Series Of Laparoscopic Cholecystectomy Research Articles

Laparoscopic cholecystectomy performed by a surgical care practitioner: a review of outcomes.

Surgical care practitioners (SCPs) are non-medical workers involved in various aspects of the management of surgical patients. The role includes assisting and performing surgical procedures. More than 60,000 laparoscopic cholecystectomies (LC) are performed annually in the UK. With ever-increasing pressure on waiting lists, it is important to look at fully utilising the skills of our entire workforce. We report what we believe is the first published series of LC performed by an SCP. A retrospective review of a prospectively collected database was performed. The primary outcome was any complication requiring intervention. Secondary outcomes were minor complications, operative time, length of stay, conversion and readmission. In total, 170 patients were operated on. Indications were biliary colic in 127 (74.7%), cholecystitis in 30 (17.6%) and pancreatitis in 13 (7.6%). Mean operating time was 65min (range 35-152min). Fifty-three operations were assisted by a consultant, 110 by a specialist or associate specialist grade (SAS) doctor and 7 by a core trainee (CT2). Some 139 (81.7%) patients were discharged on the day of surgery and 24 (14.1%) stayed one night in hospital. There were no major complications. Five patients required readmission, three with pain and two with port site infections. There were no conversions or transfusions required. There is a paucity of published data on surgical outcomes of procedures performed by SCPs. With a structured, supervised approach, SCPs could be trained to take on more complex procedures and further strengthen the surgical workforce. This study demonstrates that elective LC can be safely performed by an appropriately trained and supervised SCP.

Open-access technique and "critical view of safety" as the safest way to perform laparoscopic cholecystectomy.

The 2 main challenges of laparoscopic cholecystectomy are primary peritoneal access and safe identification, ligation, and division of the cystic duct and cystic artery. This is a 13-year period retrospective study from January 2000 to December 2012. All the operations were performed by 1 surgeon and all the data were collected from the hospitals archive. A total of 929 laparoscopic cholecystectomies were performed for symptomatic cholelithiasis. The first author was involved in all the operations either by performing or assisting in them. The open access (OA) technique was used in all cases for the creation of pneumoperitoneum. After establishing the pneumoperitoneum, the "critical view of safety" (CVS) technique was used to ligate and divide the cystic duct and cystic artery. When the OA was not possible or CVS was not feasible, the operation was converted to open. Successful establishment of pneumoperitoneum with OA was possible in 911 of 929 (98.06%) patients and CVS was achieved in 873 patients (95.82%). In 18 patients the operation was converted to open because of dense adhesions not permitting the establishment of the pneumoperitoneum. No intraoperative or postoperative complications occurred in these patients. No bile duct injury occurred in this series. Postoperative complications were recorded in 19 patients (2.04%). Five patients had bleeding from port sites, 12 patients had wound infection at the umbilical incision, and 2 patients developed subhepatic collections, which were drained percutaneously under computed tomographic guidance. In this series of laparoscopic cholecystectomies, we used the "open access" technique to create pneumoperitoneum and we obtained the "critical view of safety" for the identification of the cystic duct. Our results show that this approach is the safest way to perform and teach laparoscopic cholecystectomy.

Outcome evaluation of 10,317 laparoscopic cholecystectomies: a 17-year experience at a single center.

This study is an analysis of the large series of laparoscopic cholecystectomies and compare our results with those reported in the literature concerning complications. From December 1993 to September 2010, 10,317 patients with gallstone disease underwent laparoscopic cholecystectomy. Previously operated patients were also included in the study. We analyzed the successfulness of the results, intraoperative and postoperative complications, conversions in open cholecystectomy, mortality and reoperation rate. We registered 23.28% complications. Intraoperative complications were bleeding in 9.84%, gallbladder perforation in 8.63%, stone loss in 1.37%, common bile duct injury in 0.24% and injury of intraabdominal organs in 0.07% of cases. Postoperative complications were bleeding in 1.12%, wound infection in 0.59%, bile leakage in 0.5%, incisional umbilical hernias in 0.37%, subhepatal collection in 0.33%, residual gallstones in choledocus in 0.09%, urine retention in 0.08% and biliary peritonitis in 0.01% of patients. Conversion to open cholecystectomy was necessary in 2.13%. Reoperation was performed in 0.27%. The mortality rate was 0.019%. Our results on large number of patients are similar to other series in the newer literature but the rate of complications should be decreased. The incidence of complications decreases with growing laparoscopic experience.

