Traditional
Versus Laparoscopic
Thomas R. Gadacz,
MD,
Mark A. Talamini,
Laparoscopic cholecystectomy is a minimally invasive procedure whereby the gallbladder is removed using laparoscopic techniques. The indications are similar to those for elective traditional cholecystectomy, but selection of patients is important for success. Contraindications are currently evolving. Patients with advanced cholecystitis, abdominal sepsis, ileus, bleeding disorders, pregnancy, and morbid obesity should not undergo this procedure. The procedure requires good traditional surgical skills, as well as additional laparoscopic (and laser) skills. Operative time is slightly longer than for traditional cholecystectomy, but decreases with experience. Morbidity is low, but there is a concern about bile duct injuries. Mortality is very low (0%) and is comparable to traditional cholecystectomy (0.4%). The major advantages of laparoscopic cholecystectomy are the short hospital stay (average: 2 days) and early return to normal activity (7 days). This results in a reduction in hospital costs. Adequate training and credentialing are important processes to foster good patient outcomes.
Cholecystectomy MD, Baltimore. Maryland
L
aparoscopic cholecystectomy is a method of removing the gallbladder through four small incisions using laparoscopic techniques. This approach varies in many respects from traditional cholecystectomy. Comparisons can be made in many ways, including the indications, contraindications, equipment, technique, complications, outcome, results, benefits to the patient and surgeon, costs, training, and credentialing. Some of these comparisons may have limited validity, such as the differences in specific contraindications. This review is intended to highlight the differences. The goal of both techniques is to safely remove the gallbladder with low mortality, little morbidity, and early recovery. INDICATIONS
The indications for cholecystectomy are the same for both techniques. Gallstones and biliary symptoms are the most common indications. Other indications include gallstone pancreatitis, symptomatic gallbladder polyps, a nonfunctioning gallbladder, gallstones in patients with sickle cell disease, large gallstones (greater than 3 cm), a calcified gallbladder wall, and chronic cholecystitis. Timing is different between the two approaches. Although both techniques are applicable to elective cholecystectomy, acute cholecystitis has not been widely considered an indication for emergency laparoscopic cholecystectomy. Complications of cholecystitis and advanced disease such as emphysematous cholecystitis remain indications for traditional cholecystectomy and not laparoscopic cholecystectomy. CONTRAINDICATIONS
From the Department of Surgery, Johns Hopkins University, and the Surgical Service, Department of Veterans Affairs, Baltimore, Maryland. Requests for reprints should be addressed to Thomas R. Gadacz, MD, Blalock 609, Department of Surgery, Johns Hopkins Hospital, 600 North Wolfe Street, Baltimore, Maryland 21205. Presented as part of a postgraduate course on interventional laparoscopy during the American College of Surgeons 1990 Clinical Congress, San Francisco, California, October 12, 1990.
336
THE AMERICAN
JOURNAL
OF SURGERY
VOLUME
The only contraindications to traditional cholecystectomy are unacceptable anesthetic risks and difficulty in identifying structures within the portal area. The latter is an indication for cholecystostomy. The contraindications to laparoscopic cholecystectomy are becoming fewer. Some of the absolute contraindications have become relative contraindications. The contraindications depend upon the experience of the surgeon, as well as the preoperative and intraoperative conditions. Sepsis and peritonitis, bowel distention, and pregnancy remain absolute contraindications. Other contraindications include acute cholecystitis, cholangitis, acute pancreatitis, common duct stones, prior upper abdominal operation, portal hypertension, and a major bleeding disorder. EQUIPMENT
AND INSTRUMENTS
The equipment and instruments required for a traditional cholecystectomy are the usual abdominal instruments plus the instruments necessary to perform an intraoperative cholangiogram and a common duct exploration. All of these instruments are familiar to the
161
MARCH
1991
TRADITIONAL VERSUS LAPAROSCOPIC CHOLECYSTECTOMY
general surgeon. The equipment required to perform lap aroscopic cholecystectomy is not standard to most general surgeons, but is familiar to many gynecologists. Knowledge of this equipment is critical since the procedure may be significantly compromised if equipment failures occur. The major pieces of equipment include a high-resolution camera, high-resolution video monitors, a high-intensity light source, an insufflator with pressure and flow regulators, an irrigator, and an electrocautery and/or laser unit. Some laparoscopic equipment is well suited for diagnostic laparoscopy but is not suitable for operative work. The insufflator must be capable of a high flow of carbon dioxide (at least 6 L/minute) to maintain an adequate pneumoperitoneum since loss of the pneumoperitoneum occurs at gaskets, around instruments, and during evacuation of the laser flume or the electrocautery smoke. A high-intensity xenon