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Early minilaparoscopic cholecystectomy in patients with acute cholecystitis
The American Journal of Surgery 185 (2003) 344 –348
Laparoscopy
Early minilaparoscopic cholecystectomy in patients with acute cholecystitis Chi-Hsun Hsieh, M.D.* Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing St., Kwei-shan, 333, Taoyuan, Taiwan Manuscript received April 15, 2002; revised manuscript October 25, 2002
Abstract Background: Recently, techniques using fine-caliber instruments (2 or 3 mm in diameter) for laparoscopic cholecystectomy, called minilaparoscopic cholecystectomy (MLC), were reported to be superior to conventional LC (CLC, using 5 mm instruments) in postoperative course and cosmetic outcome. However, the use of MLC to date has been largely restricted to uncomplicated situations. Since CLC has been proved to be a safe and efficient technique for acute cholecystitis especially if conducted early, this study tests the feasibility and safety of MLC for acute cholecystitis. Methods: Sixty-nine consecutive patients with acute cholecystitis were prospectively randomized to minilaparoscopic (n ⫽ 38) or conventional laparoscopic (n ⫽ 31) cholecystectomy, and the operations were conducted within 2 days of admission whenever possible. Despite different operative techniques, both groups of patients received identical preoperative preparation, evaluation and postoperative care. The two groups were compared for patient characteristics, results of laboratory tests, predictive score for LC difficulties, operative time, operative complications, hospitalization days and need for meperidine injection for wound pain. Results: The conversion rate was 7.9% (3 of 38) for the MLC group and 6.5% (2 of 31) for the CLC group. Nine patients in the MLC group and 7 in the CLC group had concomitant choledocholithiasis and underwent endoscopic stone retrieval before operation. The age, sex, predictive score for LC difficulties, preoperative leukocyte count, length of hospital stay and requirement of intramuscular meperidine injections were similar for both groups of patients, while, the operative times were marginally longer in the MLC group (113.8 ⫾ 30.8 versus 98.2 ⫾ 33.2 minutes, P ⫽ 0.056). No major complications occurred in either group. Conclusions: The results of cholecystectomy for acute cholecystitis by MLC are as good as those of CLC if the operation is performed early, with obvious smaller incisions and minimal complications. MLC is a safe and effective procedure for patients with acute cholecystitis, and has an acceptable low conversion rate. © 2003 Excerpta Medica, Inc. All rights reserved. Keywords: Acute cholecystitis; Laparoscopic cholecystectomy; Minilaparoscopic cholecystectomy
Since the late 1980s, laparoscopic cholecystectomy (LC) has gradually overtaken open cholecystectomy (OC) as the preferred procedure for treating cholelithiasis, offering patients a shorter hospital stay, less postoperative pain, better cosmetic results and an early recovery [1–3]. These advantages are undoubtedly due to LC being a less invasive procedure than OC, generally requiring only four trocar incisions with a cumulative length of about 30 mm, and LC thus has the potential to replace the conventional large right subcostal incision used in OC. Recently, techniques using fine-caliber instruments (2 or 3
mm in diameter) for LC, called minilaparoscopic cholecystectomy (MLC), were proposed and reported to be superior to conventional LC (CLC, using 5 mm instruments) in terms of postoperative course and cosmetic outcome [4 – 6]. However, MLC was used largely in uncomplicated situations, such as cholelithiasis without acute inflammation. As conventional LC has been proven to be a safe and efficient technique for treating acute cholecystitis [7,8], this study tests the feasibility and safety of MLC in treating acute cholecystitis.
Material and methods * Corresponding author. Tel.: ⫹886-3-3281200 ext. 2158; fax: ⫹8863-3289582. E-mail address: [email protected]
During a 1-year period from January to December of 2001, patients diagnosed with cholelithiasis with acute cho-
0002-9610/03/$ – see front matter © 2003 Excerpta Medica, Inc. All rights reserved. doi:10.1016/S0002-9610(02)01417-4
C.-H. Hsieh / The American Journal of Surgery 185 (2003) 344 –348 Table 1 Score model for predicting the difficulty of laparoscopic cholecystectomy Finding
Points
White blood cell count 10 ⫻ 10 /L No visualization of the gallbladder at preoperative intravenous cholangiography Thickened gallbladder Shrunken gallbladder Previous upper abdominal surgery Biliary colic within the last 3 weeks Right upper quadrant pain Rigidity in upper right abdomen 9
1 1 1 1 2 1 1 1
Total points 0 ⫽ score 0 ⫽ “easy” gallbladder; total points 1 ⫽ score I ⫽ few difficulties expected; total points 2 ⫽ score II ⫽ several difficulties expected; total points 3 ⫽ score III ⫽ severe case; total points 4 ⫽ score IV ⫽ conversion to open cholecystectomy expected. Reprinted with permission from Sarli et al [6,9].