SILS cholecystectomy, early experience of a single institution: pilot study of 21 cases

Many surgeons have attempted to reduce the number and the size of ports in laparoscopic cholecystectomy to decrease parietal trauma and pain, and to improve cosmetic results. We report a series of laparoscopic cholecystectomies using a single-port technique (SILS) through an umbilical incision in a pilot group of 21 cases. Our goal was to validate and develop the single-port access as a viable option. All the operations were performed using an umbilical SILS port (Ethicon). Most reported techniques utilize special purpose-made instruments. This article provides a stepwise description of the procedure using all straight instruments. No special reticulating instruments or flexible telescopes were used. We report our early difficulties and concerns about the procedure and propose solutions to the problems. Patients' request for improved cosmesis impels surgeons toward the application of SILS, but the true advantage of the technique should be assessed by more evidences. For this reason, we are planning a single-institution, prospective randomized controlled trial to compare postoperative pain, operating time and cosmetic result between one port and standard laparoscopic surgery.

Major biliary complications in 2,714 cases of laparoscopic cholecystectomy without intraoperative cholangiography: a multicenter retrospective study

The ongoing debate between routine and selective users of intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) has not yet come to an end. Routine users argue that IOC decreases the rate of biliary complications such as bile duct injury, biliary leak and missed common bile duct (CBD) stones, a claim that selective users do not fully support. On the other hand, a third policy that was adopted by many other centers is performing LC without IOC. In this retrospective study, we are exploring the results of a relatively large multicenter series of LC without IOC regarding major biliary complications. We performed a retrospective analysis of LC cases operated by experienced laparoscopic surgeons, without resorting to IOC, in four surgical units of university hospitals in Egypt during a 6-year period (January 2004 through December 2009). Excluded from the study were cases with positive predictors of CBD stones, namely, sonographically detected CBD dilatation and/or CBD stones, elevated bilirubin and/or alkaline phosphatase, persistent biliary pancreatitis, cholangitis, and those who had preoperative magnetic resonance cholangiography. Of the 2,955 cases of LC reviewed, 241 were excluded, leaving 2,714 cases enrolled in the study. Fifty-five cases (2%) were converted to open surgery. Five cases (0.18%) had major bile duct injuries requiring surgical repair. Postoperative bile leakage was encountered in seven cases (0.26%). Missed CBD stones were reported in six cases (0.22%). There was no perioperative mortality in the present study. LC can be performed safely without the use of IOC, with acceptable low rates of biliary complications provided that proper detection of patients with silent CBD stones is done and facilities for pre- and postoperative endoscopic retrograde cholangiopancreatography are available.

Laparoscopic Versus Single‐Incision Cholecystectomy

Although recent reports demonstrate large series of single-incision cholecystectomies, few articles compare single-incision data with traditional laparoscopic cholecystectomy (LC) data. This article compares a large series of single-incision cholecystectomies to a series of traditional LCs performed at an urban tertiary-care center. A consecutive series of single-incision cholecystectomies was performed from August 2008 to March 2010. All cholecystectomies were attempted through a single incision on an intent-to-treat basis. Patient demographics, including height, weight, body mass index (BMI), pathologic diagnosis, ASA classification, operative time, complications, narcotic use, and length of stay (LOS), were recorded. Data for a matched cohort of patients undergoing a traditional four-port LC were gathered over a similar time period. Data were compared using a t test with a P<0.05 for significance. Single-incision cholecystectomy was successful in 81 (76%) of 107 patients. The 26 (24%) converted cases showed a higher BMI (33.0±8.7 vs. 28.4±6.4 kg/m2, P<0.05) and longer operative times (98.3±33 vs. 76.1±23 min, P<0.003). Postoperatively, the converted patients had a longer LOS compared to that of the single-incision group (1.6±1.0 vs. 1.1±0.4 days, P=0.02). Overall, the single-incision group had longer operative times compared to the four-port LC group (81.5±28 vs. 69.1±21 min, P<0.004). However, after the tenth single-incision case, there was no difference in operative times. From a narcotic standpoint, the successful single-incision patients used significantly less narcotic versus the traditional LC group (20±22.7 vs. 32.3±31.2 mg, P=0.02). The data suggests that individuals with a BMI over 33 may not be candidates for single-incision cholecystectomy. Those patients that undergo a successful single-incision laparoscopic cholecystectomy require fewer narcotics postoperatively and have a shorter LOS. Although this data is intriguing, the overall utility of single-incision procedures requires more analysis and potentially randomized trials.

