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PubMed1992

Comparison of early postoperative results for laparoscopic versus standard open cholecystectomy.

Alternative (nonresective) therapies of symptomatic cholelithiasis have been followed by frequent recurrence of gallstones. Great interest has been generated by the recent development of laparoscopic cholecystectomy, which in addition to preventing recurrence, may be associated with less patient discomfort, shorter hospital stays and more rapid return to work than standard cholecystectomy. We compared the first 25 patients who underwent laparoscopic cholecystectomy at our institution to the most recent 25 patients undergoing standard cholecystectomy by the same surgeon. The results of analysis of the two patient groups showed that they were similar in age, weight and gallstone burden. A slightly longer operative time (mean plus or minus S.E.M., 122 +/- 9 minutes versus 95 +/- 5 minutes, p) was required to perform laparoscopic cholecystectomy than standard cholecystectomy during this early experience. However, patients undergoing laparoscopic cholecystectomy had a markedly diminished usage of parental narcotic analgesia during the first 24 hours postoperatively (1.7 +/- 0.5 milligrams of morphine sulfate versus 34.5 +/- 4.1 milligrams of morphine sulfate). They also were discharged from the hospital (1.0 +/- 0 days versus 4.1 +/- 0.3 days) and returned to work or unrestricted activity (8.5 +/- 1.1 days versus 35.6 +/- 4.5 days) much sooner postoperatively than those treated by standard open cholecystectomy. Based on these favorable results, we conclude that laparoscopic cholecystectomy should be the procedure of choice for most patients with symptomatic cholelithiasis.

Adult↗

PubMed2005

[Failure of diagnosing pancreatic tumors in the course of laparoscopic cholecystectomy: surgical lessons].

INTRODUCTION: In Hungary surgeons perform approximately 24000 cholecystectomies per year. Nowadays the choice of treatment of uncomplicated cholelithiasis is laparoscopic cholecystectomy. The advantages and popularity of the procedure are well known; otherwise the exploration of the abdominal cavity is not so complete than during open surgery. In the course of laparoscopic surgery the surgeon has minimal chance to find the preoperatively not diagnosed tumour. AIMS: In our retrospective study we analysed those complains and clinical signs, when we suspect the presence of a pancreas tumour. PATIENTS AND METHODS: We analysed the clinical data of patients who were operated on with pancreatic tumor and before the surgery, laparoscopic cholecystectomy had been performed in the previous 24 month. RESULTS: In the period of 1996-2003 we operated 1515 patients with pancreatic tumor, at our clinic. 21 patients (1.39%) had laparoscopic cholecystectomy in the last 24 month, before the surgery. The age of the patients was between 50-78 (average age 65), the rate of the female and male patients was 15/6. Most of the patients had weight loss (in 11 cases it was considerable, 5.4 kg in one month) and the uncertain abdominal pain, feeling of discomfort, meteorism was also characteristic of these patients. In 16 cases (76%) the blood glucose level had been elevated. The ultrasound examination before the cholecystectomy in these cases was focused to the gall bladder. After the cholecystectomy, complains did not disappear definitely and further diagnostic steps verified the pancreatic tumour. The average time between the laparoscopic cholecystectomy and the open surgery was 10 month. In 4 cases we were able to remove the tumor, but in 17 cases only palliative operation was performed. CONCLUSIONS: If the patient is over the age of 50, especially if he is male, has weight loss and if the symptoms are not characteristic of gallbladder disease, further diagnostic steps are necessary before cholecystectomy. Complains remaining after laparoscopic cholecystectomy must be indication for urgent diagnostic steps. The life expectancy of patients with advanced pancreatic tumor is very poor.

Aged↗

PubMedDate not supplied

Late choledochal pathology after cholecystectomy for cholelithiasis.