light source is necessary to adequately illuminate the field. Dissection of the gallbladder is performed with the electrocautery or the laser. Most surgeons are familiar with the electrocautery. If the dissection is to be performed with the laser, additional training and expertise are needed. In addition to the new equipment, there are novel instruments. The most important instrument is the endoscope. End viewing and angled endoscopes are available. Many of the instruments are standard or modified gynecologic instruments. New instruments are being developed to grasp and dissect the gallbladder that are available in a variety of sizes. It is expected that many new instruments will be developed over the next few years, and many of these may be more familiar to the general surgeon. PROCEDURE A traditional cholecystectomy is performed through a right upper quadrant incision. The gallbladder is directly visualized and the dissection is performed with instruments and direct touch. The entire field is in view. The technique of dissection is standard and well known by all general surgeons. Basic principles such as good exposure and identification of the cystic duct and artery are important in both traditional and laparoscopic cholecystectomy. Some of the important differences in technique are specific to laparoscopy. The abdominal wall is not incised, but is penetrated by four small cannulas with trochars. Two of the entrance ports are 55 inch and two are ‘/ inch in diameter. The entire procedure is performed by viewing an image of the abdominal cavity on two video monitors. The field of vision is limited to the field of view of the endoscope. Unlike an open procedure, other areas of the abdomen can only be viewed by moving the endoscope rather than by shifting the eyes. The image on the video screen is two-dimensional compared with the threedimensional view of an open procedure. Hand-eye ccordination must be developed since the manipulations are performed while watching the video screen. A major disadvantage of laparoscopy is the inability to manually explore the abdomen. Visual exploration of the abdomen is limited to the intraperitoneal organs. The current instruments are not capable of clamping or controlling ma-
THE AMERICAN
jor bleeding, and manual compression is not possible. A major advantage of the endoscope is the magnification of structures and the visible detail of structures. RESULTS The operative time, incidence of bile duct injury, mortality rate, hospital stay, return to normal activity, and hospital costs from five series were reviewed [l-5]. The operative time for laparoscopic cholecystectomy is slightly longer than for traditional cholecystectomy, with the average operative time being 99 minutes for the series reviewed (range: 85 to 110 minutes). As experience is gained, an operative time of about 45 minutes can be achieved, but this increases as other surgeons are trained or more challenging cases are performed. The morbidity rates are comparable. Bile duct injury appears to be slightly higher in most of the initial reported series of laparoscopic cholecystectomy, ranging from 0% to 1.4%. Generally, duct injuries can be avoided if proper exposure is obtained. Bleeding and wound infections are less common with laparoscopic cholecystectomy. The mortality for both techniques is very low. With traditional elective cholecystectomy, the mortality rate is 0.4% [6], and with laparoscopic cholecystectomy, it ranges from 0% to 1%. The two most beneficial aspects of laparoscopic cholecystectomy are the short hospital stay and the rapid recovery. Hospital stays for the reviewed series are all less than 2 days. All series reported a protocol requiring only a lnight stay in the hospital. The average time to return to normal activity was between 6.5 and 12.8 days. These are the most dramatic differences between the two techniques. In addition to the medical benefits to the patient, the average cost for laparoscopic cholecystectomy is less than that of traditional cholecystectomy. The operating room costs are slightly higher for laparoscopic cholecystectomy, but the hospital costs are considerably less. Average savings range from $300 to $700 per patient. CREDENTIALING Traditional cholecystectomy is an integral part of every surgical training program and is performed by most general surgeons. Laparoscopic cholecystectomy requires additional training that includes not only the principles of general surgery but also laparoscopy. Various organizations are recognizing the need for a standard set of credentials to help ensure that laparoscopic cholecystectomy is performed by adequately trained surgeons. Hands-on experience is essential, and a 2- or 3-day “mini” course is essential but not sufficient. Working with surgeons who are trained and proficient in laparoscopic cholecystectomy is another way to obtain competence. If a laser is used, training in laser surgery is mandatory. Once the basic skills are achieved, surgeons should be proctored by a surgeon skilled in laparoscopic cholecystectomy. Surgeons performing laparoscopic cholecystectomy should be monitored for this as well as other surgical procedures, and the outcome should be a part of the surgical quality assurance program to ensure a good outcome for the patient.