Laparoscopic cholecystectomy in 427 adults with sickle cell disease: a single-center experience

Sickle cell disease (SCD) is common in the Eastern Province of Saudi Arabia. Patients with this disease have an increased risk for gallstones. Cholecystectomy is the most common general surgical procedure performed in patients with SCD. Laparoscopic cholecystectomy (LC) is the standard treatment for symptomatic gallstones. To date, only small series of LC in adults with SCD have been reported. We report a large series of LC in these patients. A retrospective study included all adults with SCD who underwent LC for symptomatic gallstones at King Fahad Hospital, Hofuf, Saudi Arabia, during a 13-year period. Data analyzed were patient demographics, preoperative blood transfusion, duration of operation, rates of conversion and morbidity, and length of hospital stay. There were 427 patients; 56% were women with a mean age of 21 years. Blood transfusion was used in 393 patients (92%). Nineteen patients (4.5%) had endoscopic extraction of common bile duct (CBD) stones before LC. Overall, conversion to open surgery was necessary in 21 patients (5%). However, the conversion rate significantly decreased from 9% in the first half of the study to 2% during the second half (p < 0.001). The mean operation time was 76 min. There were 31 complications (7%), mostly related to SCD. There was no mortality, and the mean hospital stay was 2.6 days. Provided that standard perioperative care is ensured and the procedure is performed by experienced surgeons, LC in adults with SCD results in low rates of conversion and morbidity, no mortality, and a short hospital stay.

Should Laparoscopic Cholecystectomy be Practiced in the Developing World?

We address the controversial issue of whether or not it is wise to perform and train laparoscopic cholecystectomy (LC) in a developing nation by reviewing the results of the first large series done in Afghanistan. Afghanistan has been devastated by 3 decades of war leaving it with deficiencies in training programs, medical technologies, and overall medical infrastructure that are among the worst in the developing world. We retrospectively reviewed 137 consecutive cholecystectomies, 102 laparoscopic and 35 open, performed by 4 senior and 3 junior surgeons trained at our hospital in Kabul from July 2005 until February 2008. Deaths, complications, conversion rate, operative time, and hospital length of stay were compared. Unrecognized major operative injuries occurred in 4 LC patients, 3 bile leaks, and 1 duodenal perforation, although there were no such injuries in the open cholecystectomy group. Complication rates were much higher for patients operated on for acute cholecystitis for both surgeon groups. Even though junior surgeons converted to open cholecystectomy more frequently than senior surgeons, they had a higher major complication rate. Hospital length of stay was 28% shorter for the laparoscopic group. The high rate of major unrecognized intraoperative complications during LC in our series underscores the difficulties inherent in performing and training LC in developing nations. Practical changes are suggested to make LC more efficient and safer in a developing world hospital.

Laparoscopic Cholecystectomy Without Intraoperative Cholangiography: Audit of Long-Term Results

There is no uniform consensus on the utility of routine intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC). In this paper, we present a 10-year retrospective audit of our cases of LC without IOC, performed by a search of readmission cases through our electronic database. Data regarding all patients subjected to LC at our unit in the period January 1996-December 2006 were obtained through our hospital database system. Subsequently, a query was made to ascertain if there were any readmissions to any of our city hospitals, up to December 2006. A total of 1321 patients underwent LC at our unit in the period January 1, 1996-December 31, 2006. The median operating time for LC without IOC was 58 minutes (range, 15-370). The median hospital stay was 2 days (range, 1-30). Postoperative outcome was uneventful in 1250 patients (94.7%). There was no mortality. Grade I and II complications occurred in the remaining 71 patients. Patients were stratified by risk of common bile duct stones (BDSs) according to clinical, ultrasonographic, and serum chemistry data. Patients with suspected BDS underwent preoperative endoscopic retrograde cholangiopancreatography (ERCP) and BDS clearance (142 patients). No patient in our series of LC was readmitted to any of the city hospitals for biliary desease up to 10 years after the operation. Our retrospective audit confirms the safety of LC without routine IOC and the rarity of readmissions for retained BDS and supports the policy of selective IOC.

