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COMPARATIVE STUDY OF LAPAROSCOPIC VERSUS

OPEN CHOLECYSYECTOMY

TARIQ SAEED, M. ZARIN, MAHMUD AURANGZEB, M. AZIZ WAZIR, ROOHUL MUQEEM

Department of Surgery, Surgical D Ward, Khyber Teaching Hospital, Peshawar

ABSTRACTObjective:To compare our results of Laparoscopic Cholecystectomy with Open Cholecystectomy regarding case

selection, technical difficulties, duration of surgery, operative complications, post operative complications, postoperative hospital stay, morbidity & mortality, patients attitude after operation, operative expenses, total expensesand general impression in the society.Design & Dura tion: Comparative study carried out from January 2002 to December 2005.Setting:Department of Surgery, Surgical D Ward, Khyber Teaching Hospital, PeshawarPatients:This study was conducted on two hundreds patients, one hundred patients were submitted to LaparoscopicCholecystectomy and the other hundred to traditional Open Cholecystectomy.

Methodology:These patients were admitted in our unit through Out-door department or in emergency as acutecholecystitis. All patients were thoroughly assessed and necessary investigations carried out. After informed consentall patients were operated on the next operation list. The patients were randomly assigned to either one of the

procedures.Results:There was no significant difference in the selection of patients in the two groups. No mortality was seen inboth the groups, but complications were more in the open procedure than the laparoscopic one. There is less pain,less hospitalization, early mobilization and early return to work in the laparoscopic surgery.Conclusion:Laparoscopic Cholecystectomy is a superior procedure in comparison to Open Cholecystectomy asregards to the results. Hence it is recommended as the first choice operation.

KEY WORDS: Cholelilthiasis, Laparoscopic Cholecystectomy, Open Cholecystectomy, Complications

O r i g i n a l A r t i c l e

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Correspondence:Dr. Tariq Saeed, Senior Registrar Surgery,No. 8 Old Doctors Flats,Khyber Teaching Hospital,Peshawar, North West Frontier Province.Phones: +92-91-5701632, +92-0302-5524826 .E-mail: [email protected]

Volume 23, Issue 2, 2007

The indications for laparoscopic cholecystectomy arethe same as that for open cholecystectomy, althoughthe rate of cholecystectomy is increased by 20%4. Theadvantages to the patients in terms of pain, stay in thehospital, recovery time, costs and cosmetic results areconsiderable. As stated by Alfred Cuscheri there have

been a few instances in the history of surgical practicewhere the benefits of a procedure became so clearlymanifested within such a short period of time5.

The traditional Open cholecystecomy was first perfor-med in 1882 by a German surgeon Carl August Langen-

buch6, while Laparoscopic cholecystectomy was firstperformed in Lyon, France by Philleppe Mouret, Qubiosand Persatt in 19877. The first laparoscopic cholecys-tectomy in Pakistan was performed in 1991 by a visitingAmerican surgeon, whereas the first such procedurewas performed in Khyber Teaching Hospital, Peshawar

by a visiting surgeon from Singapore in 19928. Now itis practiced in many centers through out the world.

INTRODUCTION

No other surgical procedure has had such a dramaticand pivotal impact on abdominal surgery as laparoscopiccholecystectomy1. Laparoscopic cholecystectomy hasrevolutionized the treatment of gall bladder disease,and is now the gold standard for the treatment of gallstones, and the commonest operation performed laparo-scopically world wide2,3.


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Laparoscopic Versus Open Cholecystectomy T. Saeed, M. Za


cases in the lap. chole. and 20 in the open chole. grouphad acute cholecystitis.

The patients were assigned to one of the groups at ran-dom, though a conscious effort was made to keep a bal-ance in the demography, as is evident from Table I andII. All the patients were operated after informed consentunder general anesthesia. In the traditional open chole-cystectomy series, right subcostal incision was given.In some patients transverse incision was used depend-ing on the built of the patient. The suture material used

for the ligature of cystic duct and cystic artery was 2/0vicryl.

In laparoscopic cholecystectomy a standard four portstechnique was used in 40 patients and the three portstechnique the remaining 60 patients. Carbon dioxidegas was used to insuflate the peritoneal cavity up to a

pressure of 10-15mmHg. Endodiathermy was used forhomeostasis and liga clips were used for the cystic ductand cystic artery occlusion. Pre-operative and peropera-tive cholangiogram was not done in any of our cases.Three doses of prophylactic antibiotics in the form of

3rd generation cephalosporins were used. Drains wereput in the gall bladder bed in selective cases.

RESULTS

In this study 100 cases were submitted to laparoscopiccholecystectomy and 100 cases to open cholecystectomy.Majority of cases were females, and in the age group41 to 60 years (Table I & II). The clinical features ofthe patients are shown in Table III. The operating timefor laparoscopic cholecystectomy was more as comparedto the open procedure (Table IV). Three cases from the

Table I. Age Distribution

Lap. Chole.