UNLABELLED: After "simple" cholecystectomy for lithiasis, biliary disorders can appear, with the onset more than 3 years postoperative, like cholangitis or transitory jaundice. Meantime, a whole range of congenital abnormalities initially ignored can become manifest: biliary tract congenital dilatations, duodenal para-Vater diverticulum, Oddi stenosis. AIM: to establish the pathological circumstances that determine late choledochal syndrome, including an analysis concerning the therapeutical approach in these cases. Patients with cholecystectomy complains of late biliary disorders (least 3 years symptom-free) between 1997-2005, were retrospectively studied. Exclusion criteria were intraoperative incidents or accidents, recognised incomplete surgical procedure, early difficult postoperative course. Therapeutical approach was endoscopical, surgical or conservative. 46 patients entered the study group; 38 underwent open cholecystectomy. Mean interval between operation and disturbances onset was 10 years. Following etiopathologic causes of late choledochal pathology were recorded: incomplete cholecystectomy, retained or primary common bile duct (CBD) stones, choledochal cyst or stenosis, Oddi stenosis, duodenal para-Vater diverticulum, anomaly biliary tree. Thirty patients undergone successful endoscopic treatment; in 8 cases endoscopy failed, in 2 cases open surgery was the first choice; 5 diagnostic endoscopic cholangiography with conservative treatment were performed; 1 patient refused any procedure. Cholecystectomy indication is regularly based on clinical and ultrasound examination criteria. Even a simple cholecystectomy can be followed after first 3 years by cholangitis, obstructive jaundice, caused by initially ignored biliary tract pathology. To avoid such omissions, routine intraoperative cholangiography and duodenal endoscopy should precede cholecystectomy. On the other side, cholecystectomy itself can cause late complaints: retained CBD stones, gallbladder stump, and iatrogenic stenosis. The duodenal para-Vater diverticulum seems to have a more important role in biliary disturbances, before and after cholecystectomy.

Aged↗

PubMed1987

Endoscopic removal of common bile duct stones without subsequent cholecystectomy.

Good results from endoscopic sphincterotomy (EST) for removing choledochal stones following cholecystectomy, have led to increasing use of the method when the gallbladder is in situ. The need for cholecystectomy after successful EST has been questioned. As cholecystectomy in elderly patients involves substantial risk, we routinely defer cholecystectomy in such patients while they remain asymptomatic. Experience of 40 cases is reported. Thirty-four were discharged without cholecystectomy and one underwent elective cholecystectomy at his own request. The remaining 33 patients were followed up for 6-53 (mean 21.5) months. Four died from causes unrelated to gallstone disease. Symptoms requiring cholecystectomy arose in two cases (6%). We found no problems due to refraining from routine elective cholecystectomy following EST for common bile duct stones. The rarity of later symptoms appears to justify a "wait and see" attitude to post-EST cholecystectomy.

Adult↗

PubMed1994

Unimpaired immune functions after laparoscopic cholecystectomy.

BACKGROUND: The advantages of laparoscopic cholecystectomy over the open procedure seem to be related to the lesser surgical trauma. Whether this is also reflected by reduced postoperative immune suppression is not known. METHODS: The perioperative cellular immunocompetence of patients undergoing either laparoscopic (n = 8) or open (n = 8) cholecystectomy was evaluated before operation and at 24 hours and 6 days after operation for inflammatory reactivity by white blood cell counting and serum interleukin-6 assessment. Immunocompetence was evaluated by skin testing with phytohemagglutinin and by phenotyping blood mononuclear cells. RESULTS: Although 24 hours after conventional cholecystectomy granulocyte and interleukin-6 levels were strongly increased, laparoscopic cholecystectomy did not affect these acute inflammation parameters. Patients who had undergone conventional cholecystectomy showed a strong reduction of phytohemagglutinin responsiveness, in contrast to laparoscopic patients (67% versus 0% reduction). Flow cytometric analysis of blood mononuclear cells revealed a distinct reduction of HLA-DR expression on monocytes in the open cholecystectomy group only. Both parameters returned to baseline levels within 6 days after operation. CONCLUSIONS: In contrast to open cholecystectomy, laparoscopic cholecystectomy does not significantly affect parameters reflecting immunocompetence. This lack of interference with cellular immune functions provides another argument favoring laparoscopic rather than open cholecystectomy.