JOURNAL OF SURGERY
VOLUME
161
MARCH
1991
337
SUMMARY Laparoscopic cholecystectomy shares basic surgical principles with traditional cholecystectomy. The ideal indication for laparoscopic cholecystectomy should be the need for elective cholecystectomy in uncomplicated cases. Surgeons need to be familiar with highly specialized and technical equipment and new instruments. Laparoscopic techniques must be mastered, hand-eye coordination developed, and laser skills acquired (if lasers are used for dissection). Results from laparoscopic cholecystectomy are good, except for a potentially higher rate of bile duct injury. Shorter hospital stays and earlier return to normal activity are the major advantages of laparoscopic cholecystectomy compared to traditional cholecystectomy.
1. Reddick EA, Olsen DO. Laparoscopic laser cholecystectomy. A comparison with mini-lap cholecystectomy. Surg Endosc 1989; 3: 131-3. 2. Zucker KA, Bailey RW, Gadacz TR, Imbembo AL. Laparoscopic guided cholecystectomy. Am J Surg 1991; 161: 36-44. 3. Fitzgibbons RJ, Jr, Schmid S, Santoscoy R, et al. Laparoscopic cholecystectomy: the beginning of a new era in general surgery. (Submitted for publication) 4. Peters JH, Ellison EC, Innes JT, et al. Safety and efficacy of laparoscopic cholecystectomy; a prospective analysis of 100 initial patients. Ann Surg 1991 (in press). 5. Gadacz TR, Talamini M, Lillemoe K, Yeo C. Laparoscopic cholecystectomy. Surg Clin North Am 1990; 70: 1249-62. 6. McSherry CK. Cholecystectomy: the gold standard. Am J Surg 1989; 158: 174-8.
338
161
THE AMERICAN
JOURNAL
OF SURGERY
VOLUME
REFERENCES
MARCH
1991
Versus Laparoscopic
Thomas R. Gadacz,
MD,
Mark A. Talamini,
Laparoscopic cholecystectomy is a minimally invasive procedure whereby the gallbladder is removed using laparoscopic techniques. The indications are similar to those for elective traditional cholecystectomy, but selection of patients is important for success. Contraindications are currently evolving. Patients with advanced cholecystitis, abdominal sepsis, ileus, bleeding disorders, pregnancy, and morbid obesity should not undergo this procedure. The procedure requires good traditional surgical skills, as well as additional laparoscopic (and laser) skills. Operative time is slightly longer than for traditional cholecystectomy, but decreases with experience. Morbidity is low, but there is a concern about bile duct injuries. Mortality is very low (0%) and is comparable to traditional cholecystectomy (0.4%). The major advantages of laparoscopic cholecystectomy are the short hospital stay (average: 2 days) and early return to normal activity (7 days). This results in a reduction in hospital costs. Adequate training and credentialing are important processes to foster good patient outcomes.
Cholecystectomy MD, Baltimore. Maryland
L
aparoscopic cholecystectomy is a method of removing the gallbladder through four small incisions using laparoscopic techniques. This approach varies in many respects from traditional cholecystectomy. Comparisons can be made in many ways, including the indications, contraindications, equipment, technique, complications, outcome, results, benefits to the patient and surgeon, costs, training, and credentialing. Some of these comparisons may have limited validity, such as the differences in specific contraindications. This review is intended to highlight the differences. The goal of both techniques is to safely remove the gallbladder with low mortality, little morbidity, and early recovery. INDICATIONS
The indications for cholecystectomy are the same for both techniques. Gallstones and biliary symptoms are the most common indications. Other indications include gallstone pancreatitis, symptomatic gallbladder polyps, a nonfunctioning gallbladder, gallstones in patients with sickle cell disease, large gallstones (greater than 3 cm), a calcified gallbladder wall, and chronic cholecystitis. Timing is different between the two approaches. Although both techniques are applicable to elective cholecystectomy, acute cholecystitis has not been widely considered an indication for emergency laparoscopic cholecystectomy. Complications of cholecystitis and advanced disease such as emphysematous cholecystitis remain indications for traditional cholecystectomy and not laparoscopic cholecystectomy. CONTRAINDICATIONS
From the Department of Surgery, Johns Hopkins University, and the Surgical Service, Department of Veterans Affairs, Baltimore, Maryland. Requests for reprints should be addressed to Thomas R. Gadacz, MD, Blalock 609, Department of Surgery, Johns Hopkins Hospital, 600 North Wolfe Street, Baltimore, Maryland 21205. Presented as part of a postgraduate course on interventional laparoscopy during the American College of Surgeons 1990 Clinical Congress, San Francisco, California, October 12, 1990.
