Laparoscopic cholecystectomy

Traditional cholecystectomy has been the standard surgical treatment of the gallstone disease for more than 100 years. The technical development led to a new surgical procedure and its rapid acceptance. This is laparoscopic cholecystectomy. Its application is becoming widespread in therapy too. But most of the surgeons are lack of technical experiences in this field. Currently it restricts the indications those are anyway the same of standard cholecystectomy. Besides its many advantages, laparoscopic cholecystectomy has its own disadvantages and being an invasive procedure, there are possibilities of complications. The latest can be reduced by the adequate choice of patients, the careful learning of the operative technic and by turning to open surgery (conversion) when it is necessary. Its morbidity is nearly equal to complications of standard cholecystectomy, but mortality rate is lower (0.05-0.2%). Our morbidity of performed 300 laparoscopic cholecystectomies was 6.4%. We had no death. The hospitalization became as short as 4 days. Our early clinical results (90%) are the same of traditional cholecystectomy. Laparoscopic cholecystectomy as a new surgical procedure involves the efficiency of the standard cholecystectomy and the noninvasive endoscopic technic. Laparoscopic cholecystectomy performed by well trained surgeons is a safe surgical procedure, its early results are excellent and makes the choice of surgical treatment, used in bile surgery richer.     

Calibration of a reflectance pulse oximeter in fetal lambs for arterial oxygen saturations below 70%

Today, laparoscopic cholecystectomy is the method of choice for treatment of symptomatic gallbladder disorders. It minimizes effects of the operation that are independent of the gallbladder, such as trauma to the abdominal wall and other soft tissue. The surgical wounds were even smaller when 2-mm trocars were used. Laparoscopic cholecystectomy using 2-mm instruments was performed in a consecutive series of 14 patients with symptomatic gallstones. The procedure was completed in 12 cases, with conversion to open surgery in two cases. Intraoperative cholangiography was always performed. The postoperative course was always uneventful. The cosmetic effect was highly satisfactory. The procedure using 2-mm instruments could be indicated in selected patients with uncomplicated gallstone disease.     

Changes in serum lipids and lipoproteins in epileptic children treated with anticonvulsants

Laparoscopic cholecystectomy is a popular treatment modality of symptomatic gallstones with decreased major complications and shortened hospital stay. Complications following laparoscopic cholecystectomy, most of them involving strictures of biliary tract have been well described in recent reports. However, there are only a few reported cases about dropped gallstones after the procedure, all of which were opaque and easily demonstrated with multiple imaging modalities. An unusual complication of laparoscopic cholecystectomy; abscess formation due to a dropped non-opaque gallstone is described in which diagnosis was suggested with the combination of ultrasound and computed tomography findings and confirmed by surgery.     

Laparoscopic cholecystectomy in pancreas transplant recipients

Laparoscopic cholecystectomy is the treatment of choice for symptomatic cholelithiasis. Since its introduction in 1987, this procedure has been employed with increasing frequency as its safety has been documented in numerous studies. Absolute contraindications to laparoscopic cholecystectomy have become relative contraindications, and patients previously felt to be at excessive risk for laparoscopic cholecystectomy are viewed as patients who may benefit from laparoscopic cholecystectomy. The use of this procedure in patients with comorbid medical conditions has the potential to decrease patient morbidity. Patients who have previously undergone solid organ transplantation and require immunosuppressive therapy are a group of patients who may benefit from laparoscopic cholecystectomy. We report four patients who have previously undergone combined renal and pancreas transplantation who underwent successful laparoscopic cholecystectomy.     

Asymptomatic gallstones revisited. Is there a role for laparoscopic cholecystectomy?