lecystitis in the emergency department of our institute were evaluated to determine the feasibility of laparoscopic treatment. Acute cholecystitis was defined clinically, including tenderness of the right upper abdomen as well as demonstration of cholelithiasis, gallbladder swelling, thickening of the gallbladder wall or the presence of pericystic fluid by ultrasonography. Patients who had previously received upper abdominal surgery, were critically ill with unstable hemodynamic status due to profound sepsis, or had concurrent disease such as liver abscess or severe acute pancreatitis, were excluded. Meanwhile, patients with jaundice, biliary pancreatitis, or dilatation of common bile duct that suspected to have choledocholithiasis underwent endoscopic retrograde cholangiopancreatography (ERCP) and then followed by stone retrieval if necessary. These patients were included in this study if clearance of stone in the bile duct was achieved. Laparoscopic surgery was performed on an early basis within 2 days of admission, or otherwise when endoscopic papillotomy for retrieval of common bile duct stone was done. That is, we did not insist that symptoms of acute cholecystitis should be controlled by medical treatment before surgery. Sarli et al [6,9] proposed a score model for predicting the difficulty of laparoscopic cholecystectomy (Table 1). The score was estimated and recorded for each patient who was a candidate for laparoscopic cholecystectomy, and except for those patients who fitted the aforementioned exclusion criteria, either MLC or CLC was attempted for each patient regardless of score. This study comprised a total of 69 consecutive patients, randomized to undergo either minilaparoscopic cholecystectomy (38 patients) or conventional laparoscopic cholecystectomy (31 patients). Despite different operative techniques, both groups of patients received the same preoperative preparation, evaluation and postoperative care. Generally, laboratory tests including complete blood cell count, total/direct bilirubin, amylase, lipase, alkaline phosphatase and aspartate aminotransferase levels, as well as
345
abdominal ultrasonography, were routinely examined in all the patients. Besides oral analgesics (acetaminophen), intramuscular injections of meperidine 50 mg per dose were administered to patients who were unable to tolerate wound pain, and patients were discharged once bedside activities were resumed and tolerable. Surgical techniques of MLC or CLC were as described elsewhere [10], and the major difference between these two methods was the size of the incisions and instruments. MLC was performed with one 10-mm port below the umbilicus and three 3-mm ports in the right subcostal region, while CLC was performed with one 10-mm port below the umbilicus, another 10-mm port in the subxyphoid region and two 5-mm ports in the right subcostal region. All the instruments used (including telescopes, trocar sets, grasping and dissecting forceps, scissors, clip applicator and hook electrode) were the products of the Karl Storz company (Germany) and were reusable. The costs of these devices were not charged to the patients since they were reused. The patient characteristics, laboratory test results and prediction of LC difficulties, operative time, operative complications, hospitalization days and need for meperidine injection for wound pain were all compared between the two groups, and quantified data values were expressed as mean ⫾ standard deviation. Data were analyzed using the SPSS 10.0 statistical software (SPSS, Chicago, Illinois), and Student t test was used for continuous variables, while the chi-square test or Fisher’s exact test was used for nominal variables. The observed differences were assumed to be statistically significant if the probability of chance occurrence was P less than 0.05.
Results This study included 69 patients; however, 3 patients from the MLC group and 2 from the CLC group were converted to open cholecystectomy owing to technical difficulties encountered during the operation, including severe swelling, gangrenous change of gall bladder that could not be handled by laparoscopic instruments, severe adhesion of surrounding tissue to the gall bladder, and gall bladder perforation and bleeding. These 5 patients were excluded from the study. The conversion rate was 7.9% for the MLC group and 6.5% for the CLC group, and thus was not statistically significant (P ⫽ 0.597). Thirty-five patients remained in the MLC group and 29 in the CLC group. The male/female ratio was 16/19 in the MLC group and 14/15 in the CLC group, while the average age was 55.7 ⫾ 17.7 years in the MLC group and 54.5 ⫾ 17.6 in the CLC group. Thirteen patients in the MLC group and 10 in the CLC group underwent endoscopic retrograde cholangiopancreatography (ERCP), among which 9 in MLC group and 7 in CLC group were found to have choledocholithiasis. EPT with stone retrieval was successfully per-
346
C.-H. Hsieh / The American Journal of Surgery 185 (2003) 344 –348
Table 2 Prediction of laparoscopic cholecystectomy difficulty using the score model listed in Table 1 Score
MLC group (n)
CLC group (n)
0 1 2 3 4 Total
0 0 21 12 2 35
0 0 13 9 7 29 P⫽0.102
MLC ⫽ minilaparoscopic cholecystectomy; CLC ⫽ conventional laparoscopic cholecystectomy.