336
THE AMERICAN
JOURNAL
OF SURGERY
VOLUME
The only contraindications to traditional cholecystectomy are unacceptable anesthetic risks and difficulty in identifying structures within the portal area. The latter is an indication for cholecystostomy. The contraindications to laparoscopic cholecystectomy are becoming fewer. Some of the absolute contraindications have become relative contraindications. The contraindications depend upon the experience of the surgeon, as well as the preoperative and intraoperative conditions. Sepsis and peritonitis, bowel distention, and pregnancy remain absolute contraindications. Other contraindications include acute cholecystitis, cholangitis, acute pancreatitis, common duct stones, prior upper abdominal operation, portal hypertension, and a major bleeding disorder. EQUIPMENT
AND INSTRUMENTS
The equipment and instruments required for a traditional cholecystectomy are the usual abdominal instruments plus the instruments necessary to perform an intraoperative cholangiogram and a common duct exploration. All of these instruments are familiar to the
161
MARCH
1991
TRADITIONAL VERSUS LAPAROSCOPIC CHOLECYSTECTOMY
general surgeon. The equipment required to perform lap aroscopic cholecystectomy is not standard to most general surgeons, but is familiar to many gynecologists. Knowledge of this equipment is critical since the procedure may be significantly compromised if equipment failures occur. The major pieces of equipment include a high-resolution camera, high-resolution video monitors, a high-intensity light source, an insufflator with pressure and flow regulators, an irrigator, and an electrocautery and/or laser unit. Some laparoscopic equipment is well suited for diagnostic laparoscopy but is not suitable for operative work. The insufflator must be capable of a high flow of carbon dioxide (at least 6 L/minute) to maintain an adequate pneumoperitoneum since loss of the pneumoperitoneum occurs at gaskets, around instruments, and during evacuation of the laser flume or the electrocautery smoke. A high-intensity xenon light source is necessary to adequately illuminate the field. Dissection of the gallbladder is performed with the electrocautery or the laser. Most surgeons are familiar with the electrocautery. If the dissection is to be performed with the laser, additional training and expertise are needed. In addition to the new equipment, there are novel instruments. The most important instrument is the endoscope. End viewing and angled endoscopes are available. Many of the instruments are standard or modified gynecologic instruments. New instruments are being developed to grasp and dissect the gallbladder that are available in a variety of sizes. It is expected that many new instruments will be developed over the next few years, and many of these may be more familiar to the general surgeon. PROCEDURE A traditional cholecystectomy is performed through a right upper quadrant incision. The gallbladder is directly visualized and the dissection is performed with instruments and direct touch. The entire field is in view. The technique of dissection is standard and well known by all general surgeons. Basic principles such as good exposure and identification of the cystic duct and artery are important in both traditional and laparoscopic cholecystectomy. Some of the important differences in technique are specific to laparoscopy. The abdominal wall is not incised, but is penetrated by four small cannulas with trochars. Two of the entrance ports are 55 inch and two are ‘/ inch in diameter. The entire procedure is performed by viewing an image of the abdominal cavity on two video monitors. The field of vision is limited to the field of view of the endoscope. Unlike an open procedure, other areas of the abdomen can only be viewed by moving the endoscope rather than by shifting the eyes. The image on the video screen is two-dimensional compared with the threedimensional view of an open procedure. Hand-eye ccordination must be developed since the manipulations are performed while watching the video screen. A major disadvantage of laparoscopy is the inability to manually explore the abdomen. Visual exploration of the abdomen is limited to the intraperitoneal organs. The current instruments are not capable of clamping or controlling ma-
THE AMERICAN
