JOURNAL OF LAPAROENDOSCOPIC SURGERY Volume 2, Number 2, 1992 Mary Ann Liebert, Inc., Publishers

Open Versus Laparoscopic Cholecystectomy: A Retrospective Comparative Study MIKES T.

GLINATSIS, M.D., JOHN P. GRIFFITH, F.R.C.S., MICHAEL J. McMAHON, Ph.D., F.R.C.S.

and

ABSTRACT Two groups of 40 patients (31 females, 9 males), matched for age and body mass index, who underwent either elective open cholecystectomy (Group I) or elective laparoscopic cholecystectomy (Group II) have been studied retrospectively to detect differences in operating time, morbidity and mortality, hospital length of stay, and use of postoperative analgesics. The two groups of patients had almost identical histories of gallstone disease. The median operating time for the patients in Group I was 45 min (range 35-95) compared with 90 min (range 50-135) in Group II. An intraoperative cholangiogram was performed in 21 of the patients in Group I and 22 patients in Group II. There were no deaths in either group. The overall complication rate was 22.5% in Group I and 10% in Group II. Median postoperative length of stay was 5 days for Group I patients (range 1-19) and 2 days for Group II patients (range 1-5). All Group I patients required postoperative intravenous or intramuscular opiates, while 10% of Group II patients did not require any analgesia at all and pain was controlled with oral analgesics alone in 16%. Median total morphine dose for Group I patients was 46.9 mg (range 9.4-180), as compared with only 15.6 mg (6.2-37.5) for Group II patients. This study concludes that laparoscopic cholecystectomy led to less complications, shorter hospital length of stay, and minimal use of postoperative analgesia.

INTRODUCTION

(LC) and other laparoscopic procedures in general of has lot a the last 2 enthusiasm, as well as disbelief, among surgeons. years surgery during generated Facts and figures from well-designed studies must be evaluated before definite conclusions can be drawn. The first papers describing the experience of laparoscopic cholecystectomy from various centers around the world have reported increasing numbers of patients treated with this new surgical modality. '"7 The results presented so far are sufficiently promising that one might argue that studies comparing the procedure with open

The

evolution of laparoscopic cholecystectomy

University Department of Surgery, Leeds General Infirmary, England. SI

GLINATSIS ET AL.

cholecystectomy (OC) are not justified. Others point out that prospective studies comparing open and laparoscopic surgery are almost impossible, due to patients' demand to have a less invasive and less painful

procedure.8

Despite the enthusiasm, these two methods do need to be compared in order to clarify the advantages or pitfalls of the new technique. For this purpose, we conducted a retrospective study comparing the two surgical procedures in consecutive patients on a surgical unit. MATERIALS AND METHODS

Laparoscopic removal of the gallbladder became routine in our department in June 1990. In order to compare laparoscopic with conventional cholecystectomy, we disregarded the initial "learning curve" of 50 laparoscopic cholecystectomies. Eighty consecutive patients who were operated upon conventionally, prior to June 1990, were entered into a computer database. From this database, and 40 patients who were the closest match for age, gender, body mass index (BMI), and ASA grade, and 40 consecutive patients who underwent laparoscopic cholecystectomy were anonymously selected. All patients conformed to the following selection criteria: (1) symptomatic disease due to stones in the gallbladder, (2) elective operation, and (3) stones in the gallbladder only. All patients were routinely followed up for a period of 1 month; this was extended if complications ensued. A 100% compliance rate to follow up achieved. Data recorded

was

body mass index (BMI), previous history, previous acute admissions for of biliary problems, history jaundice, preoperative endoscopie retrograde cholangiopancreatogram (ERCP) and sphincterotomy, operating surgeon, duration of operation, intraoperative cholangiogram, use of drain, complications, hospital length of stay, readmission, cause of readmission, relaparotomy, and postoperative analgesia. Intravenous and intramuscular opiates other than morphine (i.e., diamorphine and papaveretum) were converted to milligram of morphine for direct comparison. Anesthesia protocols were similar during the were

sex, age,

study period. Statistical analysis included Fisher's Exact test, Mann-Whitney U test, and Spearman Rank Correlation test as appropriate. Values ofp < 0.05 were regarded to be significant. RESULTS The two groups of patients consisted of 31 females and 9 males each. Patients' demographic data are 1. Due to the design of this study, there were no significant differences of age and BMI between the two groups.

presented on Table

History The history of both groups of patients is shown in Table 2. The only difference between the two groups was that there were more patients in the OC group who had been previously admitted acutely to a hospital (17 patients of OC group vs 8 patients of the LC group). Table l. Patients' Demographics3