formed for these patients, and they underwent LC after clearance of choledocholithiasis. Preoperative prediction of the difficulty of laparoscopic cholecystectomy according to the score model proposed by Sarli et al [6,9] (Table 1) revealed that a majority of cases were score II, which fell into the category of “several difficulties expected” (21 of 35 in MLC group and 13 of 29 in CLC group). Meanwhile, the other patients were categorized as “severe cases” or “conversion to open cholecystectomy expected.” However, no patients were categorized as “easy gallbladder” or “few difficulties expected.” Additionally, all the 5 converted cases were score IV and all presented with rigidity in the upper right abdomen. Table 2 lists the predicted difficulty of laparoscopic cholecystectomy of both groups of patients, and no difference existed between the two groups. Although the expected difficulties on performing laparoscopic cholecystectomy were similar in both groups of patients, the mean operative length was marginally longer in the MLC group than in the CLC group (113.8 ⫾ 30.8 versus 98.2 ⫾ 33.2 minutes, P ⫽ 0.056). The preoperative leukocyte count of the two groups was similar (10911 ⫾ 4219/ mm3 in MLC group and 12903 ⫾ 4520/mm3 in CLC group). The length of hospital stay was 4.3 ⫾ 1.7 days for MLC group patients and 4.2 ⫾ 1.6 days for CLC group patients, revealing no statistically significant difference between the two groups. The majority of patients in both groups (30 of 35 in the MLC group and 22 of 29 in the CLC group) required one or no intramuscular meperidine injection other than oral analgesics for postoperative pain control. However, 1 patient in the MLC group and 3 patients in the CLC group required 4 doses of meperidine injection. Wound infection occurred in 1 patient from the MLC group (2.9%) and 2 patients from the CLC group (6.9%). Besides, 2 patients in the MLC group suffered from shortterm postoperative ileus, making oral intake intolerable after operation. However, this complication was self-limited and the 2 patients had a noneventful recovery 2 days later. Bleeding of the subumbilical port site was noted in a patient in the MLC group, and was successfully managed by direct compression. No major complications, such as common bile
duct injury, bile leakage, intraabdominal bleeding or abscess formation were encountered in this study.
Comments The safety and efficacy of laparoscopic cholecystectomy for acute cholecystitis was controversial in the early 1990s, mainly due to its high conversion and complication rate, but was gradually accepted as the procedure of choice because it was technically achievable in most cases, especially if attempted by experienced surgeons [11–13]. The conversion rate achieved here was 7.9% in the MLC group and 6.5% in the CLC group, and no major complications were encountered. This favorable result again confirmed the currently accepted view that laparoscopic cholecystectomy is the favored procedure for managing cholelithiasis with acute cholecystitis. Whether patients with gallstones with acute cholecystits should be operated on early or be delayed until the acute phase subsides has long been controversial [14]. However, early cholecystectomy for acute cholecystitis within a few days of the onset of symptoms or admission has been proven to have the advantage of lower medical costs, owing to a shorter hospital stay, without an increased risk of morbidity and mortality. Furthermore, several authors have obtained similar results to that mentioned above by using LC to manage acute cholecystitis [7,8]. For example, Isoda [7] reported that early LC within 7 days of admission seems to be better than delayed treatment for acute cholecystitis. Besides, when the rate of conversion of LC to open cholecystectomy is considered as an indicator of the technical difficulty of LC, early LC has been demonstrated to have a significantly lower conversion possibility [8,15–17]. Teixeira [8], Koo [15], Lo (1996) [16], and Garber [17] all reported that LC carried out within the first 4 or 5 days after surgical diagnosis is an important element in decreasing conversion rate and had no adverse effects. Based on the above facts, with which this study justifies the necessity of early LC, we also attempted to perform LC for acute cholecystitis on a 24-hour basis subject to the availability of operating rooms, to minimize the length of hospital stay. Therefore, about one-third of the operations were carried out at night. The results showed that most patients could be discharged an average of 4 days after admission, although a significant portion of patients (13 of 35 in MLC group and 10 [7]29 in CLC group) needed additional ERCP examination before operation. Besides the time between diagnosis and surgery, other predisposing factors that might lead conversion of LC to open cholecystectomy have been widely discussed and identified, including leukocytosis [8,18], thickened gall bladder wall, enlarged gall bladder, adhesion [19], gall bladder empyema or gangrenous cholecystitis [20]. However, most of these factors were intraoperative findings and could not be used to predict LC difficulty before operation.
