Introduction

 

Gallstones are a major cause of morbidity with an incidence of symptomatic cholelithiasis of 2.2 per thousand inhabitants in the Western world.[1,2] Cholecystectomy is the treatment of choice for symptomatic cholelithiasis, performed via either open,  minilaparotomy or laparoscopic techniques. It is estimated that more than 700,000 laparoscopic cholecystectomies are performed annually in the United States.[3]

 

Open cholecystectomy (OC) has been the gold standard for the treatment of symptomatic cholelithiasis for more than a  century. In the United States, the overall mortality rate for elective OC is less than 1%, the morbidity rate being 4% - 6%.[4] Generally, morbidity is thought to be proportional to the size of the wound.[5] Morbidity from a long incision may cause significant pain, delayed ambulation, long hospital stays, delayed return to work and poor cosmesis.

 

In an attempt to decrease the morbidity, this surgery was performed through a shorter (<8 cm) right subcostal incision resulting in the minilaparotomy cholecystectomy (MC).[6] This technique reduced postoperative pain, quicker recovery, shorter hospital stay, better patient satisfaction compared to OC and can be done on ambulatory basis.[7]

 

In recent decades, laparoscopic cholecystectomy (LC) has become the gold standard for the treatment of symptomatic  cholelithiasis, despite an increased risk of common bile duct injury.[8,9,10,11,12] Notwithstanding the lack of strong evidence for LC’s superiority over MC, its popularity soared due to powerful marketing by industry and the appeal of technological innovation.[13] Although it is well established that LC is superior to conventional OC, the evidence for its superiority over MC has been poor, and the results of randomized controlled trials are conflicting.[14,15,16,17,18]

 

In Caribbean island communities where populations are relatively small, the number of cases is limited, the cost of instrumentation is prohibitive, the expertise in equipment maintenance and servicing is poor and operating room time is restricted, and hence considerations other than those espoused in the common literature become relevant. From such a setting we report our experience with 476 consecutive cases of MC.

 

Methods

 

Approval was obtained from the hospital authorities for reviewing the charts of the patients. All consecutive patients who underwent MC for symptomatic gall stone disease by a single surgical unit were included in the study. All surgeons in  the surgical unit had previous experience with the traditional conventional OC. Patients requiring common bile duct (CBD)  exploration (for jaundice, stones, pancreatitis) were excluded. No patient was excluded on the grounds of obesity or an acute presentation (acute cholecystitis, mass, empyema). Routine cholangiography was not done. Data recorded included demographics, clinical presentations, preoperative laboratory investigation reports, operating techniques, operating time, incision size, conversion rate to large incision cholecystectomy, perioperative complications and the duration of hospital stay.

 

Technique

 

The operation is performed under general anaesthesia with the patient in the supine position. A transverse subcostal incision within the range of 3-6 cm is made over the lateral half of the rectus abdominis muscle extending into the external oblique. During the initial period of the study, this part of the rectus abdominis was divided using diathermy. However, during the later period of study, (in more than half of the patients) this muscle was spared by dissecting it off the anterior rectus sheath and retracting it medially, before incising the posterior sheath and adjacent internal oblique and transversus abdominis. A large pack is completely inserted into the abdomen between the liver and gut. Adhesions are released if they were present.

 

If there is an acute inflammatory mass, the omentum and viscera were peeled off the tense gall bladder using index finger, prior to inserting the pack. A narrow deep retractor is used to retract duodenum and viscera away from the gall bladder, while another retracted the liver cephalad. Dissection of the cystic artery and duct are done similar to conventional OC using long instruments in the narrow tunnel, aided by a fibreoptic headlight and ‘3.5 × magnification’ surgical loupes. The cystic duct and artery are occluded separately using ligaclips (Ethicon™). The gall bladder is removed by routine antegrade dissection. No surgical drains and nasogastric tubes are used in any patient. During closure of the abdomen, 20 mL of 0.25% bupivacaine is injected into the sheath and skin under direct vision. Patients receive post-operative analgesia in the form of intramuscular pethidine. Oral fluids are introduced when the patient is fully awake and normal diet commenced the next morning after surgery.