Comparative Study of Human and Robotic Camera Control in Laparoscopic Biliary and Colon Surgery

Despite the growing clinical use of active robotic camera holders there is still a lack of clinical feasibility studies. We compared the use of a voice controlled robotic camera holder (AESOP 3000, Computer Motion, Goleta, California) to a human camera holder in a series of laparoscopic cholecystectomies and colectomies. Compliance with AESOP, abnormal operative events or complications, operative time, and the duration of hospitalization were prospectively recorded and compared to data recorded before the introduction of the robotic system. Compliance with AESOP was good. There were no abnormal operative events, no differences in operative time, complications, or the mean duration of hospitalization between the patients operated with a robotic or a human camera holder. The use of a robotic camera holder does not alter the length of the operative procedure, the duration of hospitalization, or postoperative morbidity. It is a safe and feasible approach to laparoscopic cholecystectomy or colectomy.

Laparoscopic cholecystectomy in geriatric patients

Background The results and advantages of laparoscopic cholecystectomy in the geriatric population have received minimal attention. Several early reports related high conversion rates complications and mortality. This case series review is focused on the results of laparoscopic cholecystectomy in the geriatric population in a private practice environment. Methods The records of all patients undergoing cholecystectomy by the author over the past 12 years were reviewed. The entire series consists of 248 patients in whom 239 procedures were completed laparoscopically, with 9 patients converted to an open cholecystectomy. This report identifies 82 patients who were aged 65 years or older at the time of the laparoscopic cholecystectomy. The results of this series are reported in three progressive geriatric age groups: 65 to 74, 75 to 84, and 85 to 95 years. Results All 82 geriatric patients reported from this series were symptomatic from their gallbladder disease. A majority of all patients in all age groups were female. Gallstones were present in 77 patients, and 5 patients had a gallbladder ejection fraction of less than 35%. In this series of laparoscopic cholecystectomy, 26.8% had an emergent procedure for acute cholecystitis and the remainder had an elective or semielective procedure for symptomatic cholecystitis. The majority of patients between the ages of 65 and 84 years had elective procedures whereas the majority of patients over age 85 had an emergent procedure. There were 2 deaths. The first death (age 86 years) was from extensive metastatic cancer from the gallbladder, and the second patient (age 91 years) died of sepsis and multiple system organ failure. Each patient in this entire series had an attempt at laparoscopic removal of the gallbladder. The conversion rate was 3.6% in the entire series of 248 patients and also 3.6% in the geriatric series. Ninety-one percent of the patients in this geriatric series were discharged home after only 24 to 48 hours of postoperative observation. Conclusions Laparoscopic cholecystectomy is a safe procedure in the geriatric population. The procedure should be recommended for all geriatric patients who have symptomatic cholecystitis before the development of acute cholecystitis or severe fibrosis with dense adhesions from chronic cholecystitis.

Ergonomic assessment of the static stress confronted by surgeons during laparoscopic cholecystectomy.

Only a few reports on static strain in the spine, neck, and head of the surgeon are available, describing it as "distinctly harmful." The aim of this study was to objectively prove the static burden during laparoscopic operations. For this, new industrial software called PCMAN was used, capable of measuring and comparing the postures of the surgeon at different monitor placements. Two simultaneous and synchronized video recordings of laparoscopic cholecystectomies (LC) were done using miniDV digital camcorders with the cameras standing at a 90 degrees angle to each other. Twenty operations were performed using two different placements of the monitor. In 10 cases, the monitor was placed at the patient's head in the center, and in 10 cases at the left side of the patient. Using the time codes of the recordings, different steps of the operation were identified, and the duration of these measured in seconds. Very characteristic, longer lasting postures were imported to and analyzed with the software. Results of the different setups were compared to each other, and to an "ideal" comfort posture. During the intermediate steps of the operations the rate of static phases is significantly higher. Measuring the typical postures of these phases the trunk and head are significantly more rotated and bent than in comfort positions. When the monitor was at the side of the patient facing the surgeon, results were closer to the comfort posture. It was proven that surgeons are confronted by significant static burden during LC. The software used was able to evaluate objectively the static posture of the surgeon during series of LC. Results also confirmed that the position of monitors significantly influences the surgeon's posture. Best setups for the whole team can be achieved by adjustable multiple monitor systems.