C.-H. Hsieh / The American Journal of Surgery 185 (2003) 344 –348
Therefore, the score model proposed by Sarli et al [6,9] was used to predict LC difficulty prior to surgery. According to this scoring model, all of our patients had scores of at least II or above, and were expected to have several difficulties during LC. The most frequent preoperative clinical findings that lead to this prediction were leukocytosis, thickened gallbladder wall, biliary colic within the last 3 weeks and right upper quadrant pain. However, we found that LC tended to fail in patients presenting with right upper abdomen rigidity, implying that abdominal rigidity might be an exclusion criteria for LC. Interestingly, 23 of 64 of the patients (13 of 35 in the MLC group and 10 of 29 in the CLC group) reached the criteria that require ERCP prior to operation, and 16 of them (9 of 35 in the MLC group and 7 of 29 in the CLC group) were proved to have common bile duct stones. The overall prevalence rate of having choledocholithiasis in patients with acute cholecystitis was 25% (16 of 64) in this series, which was higher than the 10% to 15% rate reported in most series. However, it is still well within the reported range of 3% to 33%. Recently, there were at least two studies (Changchien [21] in 1995 and Onken [22] in 1996) reporting similar prevalence rate of having choledocholithiasis in patients with acute cholecystitis (24.3% and 25%, respectively). The former report was a study finished by another medical center in Taiwan, which might help supporting our findings of the high prevalence rate of choledochlithiasis in Taiwan from a demographics standpoint. Many investigators have evaluated the safety, efficacy and benefits of MLC to CLC: Sarli et al [6] reported that operation time and duration of hospital stay were similar in the MLC and CLC groups, while postoperative pain was lower in MLC group; Ngoi [10] reported that analgesic consumption and cosmetic results of the MLC group were superior to those of the CLC group; and Cheah [23] reported that the MLC group in their series experienced less wound pain, had smaller scars, and required fewer intramuscular meperidine injections than did the CLC group. However, all the above mentioned findings were based on surgical results of uncomplicated cholelithiasis, and excluded patients with acute cholecystitis. The main reason for this exclusion may be that at the time of the above research the MLC technique had only recently been proposed and had just started clinical trials, meaning the feasibility of handling and dissecting fragile, edematous inflammatory gall bladder by fine-caliber laparoscopic instrument remained uncertain [23]. The results of this study showed that MLC was not clearly superior to CLC in terms of length of hospital stay and postoperative analgesic requirement for acute cholecystitis, and operative time was marginally longer for MLC group. However, from another perspective, the mean operating time for the MLC group was only 15 minutes longer than that of the CLC group (113.8 ⫾ 30.8 versus 98.2 ⫾ 33.3, P ⫽ 0.056) and its negative impact on the patients’ outcome was negligible because no complications associated with prolonged anesthesia or prolonged pneumoperitoneum (such as atelac-
347
tasis, CO2 retention or unstable hemodynamic status) were noted in the MLC group. With more difficulties to grasp and dissect acute inflammatory tissue by using fine caliber instruments, it was acceptable to have longer operation time in the MLC group (especially it was only marginally longer without actually reaching statistical difference). That is, MLC was as safe and effective as CLC in treating acute cholecystitis with the clear advantage of smaller incision wounds and postoperative surgical scar, and without creating more complications. Notably, the length of hospital stay could not be satisfactory shortened in the MLC group in this study. It can be explained by the fact that the speed of recovery in patients with acute cholecystitis treated by laparoscopic cholecystectomy depends not only on the invasiveness of the surgical procedure (5 mm or 3 mm instruments), but more importantly, on the natural course of human body to recover from acute inflammation and infection. This point of view can be supported by several reports comparing the use of laparoscopic cholecystectomy for acute cholecystitis and routine symptomatic cholelithiasis [11,12]. In these reports, postoperative recovery and length of hospital stay was longer in patients with acute cholecystitis than that with symptomatic cholelithiasis even by using identical laparoscopic techniques and procedures, demonstrating the time period needed for human body to recover from acute inflammation. In conclusion, since laparoscopic surgery aims mainly to minimize the degree of invasiveness, the MLC technique for acute cholecystitis approaches the limits of minimally invasive surgery for the disease with presently available technology. MLC is as effective as CLC in cholecystectomy for acute cholecystitis if the operation is performed early, with clearly smaller incisions as well as minimal complications and acceptable low conversion rate.
References [1] Dubois F, Icard P, Bertholet G, Levard H. Coelioscopic cholecystectomy. Preliminary report of 36 cases. Ann Surg 1990;211:60 –2. [2] Trondsen E, Reiertsen O, Andersen OK, Kjaersgaard P. Laparoscopic and open cholecystectomy. A prospective, randomized study. Eur J Surg 1993;159:217–21. [3] Berggren U, Gordh T, Grama D, et al. Laparoscopic versus open cholecystectomy: hospitalization, sick leave, analgesia and trauma responses. Br J Surg 1994;81:1362–5. [4] Kimura T, Sakuramachi S, Yoshida M, et al. Laparoscopic cholecystectomy using fine-caliber instruments. Surg Endosc 1998;12:283– 6. [5] Reardon PR, Kamelgard JI, Applebaum B, et al. Feasibility of laparoscopic cholecystectomy with miniaturized instrumentation in 50 consecutive cases. World J Surg 1999;23:128 –32. [6] Sarli L, Costi R, Sansebastiano G. Mini-laparoscopic cholecystectomy vs laparoscopic cholecystectomy. A matched case-control study. Surg Endosc 2001;15:614 –18. [7] Isoda N, Ido K, Kawamoto C, et al. Laparoscopic cholecystectomy in gall stone patients with acute cholecystitis. J Gastroenterol 1999;34: 372–5.