OBJECTIVE: To compare the mortality effects of prophylactic laparoscopic cholecystectomy with that of expectant management in persons with asymptomatic gallstones. DESIGN: Decision analytic models of the two clinical strategies using input data from a review of the published medical literature pertaining to the epidemiology, natural history, and treatment outcomes related to gallstone disease. PATIENTS: Cohorts of men and women aged 30 and 50 years with asymptomatic gallstones. INTERVENTION: Prophylactic laparoscopic cholecystectomy performed at the time of diagnosis of asymptomatic gallstones or expectant management, defined as therapeutic intervention delayed until gallstone symptoms or complications spontaneously develop. MAIN OUTCOME MEASURES: Gallstone-related deaths and gallstone-related life-years lost for each age and gender cohort, by strategy. Models were subjected to rigorous sensitivity analysis to test the robustness of the results to changes in individual input variables. Outcomes were calculated with and without discounting nonfinancial benefits. RESULTS: The prophylactic laparoscopic cholecystectomy strategy led to fewer gallstone-related deaths than the expectant management strategy, but all of the deaths in the prophylactic laparoscopic cholecystectomy group occurred earlier in life. In cohorts older than age 30 years, the expectant management strategy resulted in fewer undiscounted gallstone life-years lost than the prophylactic laparoscopic cholecystectomy strategy. Discounting favored expectant management further because life-years lost were delayed compared with prophylactic surgery. Sensitivity analysis demonstrated the superiority of expectant management over a wide range of input assumptions. CONCLUSIONS: Prophylactic laparoscopic cholecystectomy should not be routinely recommended for individuals with asymptomatic gallstones.     

Laparoscopic management of acute cholecystitis with subtotal cholecystectomy

Approximately 20 per cent of laparoscopic cholecystectomies performed for acute cholecystitis require conversion to open cholecystectomy because of severe inflammation. In a retrospective review of 125 consecutive patients undergoing laparoscopic surgery for gallbladder disease from January 1995 through June 1997, 31 had acute cholecystitis. Eight patients underwent a subtotal cholecystectomy because of severe inflammation. There were no conversions to open cholecystectomy and no intraoperative complications. Selected patients were evaluated and treated for common duct stones with preoperative endoscopy to avoid intraoperative cholangiography. One patient had a retained common duct stone successfully managed with postoperative endoscopy. Laparoscopic subtotal cholecystectomy is a safe and effective alternative to conversion to open cholecystectomy for severe inflammation associated with acute cholecystitis. Endoscopic assessment and treatment of common duct stones when indicated either before or after surgery omits the use of intraoperative cholangiography and potential injury to the inflamed ducts.     

Laparoscopic cholecystectomy in acute cholecystitis

Laparoscopic cholecystectomy was fulfilled in 108 patients admitted to the clinic with acute cholecystitis. Operations were made on 73% of them during the first four days from the beginning of the disease, 18.5% were operated upon within 5-7 days, 8.5% - 8 days later. Endoscopic papillotomy with removing the stones from the choledochus was performed in 10% of the patients before operation. Serious problems during taking the gallbladder from the inflammatory infiltration were observed in 29% of the patients. Technical problems took place more often if the patients were operated upon 5 days after the beginning of the disease. Change for open laparoscopy and standard cholecystectomy were necessary in 9 patients (8.3%). There were no lethal outcomes after laparoscopic cholecystectomy. Complications were observed in 12 patients (11.1%). The average period of staying at the hospital was (5.2 +/- 2.1) days. Laparoscopic cholecystectomy can be successfully performed in patients with acute cholecystitis by a sufficiently experienced surgeon.     

Sulbactam/ampicillin in comparison with cefuroxime for infections of the lower respiratory tract. Results of a prospective, randomized comparative study