The clinical diagnosis of chronic acalculous cholecystitis

Background. Chronic acalculous cholecystitis (CAC), a diagnosis of exclusion, appears to be more common than was previously thought. We correlated the pathology with test results and response to treatment in a prospective study to obtain data for evidence-based management. Methods. The study subjects were patients with chronic biliary symptoms but had normal sonogram results. They were further investigated with esophagogastroduodenoscopy, multidiscipline evaluations, and cholecystokinin-stimulated scintigraphy (CCK-HIDA). They were offered laparoscopic cholecystectomy (LC) when the symptoms were intransigent, and the main abnormality was a low ejection fraction (EF) as determined by CCK-HIDA. We analyzed the histologic findings of the gallbladder, CCK-HIDA EF, and clinical outcomes during the control period with a concurrent series of LC for calculus from the same surgeons. Results. Of 176 cholecystectomies for biliary pain without stones, 152 had pathologically verified CAC. EF by CCK-HIDA was low in patients with CAC (18%) and low in normal gallbladders (26%). In the same period, 497 patients had cholecystectomies for cholelithiasis. Lasting symptom relief for CAC after LC was not different from that for calculous disease (85% vs 90%). Conclusions. The syndrome consisting of chronic biliary symptoms, stone-free sonograms, low EF in CCK-HIDA, and absence of other pain sources is highly predictive for CAC, which is well treated with LC, with results similar to those for calculous disease. (Surgery 2001;130:578-83.)

Role of endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis in patients undergoing laparoscopic cholecystectomy

Background: We report our experience of selective cholangiography in a series of laparoscopic cholecystectomies and evaluate the strategy of using “stricter criteria” to select preoperative endoscopic retrograde cholangiopancreatography (ERCPs). Methods: A total of 1847 consecutive laparoscopic cholecystectomies were analyzed for use of cholangiography. A high risk of common bile duct stones (bilirubin level more than 2 mg/dL, jaundice, alkaline phosphatase level more than 150 U/L, pancreatitis, or dilated bile duct and/or stone on ultrasound or CT) was an indication for preoperative ERCP. Selective intraoperative cholangiography was performed for intermediate risk of bile duct stones. The strategy of using “stricter criteria” (jaundice and/or demonstrated bile duct stones on ultrasound or CT) for selecting preoperative ERCP was evaluated retrospectively. Results: Preoperative ERCP was performed in 135 patients (7.3%) and demonstrated bile duct stones in 43 (32%). Of 36 patients with mild gallstone pancreatitis alone, stones were found only in 6 patients (17%). Selective intraoperative cholangiography was performed in 87 (5%), and stones were found in 2 (2%); 67 (3.6%) postoperative ERCPs were performed for suspected choledocholithiasis, and stones were found in 21 (32%). Applying “stricter criteria” to select preoperative ERCP would predict ductal stones in 56%, whereas 3% of patients with stones would be missed, resulting in a 50% reduction in preoperative ERCPs. Conclusions: Even in selected patients considered likely to have choledocholithiasis, the diagnostic yield of preoperative ERCP is low. Using “stricter criteria” to select patients for preoperative ERCP can avoid unnecessary ERCPs. (Gastrointest Endosc 1998;47:50-6.)

Laparoscopic Ligation of a Leaking Cystic Duct

Laparoscopic cholecystectomy (LC) has rapidly become an acceptable surgical technique. Indeed it may become the preferred method for cholecystectomy, with the open method reserved for complicated cases. Early series of LC have shown a mortality rate of 0-1%, comparing favorably to the open method. However, complications such as bile duct injury, cystic duct leaks, and biliary collections may be more frequent. We report the first case of cystic duct leakage after LC successfully managed by subsequent laparoscopic ligation.

腹腔鏡的胆嚢摘出術の基礎的及び臨床的研究

We have carried out a series of experimental laparoscopic cholecystectomy in dogs (n=20). In our animal experiments, laparoscopic removal of the gallbladder was performed by Nd-YAG laser, ligating the cystic artery and cystic ducy with the clips used for vascular ligation. The irradiation of Nd-YAG laser for the ablation of the gallbladder using the bare quartz was done under 10-15 watts of output with 2,000-5,000J in total energy. Then, we have carried out a series of laparoscopic cholecystectomy in human (n=8) in same procedure. This procedure requires a comprehensive technical integration, such as the preparations of optimum instruments, excellent skills and the cooperation with surgeons. From the experience, it will be concluded that this poocedure has a greater advantage over the conventional open surgical methods, which surely promise the highly quality of life (QOL).