Adult↗

PubMed2000

Cholecystectomy: does subspecialization alter workload?

AIMS: Cholecystectomy is a common operation. This study reviewed the changes in workload and practice in a teaching hospital over a 4-year period, during which a hepatobiliary subspecialist unit was developed. METHODS: Computerized demographic data, and details of operations and inpatient events were reviewed for all patients undergoing cholecystectomy in a single teaching hospital from 1993 to 1997. For statistical analysis the consultants were grouped into those with a hepatobiliary interest (n = 3) and those with other primary interests (n = 6); and the workload for the first 12 months of the study was compared with that of the last 12-month period. RESULTS: Between April 1993 and April 1997, 1121 cholecystectomies were performed, of which 75 were excluded because they were performed with other simultaneous procedures. Of the remaining operations, 911 involved cholecystectomy alone (mean patient age 52. 9 years), and 135 (12.9 per cent) comprised cholecystectomy with exploration of the common bile duct (ECBD) (mean age 60.1 years). Between the first and last years studied, the rate of ECBD rose significantly from 7.4 to 14.9 per cent (P < 0.01, chi2 test), and the proportion of ECBD procedures being performed by hepatobiliary specialists rose from 31.6 to 52.7 per cent, but this was not statistically significant (P = 0.13). However, for cholecystectomy in the same period the proportion performed by hepatobiliary surgeons rose from 40.4 to 58.5 per cent, representing a highly significant trend (P < 0.001). Following cholecystectomy alone there was a significantly shorter stay associated with patients treated by hepatobiliary surgeons (P = 0.002, F test), although the median postoperative hospital stay was 2 days for both groups of surgeons (interquartile range 1-3 days for hepatobiliary and 1-4 days for non-hepatobiliary surgeons). CONCLUSIONS: Although cholecystectomy is not viewed as a specialist procedure, the trend in this teaching hospital reveals a steady increase in the proportion of cholecystectomies being performed by teams with a biliary interest. The data indicate that this practice is associated with a shorter hospital stay.

Journal Article↗

PubMed1994

Long-term pain: less common after laparoscopic than open cholecystectomy.

Persistent symptoms after cholecystectomy are common, occurring in up to 40 per cent of patients. Severe pain persists in 10 per cent of cases. A total of 450 patients were studied, 200 after open cholecystectomy and 250 after the laparoscopic operation. Patient notes were reviewed and a postal questionnaire was circulated. Responses were obtained from 155 patients (77.5 per cent) undergoing open cholecystectomy and 205 (82.0 per cent) having the laparoscopic operation. Mean (s.d.) follow-up was 32(23) months after open cholecystectomy and 15(7) months after the laparoscopic procedure. Right upper quadrant pain was more common after open cholecystectomy (9.7 versus 3.4 per cent, P < 0.05). Indigestion and heartburn were equally prevalent in the two groups. Some 59.4 per cent of patients were free from symptoms after open cholecystectomy compared with 63.4 per cent following the laparoscopic operation; there was symptomatic improvement in 30.3 and 31.7 per cent respectively. Symptoms were the same or worse in 10.3 per cent of patients after open cholecystectomy compared with 4.9 per cent after the laparoscopic operation (P < 0.05). Patients report significantly less right upper quadrant pain after laparoscopic than after open cholecystectomy.

Cholecystectomy↗

PubMedDate not supplied

Pulmonary function after cholecystectomy performed through Kocher's incision, a mini-incision, and laparoscopy.

