innovations, particularly when treating a disease in which there is well-established effective surgical therapy that can be performed with low mortality and morbidity rates. This skepticism, however, should not interfere with the introduction of new procedures that clearly are beneficial. Some aspects of laparoscopic cholecystectomy are contrary to the basic tenants and principles that we learned during our surgical training. Surgery is forever changing, however, and laparoscopic surgery is undoubtedly here to stay. The wonder is not that it was introduced but why it took general surgeons so long, considering that gynecologists have performed abdominal procedures through the laparoscope for decades. Laparoscopic cholecystectomy is proving to be a new and exciting development for general surgery. Careful, cautious experience, such as that reported by Peters and his colleagues in this issue of Annals, should be encouraged and will help to clarify the indications, safety, and efficacy of this new surgical procedure. JOHN L. CAMERON, M.D., F.A.C.S THOMAS R. GADACZ, M.D., F.A.C.S. Baltimore, Maryland