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[8] Teixeira JP, Saraiva AC, Cabral AC, et al. Conversion factors in laparoscopic cholecystectomy for acute cholecystitis. Hepatogastroenterology 2000;47:626 –30. [9] Sarli L, Pietra N, Franze A, et al. Routine intravenous cholangiography, selective ERCP, and endoscopic treatment of bile duct stones before laparoscopic cholecystectomy. Gastrointest Endosc 1999;50: 200 – 8. [10] Ngoi SS, Kok PK, Kum CK, Cheah WK. Needlescopic or minisite cholecystectomy. Surg Endosc 1999;13:303–5. [11] Kum CK, Goh PM, Isaac JR, et al. Laparoscopic cholecystectomy for acute cholecystitis. Br J Surg 1994;81:1651– 4. [12] Kum CK, Eypasch E, Lefering R, et al. Laparoscopic cholecystectomy for acute cholecystitis: is it really safe? World J Surg 1996;20:43– 8. [13] Wiesen SM, Unger SW, Barkin JS, et al. Laparoscopic cholecystectomy: the procedure of choice for acute cholecystitis. Am J Gastroenterol 1993;88:334 –7. [14] Sianesi M, Ghirarduzzi A, Percudani M, Dell’Anna B. Cholecystectomy for acute cholecystitis: timing of operation, bacteriologic aspects, and postoperative course. Am J Surg 1984;148:609 –12. [15] Koo KP, Thirlby RC. Laparoscopic cholecystectomy in acute cholecystitis. What is the optimal timing for operation? Arch Surg 1996; 131:540 – 4.
[16] Lo CM, Liu CL, Lai EC, et al. Early versus delayed laparoscopic cholecystectomy for treatment of acute cholecystitis. Ann Surg 1996; 223:37– 42. [17] Garber SM, Korman J, Cosgrove JM, Cohen JR. Early laparoscopic cholecystectomy for acute cholecystitis. Surg Endosc 1997;11:347– 50. [18] Halachmi S, DiCastro N, Matter I, et al. Laparoscopic cholecystectomy for acute cholecystitis: how do fever and leucocytosis relate to conversion and complications? Eur J Surg 2000;166:136 – 40. [19] Daradkeh S. Laparoscopic cholecystectomy: what are the factors determining difficulty? Hepatogastroenterology 2001;48:76 – 8. [20] Cox MR, Wilson TG, Luck AJ, et al. Laparoscopic cholecystectomy for acute inflammation of the gallbladder. Ann Surg 1993;218:630 – 4. [21] Changchien CS, Chuah SK, Chiu KW. Is ERCP necessary for symptomatic gallbladder stone patients before laparoscopic cholecystectomy? Am J Gastroenterol 1995;90:2124 –7. [22] Onken JE, Brazer SR, Eisen GM, et al. Predicting the presence of choledocholithiasis in patients with symptomatic cholelithiasis. Am J Gastroenterol 1996;91:762–7. [23] Cheah WK, Lenzi JE, So JB, et al. Randomized trial of needlescopic versus laparoscopic cholecystectomy. Br J Surg 2001;88:45–7.
Laparoscopy
Early minilaparoscopic cholecystectomy in patients with acute cholecystitis Chi-Hsun Hsieh, M.D.* Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing St., Kwei-shan, 333, Taoyuan, Taiwan Manuscript received April 15, 2002; revised manuscript October 25, 2002
Abstract Background: Recently, techniques using fine-caliber instruments (2 or 3 mm in diameter) for laparoscopic cholecystectomy, called minilaparoscopic cholecystectomy (MLC), were reported to be superior to conventional LC (CLC, using 5 mm instruments) in postoperative course and cosmetic outcome. However, the use of MLC to date has been largely restricted to uncomplicated situations. Since CLC has been proved to be a safe and efficient technique for acute cholecystitis especially if conducted early, this study tests the feasibility and safety of MLC for acute cholecystitis. Methods: Sixty-nine consecutive patients with acute cholecystitis were prospectively randomized to minilaparoscopic (n ⫽ 38) or conventional laparoscopic (n ⫽ 31) cholecystectomy, and the operations were conducted within 2 days of admission whenever possible. Despite different operative techniques, both groups of patients received identical preoperative preparation, evaluation and postoperative care. The two groups were compared for patient characteristics, results of laboratory tests, predictive score for LC difficulties, operative time, operative complications, hospitalization days and need for meperidine injection for wound pain. Results: The conversion rate was 7.9% (3 of 38) for the MLC group and 6.5% (2 of 31) for the CLC group. Nine patients in the MLC group and 7 in the CLC group had concomitant choledocholithiasis and underwent endoscopic stone retrieval before operation. The age, sex, predictive score for LC difficulties, preoperative leukocyte count, length of hospital stay and requirement of intramuscular meperidine injections were similar for both groups of patients, while, the operative times were marginally longer in the MLC group (113.8 ⫾ 30.8 versus 98.2 ⫾ 33.2 minutes, P ⫽ 0.056). No major complications occurred in either group. Conclusions: The results of cholecystectomy for acute cholecystitis by MLC are as good as those of CLC if the operation is performed early, with obvious smaller incisions and minimal complications. MLC is a safe and effective procedure for patients with acute cholecystitis, and has an acceptable low conversion rate. © 2003 Excerpta Medica, Inc. All rights reserved. Keywords: Acute cholecystitis; Laparoscopic cholecystectomy; Minilaparoscopic cholecystectomy
Since the late 1980s, laparoscopic cholecystectomy (LC) has gradually overtaken open cholecystectomy (OC) as the preferred procedure for treating cholelithiasis, offering patients a shorter hospital stay, less postoperative pain, better cosmetic results and an early recovery [1–3]. These advantages are undoubtedly due to LC being a less invasive procedure than OC, generally requiring only four trocar incisions with a cumulative length of about 30 mm, and LC thus has the potential to replace the conventional large right subcostal incision used in OC. Recently, techniques using fine-caliber instruments (2 or 3
mm in diameter) for LC, called minilaparoscopic cholecystectomy (MLC), were proposed and reported to be superior to conventional LC (CLC, using 5 mm instruments) in terms of postoperative course and cosmetic outcome [4 – 6]. However, MLC was used largely in uncomplicated situations, such as cholelithiasis without acute inflammation. As conventional LC has been proven to be a safe and efficient technique for treating acute cholecystitis [7,8], this study tests the feasibility and safety of MLC in treating acute cholecystitis.