Gallbladder removal using laparoscopic techniques has rapidly been adopted by surgeons around the world. Questions have been raised concerning laparoscopic cholecystectomy, including the safety of the operation, its implications for management of common bile duct stones, and the means by which surgeons should be trained. In the present series, 424 patients were referred to a single surgeon for cholecystectomy during a 22-month period. A traditional open cholecystectomy was performed in 9 patients (2.1%) because of presumed contraindications to laparoscopic cholecystectomy. Laparoscopic cholecystectomy was attempted in the remaining 415 patients (97.9%). On the basis of preoperative investigations, 19 patients (4.6%) underwent endoscopic retrograde cholangiopancreatography. Endoscopic sphincterotomy and stone extraction were performed in the 13 patients (3.1%) demonstrating choledocholithiasis. Laparoscopic cholecystectomy was converted to an open operation in 8 patients (1.9%) owing to dense adhesions, obscure anatomy, or cholangiographic abnormalities. Laparoscopic cholecystectomy was successfully performed in 407 patients (96%) in 95 +/- 2 minutes (mean +/- SEM). Surgical trainees were involved in all operations and performed 68% of the procedures under supervision. Cystic duct cholangiograms were obtained selectively in 129 patients (30.4%). Intraoperative complications occurred in 3 patients, including 1 patient with a minor injury to the common bile duct (0.2%). There was no perioperative mortality, and major complications occurred in 6 patients (1.4%). Minor complications were seen in 12 others (2.8%), and one patient required reoperation for a trocar injury to the jejunum. Prolonged follow-up has revealed one case of asymptomatic retained common bile duct stones (0.2%). Laparoscopic cholecystectomy can therefore be performed in more than 95% of patients with no mortality and minimal morbidity.(ABSTRACT TRUNCATED AT 250 WORDS)     

Laparoscopic cholecystectomy--evaluation of a prospective follow-up study]

A report is presented on 105 patients who underwent laparoscopic cholecystectomy because of symptomatic gallstone disease. Preoperative and intraoperative findings, complications and results were prospectively documented. In four (3.8%) patients the laparoscopic procedure had to be converted into open cholecystectomy. There were only minor surgical complications such as wound infection and a subhepatic haematoma. On average, patients were discharged on the second postoperative day. The operating time decreased from a median of 98 minutes in the first half to 73 minutes in the second half of the study, despite augmentation of the number of surgeons and of the indications to include patients with acute cholecystitis (n = 11), previous upper abdominal surgery (n = 7) and cirrhosis (n = 2).     

Surgical rates and operative mortality for open and laparoscopic cholecystectomy in Maryland

BACKGROUND: Since 1989, laparoscopic cholecystectomy has been widely adopted as a treatment for gallstone disease. We analyzed the association between the introduction of this procedure and three variables: the rate at which cholecystectomy was performed in Maryland, the characteristics of patients undergoing cholecystectomy in routine clinical practice, and operative mortality. METHODS AND RESULTS: We used 1985-1992 hospital-discharge data from all 54 acute care hospitals in Maryland, to identify open and laparoscopic cholecystectomies, characteristics of patients undergoing these procedures, and deaths occurring during hospitalizations in which these procedures were performed. The annual rate of cholecystectomy, adjusted for age, rose from 1.69 per 1000 state residents in 1987-1989 to 2.17 per 1000 residents in 1992, an increase of 28 percent (P < 0.001). As compared with patients undergoing open cholecystectomy, patients undergoing laparoscopic cholecystectomy tended to be younger, less likely to have acute cholecystitis or a common-duct stone, and more likely to be white and have private health insurance or belong to a health maintenance organization (P < 0.001). Although the operative mortality associated with laparoscopic cholecystectomy was less than that with open cholecystectomy (adjusted odds ratio, 0.22; 95 percent confidence interval, 0.13 to 0.37) and the overall mortality rate for all cholecystectomies declined from 0.84 percent in 1989 to 0.56 percent in 1992, there was no significant change in the total number of cholecystectomy-related operative deaths because of the increase in the cholecystectomy rate. CONCLUSIONS: In Maryland, although the adoption of laparoscopic cholecystectomy has been accompanied by a 33 percent decrease in overall operative mortality per procedure, the total number of cholecystectomy-related deaths has not fallen because of a 28 percent increase in the total rate of cholecystectomy.     

Laparoscopic cholecystectomy in cirrhotic patients: expanding indications

Cirrhosis, portal hypertension, and bleeding disorders are being considered as relative or absolute contraindications to laparoscopic cholecystectomy (LC). This report describes four cirrhotic patients with clinical portal hypertension in three and mild to severe bleeding tendency in all. Laparoscopic cholecystectomy was uniformly successful in these patients with no complications. If the surgeon exercises extreme caution in securing hemostasis and does not overlook some details concerning patient management, LC can be efficiently and safely performed in cirrhotic patients. Compared with open cholecystectomy, LC may be even more advantageous concerning the virtual elimination of incision-related complications. Our preliminary experience is encouraging and suggests more liberal use of LC in cirrhosis-portal hypertension-bleeding tendency disease complex.     

