Open versus laparoscopic cholecystectomy: an initial analysis

Quality and safety of minimally invasive surgery: past, present, and future

Adverse events because of medical errors are a leading cause of death in the United States (US) exceeding the mortality rates of motor vehicle accidents, breast cancer, and AIDS. Improvements can and should be made to reduce the rates of preventable surgical errors because they account for nearly half of all adverse events within hospitals. Although minimally invasive surgery (MIS) has proven patient benefits such as reduced postoperative pain and hospital stay, its operative environment imposes substantial physical and cognitive strain on the surgeon increasing the risk of error. To mitigate errors and protect patients, a multidisciplinary approach is needed to improve MIS. Clinical human factors, and biomedical engineering principles and methodologies can be used to develop and assess laparoscopic surgery instrumentation, practices, and procedures. First, the foundational understanding and the imperative to transform health care into a high-quality and safe system is discussed. Next, a generalized perspective is presented on the impact of the design and redesign of surgical technologies and processes on human performance. Finally, the future of this field and the research needed to further improve the quality and safety of MIS is discussed.

A population-based cohort study comparing laparoscopic cholecystectomy and open cholecystectomy

OBJECTIVES

Laparoscopic cholecystectomy (LC) has become a popular alternative to open cholecystectomy (OC). Previous studies comparing outcomes in LC and OC used small selected cohorts of patients and did not control for comorbid conditions that might affect outcome. The aims of this study were to characterize the morbidity, mortality, and costs of LC and OC in a large unselected cohort of patients.

METHODS

We used the population-based North Carolina Discharge Abstract Database (NCHDAD) for January 1, 1991, to September 30, 1994 (n = 850,000) to identify patients undergoing OC and LC. We identified the indications for surgery, complications, and type of perioperative biliary imaging used. We compared length of stay, hospital charges, complications, morbidity, and mortality between OC and LC patients. To account for variations in outcomes from differences in age and comorbidity between the OC and LC groups, we used the age-adjusted Charlson Comorbidity Index in regression analyses quantifying the association between type of surgery and outcome.

RESULTS

Our cohort consisted of 43,433 patients (19,662 LC and 23,771 OC). The mean age-adjusted Charlson Comorbidity Index score was slightly higher for the OC compared to the LC group (4.3 vs 4.1, p < 0.05). The OC patients had longer hospitalizations, generated more charges ($12,125 vs $9,139, p < 0.05), and required home care more often. The crude risk ratio comparing risk of death in OC to LC was 5.0 (95% CI = 3.9-6.5). After controlling for age, comorbidity, and sex, the odds of dying in the OC group was still 3.3 times (95% CI = 1.4-7.3) greater than in the LC group. In the LC group, the number of patients with acute cholecystitis rose over the study period, whereas the number of patients with chronic cholecystitis declined. In the OC group, the number of patients with acute and chronic cholecystitis declined. The use of intraoperative cholangiography was greater in the OC group but declined in both groups over the study period. The use of ERCP was greater in the LC group and increased in both groups over time.

CONCLUSIONS

The introduction of LC has resulted in a change in the management of cholecystitis. Despite a higher proportion of patients with acute cholecystitis, the risk of dying was significantly less in LC than in OC patients, even after controlling for age and comorbidity. Based on lower costs and better outcomes, LC seems to be the treatment of choice for acute and chronic cholecystitis.

Post cholecystectomy admission to the intensive care unit. Comparison between open, mini-lap and laparoscopic techniques

Admissions to the intensive care unit following techniques for cholecystectomy, the open, mini-lap and laparoscopic methods, were studied over an 18-month period. Of 1078 cases of operative cholecystectomy performed during that period, 28 cases (2.6%) from all groups were admitted to the intensive care unit. Cases in the open and mini-lap cholecystectomy groups were admitted for postoperative monitoring because of pre-existing medical diseases and were discharged after an average period of stay of 2.4 and 4.7 days respectively. In contrast, the average stay of patients in the laparoscopic group was 14.8 days and the majority were admitted as a result of complications related to the procedure. In this group, one patient died on the first day of admission to the unit (mortality of 8.3%). This study has shown that laparoscopic surgery, from the intensive care point of view, is a very costly surgical procedure.

The cost of laparoscopic versus open cholecystectomy in a community hospital

This retrospective study reviewed the hospital and professional costs, charges, and reimbursements for laparoscopic cholecystectomy (lap chole) and open cholecystectomy (open chole) and compared the two procedures. There was no significant difference in hospital costs between lap and open chole procedures; however, there were marked differences in the categories of costs for each procedure. The mean total (hospital and professional) charge was 8% greater for lap chole. The mean total (hospital and professional) reimbursement for patients with private insurance was 23% greater for lap chole, but no significant difference was seen for patients on Medicare or Medicaid. Lap chole patients returned to work 11 days sooner than open chole patients; this can result in a 69% decrease in short-term disability costs to employers. The clinical variables that significantly affect total charges and reimbursement are discussed.

Laparoscopic cholecystectomy in pregnancy: two case reports

Laparoscopic cholecystectomy (LC) was previously avoided in pregnancy. Two cases of LC performed in gravid women with recurrent symptoms of biliary disease are reported.