Material and methods * Corresponding author. Tel.: ⫹886-3-3281200 ext. 2158; fax: ⫹8863-3289582. E-mail address: [email protected]
During a 1-year period from January to December of 2001, patients diagnosed with cholelithiasis with acute cho-
0002-9610/03/$ – see front matter © 2003 Excerpta Medica, Inc. All rights reserved. doi:10.1016/S0002-9610(02)01417-4
C.-H. Hsieh / The American Journal of Surgery 185 (2003) 344 –348 Table 1 Score model for predicting the difficulty of laparoscopic cholecystectomy Finding
Points
White blood cell count 10 ⫻ 10 /L No visualization of the gallbladder at preoperative intravenous cholangiography Thickened gallbladder Shrunken gallbladder Previous upper abdominal surgery Biliary colic within the last 3 weeks Right upper quadrant pain Rigidity in upper right abdomen 9
1 1 1 1 2 1 1 1
Total points 0 ⫽ score 0 ⫽ “easy” gallbladder; total points 1 ⫽ score I ⫽ few difficulties expected; total points 2 ⫽ score II ⫽ several difficulties expected; total points 3 ⫽ score III ⫽ severe case; total points 4 ⫽ score IV ⫽ conversion to open cholecystectomy expected. Reprinted with permission from Sarli et al [6,9].
lecystitis in the emergency department of our institute were evaluated to determine the feasibility of laparoscopic treatment. Acute cholecystitis was defined clinically, including tenderness of the right upper abdomen as well as demonstration of cholelithiasis, gallbladder swelling, thickening of the gallbladder wall or the presence of pericystic fluid by ultrasonography. Patients who had previously received upper abdominal surgery, were critically ill with unstable hemodynamic status due to profound sepsis, or had concurrent disease such as liver abscess or severe acute pancreatitis, were excluded. Meanwhile, patients with jaundice, biliary pancreatitis, or dilatation of common bile duct that suspected to have choledocholithiasis underwent endoscopic retrograde cholangiopancreatography (ERCP) and then followed by stone retrieval if necessary. These patients were included in this study if clearance of stone in the bile duct was achieved. Laparoscopic surgery was performed on an early basis within 2 days of admission, or otherwise when endoscopic papillotomy for retrieval of common bile duct stone was done. That is, we did not insist that symptoms of acute cholecystitis should be controlled by medical treatment before surgery. Sarli et al [6,9] proposed a score model for predicting the difficulty of laparoscopic cholecystectomy (Table 1). The score was estimated and recorded for each patient who was a candidate for laparoscopic cholecystectomy, and except for those patients who fitted the aforementioned exclusion criteria, either MLC or CLC was attempted for each patient regardless of score. This study comprised a total of 69 consecutive patients, randomized to undergo either minilaparoscopic cholecystectomy (38 patients) or conventional laparoscopic cholecystectomy (31 patients). Despite different operative techniques, both groups of patients received the same preoperative preparation, evaluation and postoperative care. Generally, laboratory tests including complete blood cell count, total/direct bilirubin, amylase, lipase, alkaline phosphatase and aspartate aminotransferase levels, as well as
345
abdominal ultrasonography, were routinely examined in all the patients. Besides oral analgesics (acetaminophen), intramuscular injections of meperidine 50 mg per dose were administered to patients who were unable to tolerate wound pain, and patients were discharged once bedside activities were resumed and tolerable. Surgical techniques of MLC or CLC were as described elsewhere [10], and the major difference between these two methods was the size of the incisions and instruments. MLC was performed with one 10-mm port below the umbilicus and three 3-mm ports in the right subcostal region, while CLC was performed with one 10-mm port below the umbilicus, another 10-mm port in the subxyphoid region and two 5-mm ports in the right subcostal region. All the instruments used (including telescopes, trocar sets, grasping and dissecting forceps, scissors, clip applicator and hook electrode) were the products of the Karl Storz company (Germany) and were reusable. The costs of these devices were not charged to the patients since they were reused. The patient characteristics, laboratory test results and prediction of LC difficulties, operative time, operative complications, hospitalization days and need for meperidine injection for wound pain were all compared between the two groups, and quantified data values were expressed as mean ⫾ standard deviation. Data were analyzed using the SPSS 10.0 statistical software (SPSS, Chicago, Illinois), and Student t test was used for continuous variables, while the chi-square test or Fisher’s exact test was used for nominal variables. The observed differences were assumed to be statistically significant if the probability of chance occurrence was P less than 0.05.