Comparative pulmonary function after cholecystectomy performed through Kocher's incision, a mini-incision, and laparoscopy was evaluated. Forty-five patients were randomly and prospectively divided into three groups of 15 each, depending on the surgical access employed. Forced vital capacity (FVC), forced expiratory volume at 1 second (FEV1), and forced expiratory flow at 25% to 75% (FEF25-75%) were determined 1 to 3 days before and 16 to 24 hours after cholecystectomy. The percent reduction of FVC (p = 0.0170), FEV1 (p = 0.0191), and FEF25-75% (p = 0.0045) was smaller after laparoscopic cholecystectomy than after Kocher's incision cholecystectomy. The percent reduction of FVC (p = 0.0170) was smaller after mini-incision cholecystectomy than after Kocher's incision cholecystectomy. There was no difference in the FEV1 (p = 0.0971) or FEF25-75% (p = 0.2058) between these two groups. FEF25-75% was significantly less impaired in the laparoscopic group than in the mini-incision group (p = 0.0327). No difference between these two groups was found in FVC (p = 0.5755) or FEV1 (p = 0.3952). It is concluded that postoperative pulmonary function is less impaired after laparoscopic cholecystectomy than after either mini-incision or Kocher's incision cholecystectomy.

Adolescent↗

PubMed2002

Radical second resection provides survival benefit for patients with T2 gallbladder carcinoma first discovered after laparoscopic cholecystectomy.

Port site recurrence or peritoneal seeding is a fatal complication following laparoscopic cholecystectomy for gallbladder carcinoma. The aims of this retrospective analysis were to determine the association of gallbladder perforation during laparoscopic cholecystectomy with port site/peritoneal recurrence and to determine the role of radical second resection in the management of gallbladder carcinoma first diagnosed after laparoscopic cholecystectomy. A total of 28 patients undergoing laparoscopic cholecystectomy for gallbladder carcinoma were analyzed, of whom 10 had a radical second resection. Five patients had recurrences; port site/peritoneum recurrence in 3 and distant metastasis in 2. The incidence of port site/peritoneal recurrence was higher in patients with gallbladder perforation (3/7, 43%) than in those without (0/21, 0%) (p = 0.011). The outcome after laparoscopic cholecystectomy was worse in 7 patients with gallbladder perforation (cumulative 5-year survival of 43%) than in those without (cumulative 5-year survival of 100%) (p <0.001). Among 13 patients with a pT2 tumor, the outcome after radical second resection (cumulative 5-year survival of 100%) was better than that after laparoscopic cholecystectomy alone (cumulative 5-year survival of 50%) (p = 0.039), although there was no survival benefit of radical second resection in the 15 patients with a pT1 tumor (p = 0.65). In conclusion, gallbladder perforation during laparoscopic cholecystectomy is associated with port site/peritoneal recurrence and worse patient survival. Radical second resection may be beneficial for patients with pT2 gallbladder carcinoma first discovered after laparoscopic cholecystectomy.

Adenocarcinoma↗

PubMed2000

Prevalence of postcholecystectomy symptoms: long-term outcome after open versus laparoscopic cholecystectomy.

After cholecystectomy a certain number of patients continue to suffer from abdominal symptoms or develop such symptoms postoperatively. The aim of this study was to compare the prevalence of postcholecystectomy symptoms with open cholecystectomy during the prelaparoscopic era and those with laparoscopic cholecystectomy 4 years after introduction of the laparoscopic technique. Between July 1988 and June 1989 a total of 163 consecutive patients with elective open cholecystectomy and between September 1994 and August 1995 a total of 234 consecutive patients with elective laparoscopic cholecystectomy were prospectively evaluated using a standard questionnaire about preoperative symptoms, diagnostic modalities, and intraoperative findings. After a minimum of 12 months the patients were interviewed by telephone. Since the introduction of the minimal invasive technique the number of cholecystectomies performed at our institution increased. There was no significant difference in the prevalence of postcholecystectomy symptoms found after the open procedure compared with laparoscopic cholecystectomy: 90% of patients after open and 94% after laparoscopic cholecystectomy had no or only minor symptoms.