< 20 years

21-40 years

41-60 years

61-80 years

Total

Age Group Open Chole.

2

32

62

4

100

1

34

63

2

100

PATIENTS & METHODS

This comparative study was conducted in Surgical DUnit of Khyber Teaching Hospital, Peshawar from Jan.2002 to Nov. 2005. In this study one hundred patientswere submitted to Laparoscopic Cholecystectomy and

another hundred patients to Open traditional Cholecys-tectomy.

The age of the patients ranged from 18 to 80 years witha median age of 50 years (Table I). The female to maleratio was 9:1 in the laparoscopic group and 7.3:1 in theopen surgery group as shown in Table II. All patientsunderwent routine investigations including liver func-tions tests. The main diagnostic investigation was anultrasound examination of the abdomen to confirm cho-lelithiasis or other abnormalities in the gall bladder andthe biliary tree. Only those patients underwent upper

GI endoscopy, who were suspected of having pepticulcer disease. Patients with jaundice and of biochemi-cal or radiological evidence of stones in the common

bile duct were excluded from the study.

The indications for laparoscopic cholecystectomy weresame as that for open cholecystectomy. Most of the

patients had chronic calculus cholecystitis, 84 in thelap. chole. and 80 in the open chole. group, while 16

Table II. Sex Distribution

Lap. Chole.

Male

Female

Sex Open Chole.

10

90

12

88

Table III. Clinical Presentation

Number

Pain Rt. Hypochondrium

Post-Prandial Fullness

Nausea

Vomiting

Heart Burn

Beltching

Fever

Symptoms

90

54

30

22

26

22

14

Lap. Chole.

< 20 mins.

21-40 mins.

41-60 mins.

61-80 mins.

> 80 mins.

Op. Time Open Chole.

6

46

30

16

2

--

66

34

--

--

Table IV. Operating Time


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Laparoscopic Versus Open Cholecystectomy T. Saeed, M. Za


one has had sufficient experience in open biliary surgery,and has additional training in laparoscopic surgery. Itis important to be fully familiar with the instrumentsand technique before undertaking such an operation.Laparoscopic cholecystectomy require training creden-tialing, and granting of clinical privileges11.

Most of the contraindications for laparoscopic procedure

are now relative because of improvements and refine-ments in techniques and instruments which allow laparo-scopic exploration of the common bile duct. The contra-indications also dependent upon the experience of thesurgeon, pre and intra-operative conditions. The maincontraindications are unacceptable anaesthetic risks anddifficulty in identifying structures within the portal areaand Calots triangle12.

Laparoscopic cholecystectomy is usually performed byusing four or five small punctures in the anterior abdo-minal wall. We modified our approach in the later cases

of the series to three ports technique. The 5mm port isbeing used for both traction of Hartman's pouch andsplaying the Calots triangle. Despite the three ports wecould still carry out dissection satisfactorily.

In this study there were three conversions. In one casethe clip slipped off from the cystic artery causing profuse

bleeding and the patient had to be converted to opencholecystectomy. In 2nd case there was biliary leakagedue to common hepatic duct injury, which was manag-ed by putting a T-tube in. In the 3rd case the sloughedoff cystic duct stump was open and oozing bile, whichneeded open repair. The complications that occur withlaparoscopic cholecystectomy may occur with opencholecystetomy also but their frequency vary13. Suchcomplications include hemorrhage, bile duct injury,over looked common bile duct stones, bile leak, peri-hepatic collection and infection14.

We did not perform any intra-operative cholangiography,none the less the use of intra-operative cholangiographyduring cholecystectomy is controversial. However, ithas been reported that the routine use of intra-operativecholangiography during laparoscopic cholecystectomy

Table VI. Hospital Stay

laparoscopic cholecystectomy group had to be convertedto open procedure. One was due to profuse haemorrhagefrom the cystic artery due to slipping of the clip. In thesecond case the common hepatic duct was injured byelectrocautery during dissection, while in the third casethere was billiary leakage from the sloughed off stumpof the cystic duct.

Drains were less frequently required for the laparosco-pic cholecystectomy (Table V). The hospital stay wasalso less in laparoscopic operation as compared to open

procedure (Table VI). The comparison of complicationsbetween the two groups are mentioned in Table VII.There was no mortality in the series.

DISCUSSION

Carl Langenbuch stated that gall bladder should beremoved not because it contains stones, but because itforms them9. The goal of both laparoscopic and open

techniques is to safely remove the gall bladder withlow mortality, little morbidity, and early recovery10.

Laparoscopic cholecystectomy is a minimally invasiveprocedure where by the gall bladder is removed usinglaparoscopic technique. The indications are the sameas for open cholecystectomy. A successful out come isdependent on proper patients selection, meticuloustechnique and a positive attitude towards conversion toopen cholecystectomy4.