Results This study included 69 patients; however, 3 patients from the MLC group and 2 from the CLC group were converted to open cholecystectomy owing to technical difficulties encountered during the operation, including severe swelling, gangrenous change of gall bladder that could not be handled by laparoscopic instruments, severe adhesion of surrounding tissue to the gall bladder, and gall bladder perforation and bleeding. These 5 patients were excluded from the study. The conversion rate was 7.9% for the MLC group and 6.5% for the CLC group, and thus was not statistically significant (P ⫽ 0.597). Thirty-five patients remained in the MLC group and 29 in the CLC group. The male/female ratio was 16/19 in the MLC group and 14/15 in the CLC group, while the average age was 55.7 ⫾ 17.7 years in the MLC group and 54.5 ⫾ 17.6 in the CLC group. Thirteen patients in the MLC group and 10 in the CLC group underwent endoscopic retrograde cholangiopancreatography (ERCP), among which 9 in MLC group and 7 in CLC group were found to have choledocholithiasis. EPT with stone retrieval was successfully per-
346
C.-H. Hsieh / The American Journal of Surgery 185 (2003) 344 –348
Table 2 Prediction of laparoscopic cholecystectomy difficulty using the score model listed in Table 1 Score
MLC group (n)
CLC group (n)
0 1 2 3 4 Total
0 0 21 12 2 35
0 0 13 9 7 29 P⫽0.102
MLC ⫽ minilaparoscopic cholecystectomy; CLC ⫽ conventional laparoscopic cholecystectomy.
formed for these patients, and they underwent LC after clearance of choledocholithiasis. Preoperative prediction of the difficulty of laparoscopic cholecystectomy according to the score model proposed by Sarli et al [6,9] (Table 1) revealed that a majority of cases were score II, which fell into the category of “several difficulties expected” (21 of 35 in MLC group and 13 of 29 in CLC group). Meanwhile, the other patients were categorized as “severe cases” or “conversion to open cholecystectomy expected.” However, no patients were categorized as “easy gallbladder” or “few difficulties expected.” Additionally, all the 5 converted cases were score IV and all presented with rigidity in the upper right abdomen. Table 2 lists the predicted difficulty of laparoscopic cholecystectomy of both groups of patients, and no difference existed between the two groups. Although the expected difficulties on performing laparoscopic cholecystectomy were similar in both groups of patients, the mean operative length was marginally longer in the MLC group than in the CLC group (113.8 ⫾ 30.8 versus 98.2 ⫾ 33.2 minutes, P ⫽ 0.056). The preoperative leukocyte count of the two groups was similar (10911 ⫾ 4219/ mm3 in MLC group and 12903 ⫾ 4520/mm3 in CLC group). The length of hospital stay was 4.3 ⫾ 1.7 days for MLC group patients and 4.2 ⫾ 1.6 days for CLC group patients, revealing no statistically significant difference between the two groups. The majority of patients in both groups (30 of 35 in the MLC group and 22 of 29 in the CLC group) required one or no intramuscular meperidine injection other than oral analgesics for postoperative pain control. However, 1 patient in the MLC group and 3 patients in the CLC group required 4 doses of meperidine injection. Wound infection occurred in 1 patient from the MLC group (2.9%) and 2 patients from the CLC group (6.9%). Besides, 2 patients in the MLC group suffered from shortterm postoperative ileus, making oral intake intolerable after operation. However, this complication was self-limited and the 2 patients had a noneventful recovery 2 days later. Bleeding of the subumbilical port site was noted in a patient in the MLC group, and was successfully managed by direct compression. No major complications, such as common bile
duct injury, bile leakage, intraabdominal bleeding or abscess formation were encountered in this study.
Comments The safety and efficacy of laparoscopic cholecystectomy for acute cholecystitis was controversial in the early 1990s, mainly due to its high conversion and complication rate, but was gradually accepted as the procedure of choice because it was technically achievable in most cases, especially if attempted by experienced surgeons [11–13]. The conversion rate achieved here was 7.9% in the MLC group and 6.5% in the CLC group, and no major complications were encountered. This favorable result again confirmed the currently accepted view that laparoscopic cholecystectomy is the favored procedure for managing cholelithiasis with acute cholecystitis. Whether patients with gallstones with acute cholecystits should be operated on early or be delayed until the acute phase subsides has long been controversial [14]. However, early cholecystectomy for acute cholecystitis within a few days of the onset of symptoms or admission has been proven to have the advantage of lower medical costs, owing to a shorter hospital stay, without an increased risk of morbidity and mortality. Furthermore, several authors have obtained similar results to that mentioned above by using LC to manage acute cholecystitis [7,8]. For example, Isoda [7] reported that early LC within 7 days of admission seems to be better than delayed treatment for acute cholecystitis. Besides, when the rate of conversion of LC to open cholecystectomy is considered as an indicator of the technical difficulty of LC, early LC has been demonstrated to have a significantly lower conversion possibility [8,15–17]. Teixeira [8], Koo [15], Lo (1996) [16], and Garber [17] all reported that LC carried out within the first 4 or 5 days after surgical diagnosis is an important element in decreasing conversion rate and had no adverse effects. Based on the above facts, with which this study justifies the necessity of early LC, we also attempted to perform LC for acute cholecystitis on a 24-hour basis subject to the availability of operating rooms, to minimize the length of hospital stay. Therefore, about one-third of the operations were carried out at night. The results showed that most patients could be discharged an average of 4 days after admission, although a significant portion of patients (13 of 35 in MLC group and 10 [7]29 in CLC group) needed additional ERCP examination before operation. Besides the time between diagnosis and surgery, other predisposing factors that might lead conversion of LC to open cholecystectomy have been widely discussed and identified, including leukocytosis [8,18], thickened gall bladder wall, enlarged gall bladder, adhesion [19], gall bladder empyema or gangrenous cholecystitis [20]. However, most of these factors were intraoperative findings and could not be used to predict LC difficulty before operation.