Adult↗

PubMed2004

Small-incision (mini-laparotomy) versus laparoscopic cholecystectomy: a retrospective study in a university hospital.

BACKGROUND AND AIMS: Since the introduction of laparoscopic cholecystectomy into general practice in 1990, it has rapidly become the dominant procedure for gallbladder surgery. The aim of this study was to compare the results of the laparoscopic, open and mini-laparotomy approaches to cholecystectomy. PATIENTS AND METHODS: Our study covers a period of 6 years. A total of 1,276 patients underwent cholecystectomy for calculous biliary disease. The laparoscopic procedure was applied to 952 (74.6%) patients, while 210 (16.5%) underwent the traditional open cholecystectomy and the remaining 114 (8.9%) patients underwent mini-laparotomy cholecystectomy. RESULTS: Thirty-seven patients (3.9%) from the laparoscopic group required conversion to open cholecystectomy. Morbidity was similar in the open and laparoscopic groups (3.8%), while it was significantly lower in the mini-laparotomy group (0.8%). No major bile duct injuries occurred after the open or mini-laparotomy approaches. The median operation time was significantly shorter in the mini-laparotomy group than in the laparoscopic group (46 min vs 61 min). Hospital stay was significantly longer for the open cholecystectomy group (mean value 5.1 days) compared with the laparoscopic and mini-laparotomy groups (mean values 2.5 days and 2.7 days, respectively). Hospital expenses showed a saving of 786 Euro for each patient who underwent the open procedure and 980 Euro for each patient who underwent the mini-laparotomy approach compared with the laparoscopic one. CONCLUSION: We believe that commissioners of healthcare should question whether the benefits of laparoscopic cholecystectomy justify the additional cost after the introduction of the mini-laparotomy approach.

Adolescent↗

PubMed2002

Serum E-cadherin concentrations and their response during laparoscopic and open cholecystectomy.

BACKGROUND: Elevated serum levels of the cell adhesion molecule E-cadherin have been associated with the presence of tissue injury and inflammation. We compared soluble E-cadherin response during laparoscopic and open cholecystectomy. METHODS: The E-cadherin response to surgery was studied in 16 patients undergoing laparoscopic cholecystectomy and 12 patients undergoing open cholecystectomy. Serum E-cadherin levels were measured by an enzyme immunoassay (ELISA) preoperatively, 10 and 30 min after the commencement of surgery, and at 6 and 24 h following the operation. RESULTS: Serum E-cadherin levels decreased progressively during laparoscopic cholecystectomy; their concentrations at 24 h after surgery were significantly lower when compared with preoperative values. In the open cholecystectomy group, serum E-cadherin levels did not differ from preoperative values at any time point. Serum E-cadherin concentrations at 24 h after surgery and the cumulative E-cadherin response were significantly higher in the open cholecystectomy group than in the laparoscopic group. CONCLUSION: Compared with open cholecystectomy, the cumulative E-cadherin response is significantly reduced following laparoscopic cholecystectomy.

Cadherins↗

PubMed1997

Early laparoscopic cholecystectomy for acute cholecystitis.