The TRAIL to selective tumor death

BACKGROUND: The aim of this study was to assess the cost effectiveness of routine preoperative blood type and screen testing before laparoscopic cholecystectomy. METHODS: All 2,589 laparoscopic cholecystectomies and 603 open cholecystectomies performed at our institution between January 1990 and December 1996 were retrospectively reviewed to identify the incidence and causes of blood transfusions. With the use of ICD-9-CM coding, a computerized retrospective research was done to match the corresponding codes for the aforementioned operations and blood transfusion. Individual charts were reviewed to identify the indications for blood transfusion. RESULTS: Of the 2,589 laparoscopic cholecystectomies performed, 12 patients required blood transfusion, and of the 603 open cholecystectomies, 33 patients required blood transfusion. The incidence of blood transfusions was 0.46% for laparoscopic cholecystectomy and 5.47% for open cholecystectomy. Two of the blood transfusions given intraoperatively were due to major vascular injury in the laparoscopic cholecystectomy group. The remaining blood transfusions were found to be the result of preexisting medical conditions including sickle-cell anemia, end-stage renal disease, and chronic iron deficiency anemia. CONCLUSIONS: Laparoscopic cholecystectomy has become a widely used therapeutic modality in general surgery. The procedure is safe, effective, and well tolerated by the patient. In the era of managed healthcare, the cost effectiveness of commonly ordered tests is frequently questioned. In the absence of preoperative indications, routine preoperative blood type and screen testing should be eliminated for laparoscopic cholecystectomy. The elimination of routine preoperative blood type and screen testing could have saved our institution $79,800 during a 6-year period.     

Wash out technique for proximal anastomosis in atherosclerotic ascending aorta

BACKGROUND: The wide acceptance of laparoscopic cholecystectomy (LC) has resulted in increased rates of cholecystectomy. However, the increased rate of LC bears the possibility of concomitantly missing other intra-abdominal pathologic states that exist concurrently with this procedure. The purpose of this report was to evaluate data on LC with regard to missed pathologies of other organs in a clinical prospective follow-up. METHODS: The clinical prospective follow-up of 676 patients treated laparoscopically for gallstone disease at our unit since January 1993, was studied. Converted procedures were excluded from the follow-up study. RESULTS: Among 676 patients who underwent LC, 4 patients (0.6%) required readmission for missed pathology of another organ. The diagnostic delay ranged from 2 weeks to 7 months. The readmissions were due to colonic cancer (2 cases), carcinoma of the stomach (1 case), and fibrosis of the mesenterium of small bowel causing ileus (1 case), which are demonstrated in detail. According to retrospective analysis of the symptoms, none of the patients had typical biliary pain at the time of laparoscopic procedure. CONCLUSIONS: The demand for LC from patients and practitioners is becoming increasingly more frequent, as all become aware of its benefits. However, on the basis of data from the literature and this study, the authors would like to emphasize the need for careful history-taking, thorough investigation, and comparison with gallstone symptoms before LC is performed. It is emphasized, however, that surgeons using laparoscopic approaches should learn techniques of full diagnostic laparoscopy, which should be performed at the beginning of every procedure.     

Changes in and acceptance of surgical and noninvasive therapy procedures in cholecystolithiasis