 

The patients are reviewed in the out-patient clinic and complications recorded. Wound infection was defined as erythema and warmth with or without oozing from the incision site. Conventionally, patients who undergo MC are followed up postoperatively during the first week, fourth week, followed by 12 weeks and later until a period of 5 years.

 

Results

 

MC was performed in 476 consecutive patients with symptomatic gall stones. There were 404 females and 72 males. The median age was 47 years (range 19 – 82 years) and the median Body Mass Index (BMI) was 25. 314 (66%) patients presented with chronic calculous cholecystitis, 147 (31%) with acute cholecystitis, 11 (2.3%) with empyema of the gall bladder  and 4 (0.8%) presented with mucocoele. The mean length of the minilaparotomy incision was 4.8 cm (range 3-6 cm). Overall mean operating time was 31 minutes (range 18-80 min).

 

There were 19 (4%) conversions to conventional OC; In 8 patients, this was to explore the CBD based on the intraoperative  findings of a dilated CBD; in another 8 patients who all had acute choelcystitis, this was done because of difficult dissection and in 3 patients due to abnormal anatomy. The lateral half of the rectus abdominis was divided in all 19 conversions and 207 of the MC’s. Rectus sparing was done in 252 cases. No major ductal injury was encountered. There were no reoperations, 7 had minor wound infections and none had incisional hernias. One patient developed pain and jaundice 6 weeks post MC. She had no clinical, biochemical or ultrasound features of choledocholithiasis pre-operatively.

 

ERCP confirmed a previously unsuspected CBD stone, which was treated by sphincterotomy. All 19 conversions to OC were administered intravenous antibiotics for 24 hours; the remaining patients received only preoperative surgical prophylaxis. All patients were allowed oral fluids when fully awake, but 12 (9 in the conventional OC and 3 in the MC group) had  significant vomiting and tolerated fluids only after 24 hours. Overall, post-operatively patients stayed in the hospital ranging from 8 – 94 hours, the median being 22 hours. However, the hospital stay for the 12 patients who had significant nausea and vomiting ranged from 20 – 94 hours the median being 66 hours. For the remaining 454 patients, median hospital stay was 20 hours (range 8-60 hours).

 

445 patients in the MC group were followed up until the late postoperative period. 90% of these patients returned to their routine work within 16 days of surgery, and to full activity by 28 days. 12 patients in the MC group were lost to long-term (later than 12 weeks) follow up.

 

There was no major morbidity, no bile leaks and no reexploration.

 

There was no mortality in this case series.

 

Discussion

 

The major finding of the present study is the good outcome of MC in our setting. Establishing a LC service in developing nations is controversial, some studies questioning its feasibility while others favouring it.[19,20,21,22] MC has been found to be a safe alternative to LC in the third world.[23]

 

Making the switch from conventional OC to LC requires utilization of valuable and often limited material and personnel resources. To perform LC the surgeon must undergo long periods of specialized training to obtain the skills and privileges to practice LC.[24] However, MC is a simple modification of the routine OC, which can easily be taught to surgeons as well as surgical trainees,[18,19] and can be performed by any general surgeon in most hospitals in the developing world.[25] In our setting, no special training was needed to switch from OC to MC.

 

Chung et al have shown that in the LC era, the trainees’ exposure to open surgery is reduced, adversely affecting their confidence and experience to manage complications required during LC.[26] They often need to get senior assistance in these  situations. With MC and conversion to OC, as in our setting,no such difficulty exists.

 

MC is performed using standard surgical instruments without much capital investment. [26] The initial capital outlay, the recurrent cost for disposables and maintenance cost of equipment for LC is quite expensive. This cost becomes more prohibitive when the number of patients is small such as in our situation.

 

MC performed through a 6 cm incision, maximally extended to 8 cm, is cosmetically acceptable.[6] Keus et al reported no difference in body image, cosmesis and self-confidence when MC is compared to LC.[27] The mean incision size (4.8 cm) in our study provided adequate exposure with good cosmesis even in obese patients and emergency situations; about one-third of our cases were emergencies.

 

The operating time is shorter for MC compared to LC.[15,16,19] This allows greater turnover of patients and efficient use of theatre time which is very important in developing countries where operating theatre time is quite limited. In a previous review of 5556 patients, MC took 16.4 minutes less than LC.[15] Our operating time of 31 minutes is considerably less than that reported for most series of LC.