BACKGROUND: The timing of laparoscopic cholecystectomy for acute cholecystitis remains controversial. METHODS: One hundred ninety-four patients with acute cholecystitis were reviewed. The conversion rates for the various number of days of symptoms before surgery were analyzed. The conversion rate dramatically increased from 3.6% for those patients with 4 days of symptoms to 26% for those patients with 5 days of symptoms. The mean number of days of symptoms prior to surgery in those patients who underwent successful laparoscopic cholecystectomy was 4.1 as compared to 8.0 in those patients who required open cholecystectomy (p < 0.0001). Based on this data the patients were divided into two groups. Group 1 consisted of 109 patients who underwent laparoscopic cholecystectomy within 4 days of onset of symptoms and group 2 consisted of 85 patients who underwent laparoscopic cholecystectomy after more than 4 days following onset of symptoms. RESULTS: The conversion rate from laparoscopic to open cholecystectomy was 15%. The conversion rate for group 1 was 1.8% as compared to 31.7% for group 2 (p < 0.0001). Indications for conversion were inability to identify the anatomy secondary to inflammatory adhesions (68%), cholecystoduodenal fistula (18%), and bleeding (14%). The major complication rate for group 1 was 2.7% as compared to 13% for group 2 (p = 0.007). The mortality rate for all patients with attempted laparoscopic cholecystectomy for acute cholecystitis was 1.5%. The average procedure time for group 1 was 100 +/- 37 min vs 120 +/- 55 min in group 2. The average number of postoperative hospital days in group 1 was 5.5 +/- 2.7 days as compared to 10.8 +/- 2.7 days in group 2. CONCLUSIONS: We advocate early laparoscopic cholecystectomy within 4 days of onset of symptoms to decrease major complications and conversion rates. This decreased conversion rate results in decreased length of procedure and hospital stay.

Acute Disease↗

PubMed1994

Reasons for conversion from laparoscopic to open cholecystectomy in an urban teaching hospital.

BACKGROUND: Although laparoscopic cholecystectomy has replaced open cholecystectomy for the majority of patients, it is clear that a substantial minority will require laparotomy for safe and successful removal of the gallbladder. PATIENTS AND METHODS: Seven hundred forty-six laparoscopic cholecystectomies performed at LAC+USC Medical Center for January 1991 to May 1993 were retrospectively reviewed. Hospital stay, laboratory values, and complications, as well as the need for and reason for conversion to open cholecystectomy were recorded. There were 661 females and 85 males, with a mean age of 38 years (range 15 to 92). RESULTS: One hundred one (14%) of the 746 patients were converted to open cholecystectomy. Difficult dissection secondary to inflammation or adhesions and the need to treat common-bile-duct stones were the most common reasons for conversion. Patients requiring conversion to open cholecystectomy were more likely to have been admitted through the emergency department (72% versus 46%, P < 0.0001), have had prolonged hospital stays prior to surgery (mean time from admission to surgery 4.4 days versus 2.8 days, P < 0.0001), and to have had a thickened gallbladder wall on preoperative ultrasound (54% versus 20%, P < 0.001). CONCLUSIONS: The most common reasons for conversion to open cholecystectomy are inflammation and adhesions secondary to severe acute and chronic disease and/or the need for clearance of the common bile duct. Patients who were admitted to the emergency department, particularly if they were managed nonoperatively for a period of time and had a preoperative diagnosis of acute cholecystitis, were more likely to require conversion to open cholecystectomy.

Adolescent↗

PubMed1993

Mini-lap cholecystectomy.

With the introduction of laparoscopic cholecystectomy, the surgical community witnessed a revolution in basic ideology. Gone are the days when surgeons spoke of wounds healing "from side to side, and not top to bottom." The surgical community has become aware of the concept of minimally invasive surgery. Despite this recent advance, surgeons have long realized that the surgical wound does contribute to morbidity and mortality. The mini-lap cholecystectomy, described as early as 1982, is an indication that surgeons are making an attempt to reduce this morbidity. Mini-lap cholecystectomy is now being suggested as an alternative to laparoscopic cholecystectomy--a technique that boasts many of the same benefits without the problems inherent in laparoscopic surgery. The author has reviewed the literature for mini-lap cholecystectomy, laparoscopic cholecystectomy, and conventional cholecystectomy. Using this "historical" database, he then compares the three techniques to determine whether mini-lap cholecystectomy is a viable alternative.

Cholecystectomy↗

PubMed2000

Impact of laparoscopic cholecystectomy: a population-based study.