Laparoscopic technique is difficult to master, provided

< 2 days

3-4 days

5-6 days

7-8 days

Hosp. Stay

--

20

50

30

Lap. Chole. Open Chole.

40

40

18

2

Table V. Use and Duration of Drain

No Drain

< 12 hours

12-24 hours

24-48 hours

Drain

21

26

51

2


30

20

49

1

4

2

2

--

Table VII. Complications

Complication

Vomitting

Wound infection

Haemorrhage

Abdo. infection


3

6

--

2


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336-38.

7. McSherry CK. Open Cholecystectomy. Am J Surg1993; 165: 435-39.

8. Aurangzeb M, Kabir M, Jan MA, Saeed T. Laparo-

scopic Cholecystectomy: Review of 100 cases in Peshawar. Pak J Surg 1995 Apr- Jun; 11(2): 114-116.

9. Oslen DO. Mini versus Lap. Cholecystectomy. AmJ Surg 1993; 165: 440-43.

10. Dirksen CD, Schmitz RF, Hans KM, Nieman FH,Hooqenboom LJ, Go PM. Ambulatory LaparoscopicCholecystectomy is as effective as hospitalizationfrom a social perspective and less expensive. NedJijdschr Geneesh 2001; 15: 2434-39.

11. Dent LT. Training, crendentialling and granting ofclinical privileges for Laparoscopic general surgery.Am J Surg 1991; 161(3): 399-403.

12. Baltas B, Lazer GY, Vattaty P, Rangel R. Compli-cation after Laparoscopic Cholecystectomy. Br JSurg 1994; 81: 8.

13. Deziel DJ, Millikan KW, Econnomou SG, et al.Complication of Laparoscopic Cholecystectomy.

A national survey of 1, 292 hospitals and an analysisof 77,604 cases. Am J Surg 1993; 165-9.

14. Zucker KA, Bailey RW, Gadacz TR, Imbembo AL.Laparoscopic Cholecystectomy. Am J Surg 1991;161: 36-44.

15. Hunter JG. Exposure, dissection and Laser versusElectrosurgery guided Cholecystectomy. Am J Surg1993; 165: 492-496.

16. Gerald ML, et al. Multipractice analysis of Laparos-copic Cholecystectomy in 1983 patient. Am J Surg1992; 163: 221.

17. Berggeren U, et al. Laparoscopic versus Open Cho-lecystectomy. Hospitalization, sick leave, analgesicand trauma response. Br J Surg 1994; 81: 1362-65.

18. White J. Laparoscopic Cholecystectomy and newand evolving Laparoscopic techniques. Am J Surg1993; 165: 536-540.

19. Shamim M, Dahri MM, Memon AS. Complicationsof Laparoscopic Cholecystectomy. Pak J Surg 2006;22: 70-77.

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Laparoscopic Versus Open Cholecystectomy T. Saeed, M. Z


reduces the incidence, level and severity of bile ductinjuries. Electrocautery was used for dissection and forhaemostasis. It is more rapid and economical; laser canalso be used but it adds more cost to the operation15.

Our experience, like other authors16-19, reveal a shorter

hospital stay, early recovery, faster return to work andfewer complications in patients undergoing laparoscopiccholecystectomy. This accounts for lesser cost of laparos-copic cholecystectomy although the operation expensesare more because the instruments are very expensive.Employing reusable instruments also decreases the cost.More over in public sector hospitals laparoscopic ins-truments are provided by the government.

CONCLUSION

Laparoscopic cholecystectomy is getting popular bec-ause of its good results in terms of short stay in hospital,

early mobilization and return to work, good cosmeticresults and good media coverage. It has good future for

both the patients and the surgeons. Laparoscopic chole-cystectomy has proven to be a safe procedure with lowmorbidity and an equal mortality rate as compared toopen cholecystectomy.

ACKNOWLEDGEMENT

We are thankful to Mr. Gohar Said for his help in thetyping of this manuscript.

REFERENCES

1. Stochman PT, Dunnegan DL, Ashley SW. Laparos-copic cholecystectomy: The new gold standard.Arch Surg 1992; 127(8): 917-923.

2. Ji W, Li LT, Li JS. Role of Laparoscopic SubtotalCholecystectomy in the treatment of complicatedcholecystitis. Hepatobilpancreat Dis Int 2006; 5(4):584-9.

3. Cuschieri A. Laparoscopic Cholecystectomy. J RColl Surg Edinb 1999; 44: 187-92.

4. Lan CM, Murray FE, Cuscheiri A. Increased Chole-cystectomy rate after the introduction of Laparosco-

pic Cholecystectomy in Scotland. Gut 1996; 38: 282-4.

5. Wayand WU, Gatter T. Lap Chole: The Austrianexperience. J R Coll Surg Edinb 1993; 38(3): 152.

6. Gadacz TR, Talamini MA. Traditional versus Lap-aroscopic Cholecystectomy. Am J Surg 1999; 161:

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