 

LC has a spectrum of complications such as postoperative ventilatory compromise, thromboembolic and cardiac complications, gas embolus, hypercarbia, retroperitoneal vessel injury, bowel injury, bile duct injury and persistent bile leak.[28,29,30,31] Management of these complications may need sophisticated investigative and therapeutic interventions, specialized personnel and intensive care facilities which may be unavailable or in limited supply in developing nations. MC has been reported to have a lower rate of bile duct injury than LC (2 in 2500).[32] In our series, no major ductal injury was encountered.

 

There were 7 minor wound infections, no reoperations, and no incisional hernias. Port site hernia, a well documented complication of LC, was not encountered in our study because of excellent visualization of the sheath in a small transverse incision.

 

Analgesic consumption studies show a slight increase in pain in MC over LC which can be reduced by muscle splitting rather than muscle dividing techniques.[33,34] We have not used muscle splitting but find that oral analgesia is usually adequate after 24 hours. There seems, in our experience, to be minimal difference in pain in the rectus sparing versus the rectus dividing MC incisions.

 

Similar to previous reports, in our study, MC was done mostly on ambulatory basis and patients were discharged home on oral analgesics and normal diet within 24 hours.

 

In conclusion, the present study highlights a good outcome for MC and provides data to reinforce the view that MC is a  safe, minimally invasive procedure. We suggest that MC shouldbe the gold standard for cholecystectomy in developing country settings. When all available data are critically evaluated and increase in the awareness of the advantages of MC, it may very well be recognized as the preferred method of cholecystectomy even in developed nations.

 

References

1.     Legorreta AP, Silber JH, Costantino GN, Kobylinski RW, Zatz SL. Increased cholecystectomy rate after the introduction of laparoscopic cholecystectomy. JAMA. 1993;270:1429–32.

2.     Steiner CA, Bass EB, Talamini MA, Pitt HA, Steinberg EP. Surgical rates and operative mortality for open and laparoscopic cholecystectomy in Maryland. N Engl J Med. 1994;330:403–8.

3.     Sandler RS, Everhart JE, Donowitz M, Adams E, Cronin K, Goodman C, et al. The burden of selected digestive diseases in the United States. Gastroenterology. 2002;122:1500–11.

4.     Deziel DJ, Millikan KW, Economou SG, Doolas A, Ko ST, Airan MC. Complications of laparoscopic cholecystectomy. A national survey of 4, 292 hospitals and an analysis of 77, 604 cases. Am J Surg. 1993;165:9–14.

5.     Assalia A, Schein M, Kopelman D, Hashmonai M. Minicholecystectomy vs. conventional cholecystectomy. A prospective randomized trial. Implications in the laparoscopic era. World J Surg. 1993;17:755–9.

6.     O’Dwyer PJ, Murphy JJ, O’Higgins NJ. Cholecystectomy through a 5 cm subcostal incision. Br J Surg. 1990;77:1189–90.

7.     Ledet WP. Ambulatory cholecystectomy without disability. Arch Surg. 1990;125:1434–5.

8.     Begos DG, Modlin IM. LC: from gimmick to gold standard. J Clin Gast. 1994;19:325–30.

9.     Adamsen S, Hansen OH, Funch-Jensen P, Schulze S, Stage JG, Wara P. Bile duct injury during laparoscopic cholecystectomy; a prospective nationwide series. J Am Coll Surg. 1997;184:571–8.

10.   Flum DR, Cheadle A, Prela C, Dellinger EP, Chan L. Bile duct injury during cholecystectomy and survival in Medicare beneficiaries. JAMA. 2003;290:2168–73.

11.   Ooi LL, Goh YC, Chew SP, Tay KH, Foo E, Low CH, et al. Bile duct injuries during laparoscopic cholecystectomy: a collective experience of four teaching hospitals and results of repair. Aust NZ J Surg. 1999;69:844–6.

12.   Waage A, Nilsson M. Iatrogenic bile duct injury: a population based study of 152 776 cholecystectomies in Swedish Inpatient Registry. Arch Surg. 2006;141:1207–13.

13.   Escarce JJ. Externalities in hospitals and physician adoption of a new surgical technology: an exploratory analysis. J Health Econ. 1996;15:715–34.