Open Age Body Mass ASA Value

Index

Laparoscopic

52.5(24-80) 26.5(17.8-34.7) 1.7(1-4)

"Values represent medians (range) bMann-Whitney U test cNot significant 82

(30-91) 23.6(20.2-35.7) 1.6(1-3) 54

p

valueb 0.5 0.12

(ns)c

OPEN VERSUS LAPAROSCOPIC CHOLECYSTECTOMY Table 2. Patients' History Data

of History (months) median (range) Previous Jaundice # of patients (%) Previous Acute Admission # of patients (%) Preoperative ERCP # of Patients (%)

Length

Open

Laparoscopic

p value

12(0-240)

15(1-240)

0.34 (*)

5(12.5)

0.22 (**)

(20)

0.018 (**)

6(15)

7(17.5)

0.22 (**)

1(2.5)

4(10)

0.12 (**)

3(1.2) 17

Preoperative Sphincterotomy

(42.5)

8

# of Patients (%)

(*) Mann-Whitney U

Operative

test

(**) Fisher's Exact test

details

The operating surgeons are listed on Table 3. It is obvious that in the LC group the majority of cases have been performed by a consultant surgeon. In addition, since laparoscopic cholecystectomy is a new technique, operations performed by surgeons in training were closely supervised by the consultant. The median operating time for OC was 45 min (range 35-95 min), compared with 90 min (range 50-135 min) for laparoscopic operation (p < 0.05, Mann-Whitney U test). The policy of the department is to attempt an intraoperative cholangiogram through the cystic duct during elective procedures, unless the patient has had a successful preoperative ERCP. In this series, intraoperative cholangiography was attempted in 34 patients in the OC group and in 33 patients of the LC group. The cholangiogram was successful in 21/34 patients in the former group (success rate 61.8%) and in 22/33 patients in the latter (success rate 66.7%). The reason for failure was the presence of a very narrow cystic duct, or obliteration of the duct lumen which could not be overcome. Only eight patients (20%) of the OC group had a drain inserted, while the policy for the LC group was to drain all patients through a 4 mm silicon rubber tube. The drain was routinely removed the morning after the operation, unless there were indications to retain it.

Morbidity There

were no

deaths in either group of patients.

Complications developed postoperatively

in 4

patients

(10%) from the OC group and in 3 patients (7.5%) from the LC group not significant (N.S.) while they were still in the hospital. A list of the complications and their treatment is presented in Table 4. Five patients in the OC group (12.5%) and one patient (2.5%) in the LC group were readmitted to the hospital because of complications which developed after discharge from the hospital. The difference is statistically significant (p 0.02, Fisher's Exact test). The causes for readmission are listed on Table 5. =

Table 3. Seniority

of the

Open (%) Consultant Senior Registrar

Registrar

14

24 2

(35) (60) (5) 83

Operating Surgeon

Laparoscopic (%) (62.5) (35) 1 (2.5)

25 14

GLINATSIS ET AL. Table 4. Complications Prior

to

Discharge

Hospital

Laparoscopic

Open retention—transferred under of urologists (R) Subphrenic fluid collection— Needle aspiration under U/S Wound infection Chest infection

Small amount of bile leak and subhepatic collection—settled Small amount of bile leak—settled Possible cardiac ischémie episode

Urinary the

from

care

In total, nine

patients in the OC group (22.5%) and four patients in the LC group (10%) developed The difference is statistically significant (p complications. 0.031, Fisher's Exact test). There postoperative were only two major complications, both occurred in the OC group (subphrenic abscess, biliary peritonitis), one of which (biliary peritonitis) led to relaparotomy. =

Hospital length of stay postoperative hospital length of stay was 5 days for the OC patients (range 1-19 days) and 2 days (range 1-5) for the LC patients. The difference is statistically very significant (p < 0.001, MannWhitney U test). All LC patients who stayed in the hospital for more than 2 days did so for personal reasons only, apart from one patient in whom there was suspicion of a postoperative cardiac ischémie episode (not confirmed). The median

Use

of postoperative analgesics and antiemetics

After OC, all patients required opiate analgesia for postoperative pain control. Six patients (15%) required intravenous or intramuscular opiates only, while the remainder (85%) required oral compound analgesic supplements (combination of codeine and paracetamol) in addition to parenterally administered opiates. The median dose of morphine for patients after OC was 34.4 mg during the first 24 postoperative h (range 9.4-75 mg) and 46.9 mg in total (range 9.4-180 mg). In the LC group, 4 patients (10%) did not require any analgesia after surgery, 12 patients (30%) required intramuscular opiates, and 18 patients (45%) had parenteral opiates plus oral supplements of compound analgesics. Three patients (7.5%) received oral compound analgesia only and three others (7.5%) had oral paracetamol only. All LC patients who required analgesics did so only during the first 20 postoperative h