BACKGROUND: We assessed the effect of the introduction of laparoscopic cholecystectomy on surgical outcomes in routine practice. METHODS: Hospital discharge and death-certificate data were linked for all patients undergoing cholecystectomy (n=85120) in Scottish public-sector hospitals (n=51) between January, 1981, and June, 1999. The primary endpoints were cholecystectomy rate, hospital stay, and postoperative mortality. Regression methods were used to examine the effect of laparoscopic experience and surgeon caseload on postoperative mortality and hospital stay. FINDINGS: From 1989 to 1999, the proportion of cholecystectomies done laparoscopically rose from none to 80%, and the age-standardised cholecystectomy rate increased by 20% (95% CI 15-26). Postoperative mortality did not change in the 1990s (odds ratio 0.99 [0.7-1.4], p=0.99). The mean postoperative hospital stay fell from 8.0 (SD 3.7) to 2.9 (3.2) days. There was wide variation between hospitals in the proportion of cholecystectomies done laparoscopically and in average hospital stay. For individual surgeons, increasing laparoscopic experience and annual caseload were associated with higher proportions of laparoscopic procedures and shorter hospital stays. Postoperative mortality was higher during the first ten laparoscopic cholecystectomies done by a surgeon (compared with >200 procedures, odds ratio 2.3 [1.2-4.6], p=0.015). INTERPRETATION: The laparoscopic method reduced hospital stay but had no overall effect on postoperative mortality. Studies to assess the appropriateness of the increased cholecystectomy rate are merited. The wide variation in the proportion done laparoscopically, together with evidence of better results for surgeons doing more procedures, suggests scope for further reductions in hospital stay and morbidity.

Adult↗

PubMed1999

Teaching gall bladder surgery: remembrance of things past, or defensive cholecystectomy revisited.

Among the remaining concerns for surgeons performing laparoscopic cholecystectomy are the incidence of bile duct injury and the rate of conversion to open operation. The open operation itself, now infrequently performed, and then only for complicated disease, poses a particular challenge to the surgeon in training. The lessons learned from the era of open cholecystectomy as summarized in the principles of defensive cholecystectomy, provide useful guidelines for the laparoscopic surgeon, particularly with regard to the objectives of dissection in Calot's triangle. Attainment of these objectives during laparoscopic cholecystectomy may be easily recorded and are useful exercises for teaching and quality assurance. Flexibility with laparoscopic dissection can be taught to reflect the development of the laparoscopic technique and should allow most patients with gallstones to be treated laparoscopically. Alternative operations (cholecystostomy and subtotal cholecystectomy) may be appropriately performed laparoscopically in the occasional patient where safe cholecystectomy may not be possible by either technique. Whenever the opportunity arises, open cholecystectomy should be carefully taught to the trainee surgeon, emphasizing the principles of defensive cholecystectomy.

Cholecystectomy↗

PubMed1993

Advantages of laparoscopic cholecystectomy in the elderly and in patients with high ASA classifications.

Two hundred and thirty-three patients underwent cholecystectomy at Mercy Hospital of Pittsburgh during the popularization of laparoscopic cholecystectomy. Laparoscopic cholecystectomy was performed in 167 of these patients while the remaining 66 patients had an open cholecystectomy. A statistically significant increase in the incidence of morbidity was observed with advancing age (p < 0.001, odds ratio 2.33) as well as in patients with higher ASA classes (p < 0.001, odds ratio 2.31). Overall, laparoscopic cholecystectomy was associated with a markedly lower incidence of morbidity than the open procedure (7% versus 47%, p < 0.001). A multiple logistic regression model was applied to the study population due to the fact that those patients who underwent open cholecystectomy tended to be older individuals with more clinically significant associated medical conditions than those individuals who underwent the laparoscopic procedure. When the logistic regression model was applied to control for the differences in age, associated illnesses, and ASA class between the two groups; a seven fold increase in the risk of morbidity was found in the open group as compared to the laparoscopic group (p < 0.001, odds ratio 7.31). These findings favor the use of laparoscopic cholecystectomy over open cholecystectomy in all eligible patients, especially elderly patients and those patients in higher ASA classes.

Adolescent↗