BACKGROUND: The treatment of cholecystolithiasis has changed fundamentally in recent years due to the development of non-surgical techniques (extracorporeal shockwave lithotripsy [ESWL], oral litholysis) and the implementation of laparoscopic cholecystectomy. PATIENTS AND RESULTS: Retrospective analysis of 2270 patients (1649 women, 621 men; age: 47.2 +/- 14 years) presenting with gallstone disorders in a university medical outpatients department between 1988 and 1992 in order to be instructed as to the most suitable therapy method bear witness to the rapid change in therapeutic procedure. Laparoscopic removal of the gallbladder has virtually supplanted conventional cholecystectomy, and within 5 years the proportionate role of ESWL has declined from 21 to 12%. Over the years, the proportion of patients requiring no therapeutic intervention remained constant (at about 20%). The therapeutic recommendations of the "experts" were implemented in almost 80% of cases. The majority of patients were satisfied with the chosen therapeutic approach (surgery: 93.0%, ESWL: 77.6%), although 44% of ESWL-patients and 36% of surgically managed patients reported complaints which persisted even after completion of therapy. Despite unsuccessful ESWL (residual fragments or recurrent stones) 58/95 (61%) of interviewed patients would again give preference to this non-invasive modality in the event of a renewed therapeutic decision. CONCLUSION: Only a few years after its introduction, laparoscopic cholecystectomy has asserted itself as the predominant treatment option. But as far as acceptance and preference by the patient are concerned extracorporeal shockwave lithotripsy--as a non-invasive treatment modality--also enjoys high popularity and can be recommended as an alternative to surgery in suitable patients chosen according to the currently established stringent selection criteria.     

Laparoscopic cholecystectomy for gallbladder stones

The authors describe the technique for the treatment of gallbladder stones using a laparoscopic approach and discuss the diagnostic and operative flow chart stressing complications and ways to avoid them. A total of 2517 non-selected patients underwent surgery since october 1990 up to september 1995. 252 were affected by acute cholecystitis (10%); 172 underwent emergency laparoscopic cholecystectomy. ERCP was performed in 278 patients (11.04%): 177 underwent endoscopic sphincterotomy and laparoscopic cholecystectomy, 21 underwent laparoscopic cholecystectomy before sphincterotomy, 8 laparoscopic cholecystectomy and ESWL. Laparoscopic cholecystectomy was converted into laparotomy in 37 patients (1.4%); surgery was abandoned in 3 patients following to onset of intense bradycardia. Major complications were observed in 0.63%; bile duct injury occurred in four patients (0.15%). One patient died following a massive intraoperative myocardial infarction. Average operative time was 21 minutes. Only 22.8% of patients required mild analgesia on the first day after surgery. The average hospital postoperative stay was 2.6 days. Return to work took place in 98% of non complicated patients within one week of being discharged from hospital.     

The Glasgow Coma Score: reliable evidence?

This study examined the selected hormonal responses to, and hormone-mediated glucose metabolism during minimally invasive surgery in, patients undergoing laparoscopic cholecystectomy for symptomatic gallstone disease. Thirty-two patients with symptomatic gallstone disease were included in this study and scheduled for open or laparoscopic procedure in a randomized trial. Results are expressed as mean and standard error of the mean. Statistical evaluations were performed with Mann-Whitney U and Wilcoxon signed-rank tests. Blood cortisol, glucagon, insulin, and glucose concentrations were measured immediately in the preoperative period and 6 h after surgery. Blood cortisol, glucagon, and glucose concentrations increased significantly after open and minimally invasive surgery, while insulin levels and the insulin:glucagon ratio remained unchanged. The rise of glucagon and cortisol values was found to be significantly higher in the postoperative period of the open procedure, than in the laparoscopic approach. However, in the patients who underwent open surgery, the increase in glucose concentrations was not significantly higher in the postoperative period. Surgery-induced hormonal effects on the islets increase glucagon and suppress insulin secretion. The glucagon-mediated increase in hepatic glucose production is excluded by the posttraumatic insulin levels from the insulin-sensitive tissues. A bihormonal setting favors a greater rate of hepatic glucose production in both open and laparoscopic surgery. Hormonal changes do reflect the degree of surgical stress, but their metabolic consequences are not parallel to the grade of surgical trauma in minimally invasive surgery.     