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Therefore, the score model proposed by Sarli et al [6,9] was used to predict LC difficulty prior to surgery. According to this scoring model, all of our patients had scores of at least II or above, and were expected to have several difficulties during LC. The most frequent preoperative clinical findings that lead to this prediction were leukocytosis, thickened gallbladder wall, biliary colic within the last 3 weeks and right upper quadrant pain. However, we found that LC tended to fail in patients presenting with right upper abdomen rigidity, implying that abdominal rigidity might be an exclusion criteria for LC. Interestingly, 23 of 64 of the patients (13 of 35 in the MLC group and 10 of 29 in the CLC group) reached the criteria that require ERCP prior to operation, and 16 of them (9 of 35 in the MLC group and 7 of 29 in the CLC group) were proved to have common bile duct stones. The overall prevalence rate of having choledocholithiasis in patients with acute cholecystitis was 25% (16 of 64) in this series, which was higher than the 10% to 15% rate reported in most series. However, it is still well within the reported range of 3% to 33%. Recently, there were at least two studies (Changchien [21] in 1995 and Onken [22] in 1996) reporting similar prevalence rate of having choledocholithiasis in patients with acute cholecystitis (24.3% and 25%, respectively). The former report was a study finished by another medical center in Taiwan, which might help supporting our findings of the high prevalence rate of choledochlithiasis in Taiwan from a demographics standpoint. Many investigators have evaluated the safety, efficacy and benefits of MLC to CLC: Sarli et al [6] reported that operation time and duration of hospital stay were similar in the MLC and CLC groups, while postoperative pain was lower in MLC group; Ngoi [10] reported that analgesic consumption and cosmetic results of the MLC group were superior to those of the CLC group; and Cheah [23] reported that the MLC group in their series experienced less wound pain, had smaller scars, and required fewer intramuscular meperidine injections than did the CLC group. However, all the above mentioned findings were based on surgical results of uncomplicated cholelithiasis, and excluded patients with acute cholecystitis. The main reason for this exclusion may be that at the time of the above research the MLC technique had only recently been proposed and had just started clinical trials, meaning the feasibility of handling and dissecting fragile, edematous inflammatory gall bladder by fine-caliber laparoscopic instrument remained uncertain [23]. The results of this study showed that MLC was not clearly superior to CLC in terms of length of hospital stay and postoperative analgesic requirement for acute cholecystitis, and operative time was marginally longer for MLC group. However, from another perspective, the mean operating time for the MLC group was only 15 minutes longer than that of the CLC group (113.8 ⫾ 30.8 versus 98.2 ⫾ 33.3, P ⫽ 0.056) and its negative impact on the patients’ outcome was negligible because no complications associated with prolonged anesthesia or prolonged pneumoperitoneum (such as atelac-
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tasis, CO2 retention or unstable hemodynamic status) were noted in the MLC group. With more difficulties to grasp and dissect acute inflammatory tissue by using fine caliber instruments, it was acceptable to have longer operation time in the MLC group (especially it was only marginally longer without actually reaching statistical difference). That is, MLC was as safe and effective as CLC in treating acute cholecystitis with the clear advantage of smaller incision wounds and postoperative surgical scar, and without creating more complications. Notably, the length of hospital stay could not be satisfactory shortened in the MLC group in this study. It can be explained by the fact that the speed of recovery in patients with acute cholecystitis treated by laparoscopic cholecystectomy depends not only on the invasiveness of the surgical procedure (5 mm or 3 mm instruments), but more importantly, on the natural course of human body to recover from acute inflammation and infection. This point of view can be supported by several reports comparing the use of laparoscopic cholecystectomy for acute cholecystitis and routine symptomatic cholelithiasis [11,12]. In these reports, postoperative recovery and length of hospital stay was longer in patients with acute cholecystitis than that with symptomatic cholelithiasis even by using identical laparoscopic techniques and procedures, demonstrating the time period needed for human body to recover from acute inflammation. In conclusion, since laparoscopic surgery aims mainly to minimize the degree of invasiveness, the MLC technique for acute cholecystitis approaches the limits of minimally invasive surgery for the disease with presently available technology. MLC is as effective as CLC in cholecystectomy for acute cholecystitis if the operation is performed early, with clearly smaller incisions as well as minimal complications and acceptable low conversion rate.
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