jor bleeding, and manual compression is not possible. A major advantage of the endoscope is the magnification of structures and the visible detail of structures. RESULTS The operative time, incidence of bile duct injury, mortality rate, hospital stay, return to normal activity, and hospital costs from five series were reviewed [l-5]. The operative time for laparoscopic cholecystectomy is slightly longer than for traditional cholecystectomy, with the average operative time being 99 minutes for the series reviewed (range: 85 to 110 minutes). As experience is gained, an operative time of about 45 minutes can be achieved, but this increases as other surgeons are trained or more challenging cases are performed. The morbidity rates are comparable. Bile duct injury appears to be slightly higher in most of the initial reported series of laparoscopic cholecystectomy, ranging from 0% to 1.4%. Generally, duct injuries can be avoided if proper exposure is obtained. Bleeding and wound infections are less common with laparoscopic cholecystectomy. The mortality for both techniques is very low. With traditional elective cholecystectomy, the mortality rate is 0.4% [6], and with laparoscopic cholecystectomy, it ranges from 0% to 1%. The two most beneficial aspects of laparoscopic cholecystectomy are the short hospital stay and the rapid recovery. Hospital stays for the reviewed series are all less than 2 days. All series reported a protocol requiring only a lnight stay in the hospital. The average time to return to normal activity was between 6.5 and 12.8 days. These are the most dramatic differences between the two techniques. In addition to the medical benefits to the patient, the average cost for laparoscopic cholecystectomy is less than that of traditional cholecystectomy. The operating room costs are slightly higher for laparoscopic cholecystectomy, but the hospital costs are considerably less. Average savings range from $300 to $700 per patient. CREDENTIALING Traditional cholecystectomy is an integral part of every surgical training program and is performed by most general surgeons. Laparoscopic cholecystectomy requires additional training that includes not only the principles of general surgery but also laparoscopy. Various organizations are recognizing the need for a standard set of credentials to help ensure that laparoscopic cholecystectomy is performed by adequately trained surgeons. Hands-on experience is essential, and a 2- or 3-day “mini” course is essential but not sufficient. Working with surgeons who are trained and proficient in laparoscopic cholecystectomy is another way to obtain competence. If a laser is used, training in laser surgery is mandatory. Once the basic skills are achieved, surgeons should be proctored by a surgeon skilled in laparoscopic cholecystectomy. Surgeons performing laparoscopic cholecystectomy should be monitored for this as well as other surgical procedures, and the outcome should be a part of the surgical quality assurance program to ensure a good outcome for the patient.
JOURNAL OF SURGERY
VOLUME
161
MARCH
1991
337
SUMMARY Laparoscopic cholecystectomy shares basic surgical principles with traditional cholecystectomy. The ideal indication for laparoscopic cholecystectomy should be the need for elective cholecystectomy in uncomplicated cases. Surgeons need to be familiar with highly specialized and technical equipment and new instruments. Laparoscopic techniques must be mastered, hand-eye coordination developed, and laser skills acquired (if lasers are used for dissection). Results from laparoscopic cholecystectomy are good, except for a potentially higher rate of bile duct injury. Shorter hospital stays and earlier return to normal activity are the major advantages of laparoscopic cholecystectomy compared to traditional cholecystectomy.
1. Reddick EA, Olsen DO. Laparoscopic laser cholecystectomy. A comparison with mini-lap cholecystectomy. Surg Endosc 1989; 3: 131-3. 2. Zucker KA, Bailey RW, Gadacz TR, Imbembo AL. Laparoscopic guided cholecystectomy. Am J Surg 1991; 161: 36-44. 3. Fitzgibbons RJ, Jr, Schmid S, Santoscoy R, et al. Laparoscopic cholecystectomy: the beginning of a new era in general surgery. (Submitted for publication) 4. Peters JH, Ellison EC, Innes JT, et al. Safety and efficacy of laparoscopic cholecystectomy; a prospective analysis of 100 initial patients. Ann Surg 1991 (in press). 5. Gadacz TR, Talamini M, Lillemoe K, Yeo C. Laparoscopic cholecystectomy. Surg Clin North Am 1990; 70: 1249-62. 6. McSherry CK. Cholecystectomy: the gold standard. Am J Surg 1989; 158: 174-8.
338
161
THE AMERICAN
JOURNAL
OF SURGERY
VOLUME
REFERENCES
MARCH
1991
![[Ambulatory laparoscopic cholecystectomy by minilaparoscopy versus traditional multiport ambulatory laparoscopic cholecystectomy. Prospective randomized trial].](/assets/img/hold.png)