Laparoscopic cholecystectomy in cirrhotic patients

BACKGROUND/AIMS: Laparoscopic and open cholecystectomy are the safest procedures for all diseases related to stones in the gallbladder as they have a low morbidity and mortality rate. However, the safety of laparoscopic cholecystectomy in cirrhotic patients has not been investigated. The goal of this study was to evaluate the safety of laparoscopic cholecystectomy in cirrhotic patients. METHODOLOGY: A retrospective study of laparoscopic cholecystectomy in cirrhotic versus non-cirrhotic patients was performed. Between January 1991 and November 1994, 605 laparoscopic cholecystectomies for symptomatic gallbladder diseases were performed. There were 21 patients in the cirrhotic (group A) and 584 patients in the non-cirrhotic (group B). RESULTS: There was no operative mortality in either group and the postoperative complication rates were 4.8% and 5.8% in group A and B, respectively (p > 0.05). Prolonged operative time in group A was 84.47 +/- 36.01 min vs group B 62.20 +/- 25.37 min (p < 0.01). The estimated intraoperative blood loss in group A was larger than in group B (140.76 +/- 201.19 ml vs 35.02 +/- 50.11 ml, p < 0.01). The readmission rate was higher in group A (9.5%) than in group B (1.37%) (p < 0.05). The hospital stay in group A and B were 4.12 +/- 2.15 D, 3.50 +/- 1.50 D respectively (p > 0.05). The incidence of conversion and re-operation rates indicated no difference between cirrhotic and non-cirrhotic groups. CONCLUSIONS: Laparoscopic cholecystectomy can be safely performed in mild cirrhotic patients with more operative times and meticulous management of intraoperative bleeding.     

Laparoscopic ultrasound: a valuable adjunct to laparoscopic surgery

Laparoscopic ultrasound represents a recent merger in the laparoscopic technology and intraoperative ultrasound and shows a diagnostic accuracy higher than preoperative studies. Laparoscopic ultrasound can be used during laparoscopic cholecystectomy to screen the bile duct. It is particularly useful for diagnosing and staging malignancies, including hepatobiliary, pancreatic and gastroesophageal cancers. By demonstrating the interior of organs and deep structures, it can compensate for the limitation of laparoscopic examination. Laparoscopic ultrasound will become a valuable adjunct to laparoscopic surgery.     

Effect of reperfusion modality on outcome in nonsmokers and smokers with acute myocardial infarction (a Primary Angioplasty in Myocardial Infarction [PAMI] substudy). PAMI Investigators

BACKGROUND: We present our experience with laparoscopic cholecystectomy in pregnant patients, with consideration of the physiological changes of pregnancy affecting anesthetic and surgical management. METHODS: We reviewed the medical records of all pregnant patients undergoing laparoscopic surgery at Brigham and Women's Hospital between January 1, 1991 and April 30, 1995. RESULTS: Laparoscopic cholecystectomy was performed without complication in ten patients (gestational age 9-30 weeks). Details of anesthetic and surgical management are described. The anesthetic and surgical implications of pregnancy-associated physiological changes in the gastrointestinal, respiratory, cardiovascular, and central nervous system are reviewed. CONCLUSIONS: With appropriate attention to the altered physiology of pregnancy, laparoscopic cholecystectomy can be performed safely and effectively during pregnancy.     

The PR-1a promoter contains a number of elements that bind GT-1-like nuclear factors with different affinity

In less than a decade, laparoscopic methods have dramatically improved the safety and convenience of cholecystectomy. As a result, the number of cholecystectomies performed nationwide has increased significantly. Whether this increase is a reflection of any major change in operative indications is unclear; the actual answer may vary from community to community. Silent gallstones continue to represent a sometimes contentious therapeutic dilemma. Because their natural history is unlikely to have changed, the management guidelines previously established for open cholecystectomy continue to have relevance today. Thus, it can be agreed that the majority of patients with silent gallstones do not require a cholecystectomy. The changing risk-benefit ratio suggests that some liberalization of these guidelines may now be in order. Already a number of transplantation surgeons have begun to recommend pretransplant cholecystectomy for asymptomatic patients who are found to have gallstones during screening. Available evidence also appears to support the use of pre-emptive laparoscopic cholecystectomy for other indications such as in selected women of childbearing age, young children, and patients with very large gallstones. The problem of silent gallstones in diabetics continues to be more enigmatic, but some complicated diabetics are probably best managed with operation. Other patient groups who are at high risk of having adverse outcomes from expectant management will be more precisely identified by future research efforts. Laparoscopic cholecystectomy should also be helpful in patients with various forms of acalculous biliary disease. However, special caution is advisable in approaching chronic acalculous cholecystitis until more specific and reproducible diagnostic methods are further validated.