Table 5. Complications

after

from

Hospital

Laparoscopic

Open

Leg swelling—No

Discharge

DVT

proved—settled

Acute confusion—settled Removal of a subcuticular suture under anesthesia Right subphrenic abscess—needle aspiration under ultrasound

Biliary peritonitis—relaparotomy—no obvious point of leakage was detected during the operation. 84

abdominal pain 2 weeks after surgery—settled

Nonspecific

OPEN VERSUS LAPAROSCOPIC CHOLECYSTECTOMY

Laparoscopic (Total)

Open (24 First Hrs)

Open (Total)

-\ 0

20

40

Postoperative dose of morphine for analgesia postoperative hours after open surgery (middle bar) and FIG. 1.

60 after total

80 100 120 140 160 180 200 mg of morphine

laparoscopic cholecystectomy (top bar), during 24 first postoperative dose after open surgery (lower bar). Bars

represent the range.

The median morphine dose was 15.6 mg (range 6.2-37.5 mg), which was significantly less than in the OC group (p < 0.001, Mann-Whitney U test) (Fig. 1). The dose of postoperative morphine used in both OC and LC groups did not correlate with either age (p 0.372 and p 0.07, respectively), or body mass index (p 0.22 and p 0.728, respectively, Spearman Rank Correlation). Antiemetics were prescribed for 30 patients in the OC group (80%), compared to 26 patients (65%) in the LC group. Patients in the former group were given more than one dose of antiemetics, and for a longer period than the LC group. =

=

=

=

DISCUSSION

Although the number of patients included in this study is relatively small compared to the number of patients undergoing cholecystectomy every day, it does document several important differences between laparoscopic and conventional cholecystectomy in two groups of carefully matched patients. The operating time for laparoscopic cholecystectomy was about twice that needed to perform open cholecystectomy. However, this is a small cost when set beside the considerable advantages in postoperative discomfort and complications conferred by the laparoscopic technique. It is possible that with improved equipment and greater familiarity with the technique, the operating time will be reduced. In this series, laparoscopic cholecystectomy produced less morbidity than open surgery. The number of complications after open cholecystectomy seemed rather high, possibly due to careful monitoring and follow up of the patients and detailed record keeping; it is, however, comparable to other series.9"" Complications after laparoscopic surgery were minimal and within the limits reported by others.46,8'2 The length of hospital stay for cholecystectomy has been dramatically reduced by the introduction of the laparoscopic technique. The hospital stay can be reduced by removing the gallbladder through a "mini" 85

GLINATSIS ET AL. '2 2incision. An experienced biliary surgeon is required and the overall time of convalescence is still high. The postoperative length of stay is also dictated by other non-medical factors (i.e., socioeconomic, organizational, etc). It has already been proven that LC can be performed on an outpatient basis,'3 and this cost savings (shorter hospital stay) has been calculated to result in a savings of up to £900 per patient in the United Kingdom5 and between $300 and $700 in the United States.6 Obviously, cost issues relate mainly to the organization and finance of the health care system in each country. Our results clearly show the great advantage of laparoscopic cholecystectomy as far as reduction of postoperative pain is concerned. The amount of postoperative analgesia required was considerably less, and in some instances, not needed at all. The fact that we found no correlation between age or body mass index and the dose of morphine required for postoperative analgesia might suggest that we have been recording nursing practices rather than an actual need for analgesia, and this is a point that needs further investigation and evaluation. Unfortunately, papers published so far give few details about postoperative analgesics requirements4,6 and thus it is difficult to compare our observations with other series.

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8.

Neugebauer E, Troidl H, Spangenberger W, Dietrich A, Lefering R: Conventional versus laparoscopic cholecystectomy and the randomized controlled trial. BrJ Surg 1991;78:150-154.

9. Den Besten L, Berci G: The current status of biliary tract surgery: World J Surg 1986;10:116-122. 10. 11.

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Crumplin MKH, Jenkinson LR, Kassab JY, Whitaker CM, Al-Boutiari FH: Management of gallstones in a district general hospital. BrJ Surg 1985;72:428-432. Habib NA, FooCL, El-Masry R, etal: Complications of cholecystectomy in district general hospitals. BrJ Clin Pract 1990;44:189-192.

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Address reprint requests to: Michael J. McMahon, Ph.D., F.R.C.S.

University Department of Surgery

Leeds General Infirmary Great George Street Leeds LSI 3EX

England 86