14.   Keus F, de Jong, J Gooszen HG, Laarhoven CJHM. Laparoscopic versus open cholecystectomy for patients with symptomatic cholecystolithiasis. Cochrane Database Syst Rev. 2006, Issue 4. Art. No: CD 006231. DOI 10. 1002/14651858. CD006231.

15.   Keus F, Gooszen HG, Laarhoven CJHM. Systematic review: open, small-incision or laparoscopic cholecystectomy for symptomatic cholecystolithiasis. Aliment Pharmacol Ther. 2009;29,359–78.

16.   McGinn FP, Miles AJG, Uglow M, Ozmen M, Terzi C, Humby M. Randomized trial of laparoscopic cholecystectomy and mini cholecystectomy. Br J Surg. 1995;82:1374–7.

17.   Ros A, Gustafsson L, Drook H, Nordgren CE, Thorell A, Wallin G, et al. Laparoscopic cholecystectomy versus mini-laparotomy cholecystectomy. A prospective randomized single-blind study. Ann Surg. 2001;234:741–9.

18.   Keus F, Werner JEM, Gooszen HG, Oostvogel HJM, van Laarhoven CJ. Randomized clinical trial of small-incision and laparoscopic cholecystectomy in patients with symptomatic cholecystolithiasis. Arch Surg. 2008;143:371–7.

19.   Teerawattananon Y, Mugford M. Is it worth offering routine laparoscopic cholecystectomy in developing countries? A Thailand case study. Cost Eff Resour Alloc. 2005;3:10.

20.   Manning RG, Aziz AQ. Should laparoscopic cholecystectomy be practiced in the developing world? Ann Surg.2009;249:794–8.

21.   Asburn HJ, Berguer R, Altamirano R, Castellanos H. Successfully establishing laparoscopic surgery programs in developing countries: clinical results and lessons learned. Surg Endosc. 1996;10:1000–3.

22.   Sharma AK, Rangan HK, Choubey RP. Mini-lap cholecystectomy: a viable alternative to laparoscopic cholecystectomy for the third world. Aust NZ J Surg. 1998;68:774–7.

23.   Bal S, Reddy LG, Parshad R, Guleria R, Kashyap L. Feasibility and safety of day care laparoscopic cholecystectomy in a  developing country. Postgrad Med J. 2003;79:284–8.

24.   Guidelines for granting of privileges for laparoscopic and/or thoracoscopic general surgery. Society of American Gastrointestinal Endoscopic Surgeons (SAGES). Surg Endosc. 1998;12:379–80.

25.   Al-Tameem MM. Minilaparotomy cholecystectomy. J R Coll Surg Edinb. 1993;38:154–7.

26.   Chung RS, Wojtaik L, Pham O, Chari V, Chen P. The decline of training in open biliary surgery. Effect on the residents’ attitude toward bile duct surgery. Surg Endosc. 2003;17:338–40.

27.   Keus F, de Vries J, Gooszen HG, van Laarhoven CJ. Laparoscopic versus small-insision choleystectomy: Health status in a blind randomized trial. Surg Endosc. 2008;22:1649–59.

28.   Widdison AL. Systemic review of the effectiveness and safety of laparoscopic cholecystectomy. Ann R Coll Surg Engl. 1996;78:476.

29.   MacMahon AJ, Baxter JN, O’Dwyer PJ. Preventing complications of laparoscopy. Br J Surg. 1993;80:1593–4.

30.   Lee JD, Kim SM, Park CH. Complications of laparoscopic cholecystectomy. Clin Nucl Med. 1993;18:151–2.

31.   McMahon AJ, Fullerton J, Baxter N, O’ Dwyer PJ. Bile duct injury and bile leakage in laparoscopic cholecystectomy. Br J Surg. 1995;82:307–13.

32.   Olsen DO. Minilap cholecystectomy. Am J Surg. 1993;165:440–3.

33.   Tate JJ, Lau WY, Leung KL, Li AK. Laparoscopic versus miniincision cholecystectomy. Lancet. 1993;341:1214–5.

34.   Baguley PE, De Gara CJ, Gagic N. Open cholecystectomy-muscle splitting versus muscle dividing incision: a randomized study. J R Coll Surg Edinb. 1995;40:230–2.