Peritoneoscopic cholecystectomy has opened the door to minimally invasive surgery

In 1989 a new trend occurred in the surgical treatment of a diseased gall-bladder, laparoscopic cholecystectomy (LC). Laparoscopic surgery is now accepted world-wide as the choice of treatment with the advantages of less pain, good cosmesis, short hospital stay and early recovery. It is also a curative procedure for cholelithiasis as well as a cholecystectomy. The rate of conversion to open surgery is about 5% and the rates of bile duct injury are 0.1-0.6%. This new approach revives controversies concerning cholecystectomy; namely indication, use of intra-operative cholangiography, ductal calculi and pregnancy. There are new issues to consider, including use of a Veress needle for pneumoperitoneum, type of trocars, cardiovascular responses to pneumoperitoneum using carbon dioxide and so on. With increasing use, these difficulties will be overcome. Advances in technology are expected to make even more new types of surgery possible, even perhaps extending into robotic surgery.

Cost-effectiveness of laparoscopic cholecystectomy versus open cholecystectomy

To assess the cost-effectiveness of laparoscopic cholecystectomy versus open cholecystectomy from the payer's perspective, we estimated the probabilities of potential outcomes of each procedure, associated quality-of-life effects, and related direct medical charges and incorporated these estimates into a computerized simulation model. The model projects that laparoscopic cholecystectomy will be more effective than open surgery in terms of total mortality and quality-adjusted survival, for both sexes and all ages. Projected 5-year cumulative charges are lower for laparoscopic cholecystectomy than for open cholecystectomy ($5,354 versus $5,525 for 45-year-old women; $6,036 versus $6,830 for 45-year-old men), and the differences increase substantially with increasing age. We concluded that laparoscopic cholecystectomy is likely to be less costly and more effective than open cholecystectomy for most patients, as long as it does not routinely require preoperative cholangiography and is not associated with increased professional fees or increased risks of retained stones or bile duct injury.

Laparoscopic cholecystectomy: an initial community experience

The initial 950 consecutive laparoscopic cholecystectomies performed in one city at four hospitals by 30 general surgeons are reported, covering a period from April 4, 1990 to April 3, 1991. There were two operative deaths (0.2%), three common bile duct lacerations (0.3%), two subhepatic abscesses, two bowel perforations, and three bile leaks, two requiring laparotomy. Seven episodes of bleeding occurred, of which five required laparotomy, but none involved a major vessel. Sixty-five procedures were converted to open (6.7%). The mean operative time was 85.4 min. Intraoperative cholangiography was adequately completed in 49.8% and not attempted in 30.3%. Thirteen patients (2.7%) were found to have common duct stones. The pathologic diagnoses were chronic cholecystitis in 784 patients (82.5%), acute cholecystitis in 145 (15.3%), and cancer of the gallbladder in one (0.1%). Hospital stays ranged from 4 h to 31 days (mean 49.5 h). This procedure can be learned and performed safely in a community setting.

A comparison of outcome and cost of open vs. laparoscopic cholecystectomy

One hundred elective completed laparoscopic cholecystectomies performed during the period July 1990 to June 1991 were prospectively analyzed for age, sex, and the study variables. A control group of 100 age- and sex-matched patients undergoing elective open cholecystectomy in the year prior to the advent of laparoscopic cholecystectomy was retrospectively analyzed. Both groups were comparable with regard to height, weight, severity of disease, and co-morbidity. The mean operative time for the laparoscopic cholecystectomy group was 107 min vs. 72 min for the open cholecystectomy group. Other significant differences included the use of cholangiography (24% vs. 93%), placement of drains (4% vs. 27%), and morbidity (3% vs. 7%). There was no mortality in either group. The mean length of hospital stay was 1.6 days for the laparoscopic cholecystectomy group vs. 4.8 days in the open cholecystectomy group. The resultant difference in hospital charges to the patient favored laparoscopic cholecystectomy with a mean charge of $6471 vs. $8896 for the open cholecystectomy group. The results of this study support the conclusions that laparoscopic cholecystectomy is a safe and effective alternative to open cholecystectomy and results in a significantly shorter hospital stay with considerable cost savings.

Laparoscopic cholecystectomy during pregnancy

There is a strong association between pregnancy and gallstones. When acute cholecystitis or recurring bouts of biliary colic occur during pregnancy, medical therapy is usually initiated but occasionally fails. Laparoscopic cholecystectomy has recently been described for the treatment of symptomatic cholelithiasis, but many authors consider pregnancy to be an absolute contraindication to this operation. We herein describe the management of markedly symptomatic cholelithiasis during the second trimester of pregnancy using laparoscopic techniques in five patients. Tocolytic medications were administered perioperatively in two patients, and open laparoscopy or the use of an alternative site for insertion of the initial port was used in all patients. Laparoscopic cholecystectomy without cholangiograms was successful in all five patients and postoperative hospitalization ranged from 24 to 48 h. Uncomplicated term delivery has occurred in three of the five patients; in the other two patients, normal pregnancies are continuing. Laparoscopic cholecystectomy can be performed safely during pregnancy, as long as the patient is monitored carefully and specific precautions are observed.