Mini-laparotomy cholecystectomy: A reasonable answer to a difficult situation

Mini-laparotomy cholecystectomy:

A reasonable answer to a difficult situation

Hatem AI Wagih, MD; Essam Gabr, MD; Ahmed Shaabaan, MD

Division of General, Head & Neck and Endocrine Surgery, Alexandria Main

University Hospital, Egypt.

Abstract

Introduction:Laparoscopic cholecystectomy is the gold standard  treatment modality  for symptomatic calculus cholecystitis. Patients  who are unfit for laparoscopy such as elderly patients with severe cardiopulmonary disease, mini-laparotomy cholecystectomy may be a good alternative to laparoscopic cholecystectomy.

Objectives: To compare between mini-laparotomy cholecystectomy (MLC) and laparoscopic

cholecystectomy (LC) as regards operative time, risk of complications,  postoperative hospital stay, return to normal activities and aesthetic results.

Patients and methods: A study of 50 patients with gall stones who underwent LC (group A, n = 25 patients) or MLC (group B, n = 25 patients). Age, sex, Body Mass Index (BMI), pain scores (visual analog scale), analgesic consumption,  operative time, complications, length of hospital stay,  return  to normal  daily  activities and  patient satisfaction were  recorded.

Results: In this study, both groups were found to be matching, with no statistically significant difference, in their preoperative assessment.  In group A; the overall  operative  time ranged between (30 and 55 minutes) with a mean of39.50 ±2.0347 minutes. In group B; the operative time ranged between (30 and 50 minutes) with a mean of 40.857±1.56 minutes. There was no statistically significant  difference  between  the operative  time in both groups (p=0.601). No statistically  significant difference  was found between the mean postoperative pain score and postoperative analgesic consumption in both groups (p= 0.952, 0.843 respectively).Postoperative hospital stay, return to normal daily activities, postoperative complications and patient satisfaction were comparable in both groups.

Conclusions: In non obese patients mini-laparotomy cholecystectomy can be a good alternative to laparoscopic cholecystectomy in developing  countries  where laparoscopy  is not available and in patients who are not fit for laparoscopy  such as patients with severe cardiopulmonary disease.

Key words: Mini-laparotomy cholecystectomy, laparoscopic cholecystectomy, non obese

patients, severe cardiopulmonary  disease.

Introduction:

Since  the  introduction of  laparoscopic cholecystectomy (LC) as a minimally invasive procedure alternative to the conventional open cholecystectomy, the procedure  has quickly become the treatment of choice for gallbladder disease. More  than  any other  laparoscopic procedure, LC has epitomized the advantages of minimal access surgery.It has been shown to be consistently superior in terms of post­ operative recovery and has resulted in earlier discharge from  hospital and  return  to full activity.  The   main  reason  for   these

improvements has been the replacement of a long surgical incision with several small port site  incisions. The  expected reduction in postoperative pain, as a consequence, has also been proven  by prospective trialsl-4. Mini­ laparotomy cholecystectomy can be a good alternative to laparoscopic cholecystectomy in developing countries where laparoscopy is not available and in patients who  are unfit for laparoscopy such  as  patients with  severe cardiopulmonary disease with  results comparable to   that   of   laparoscopy5-7.

Patients and methods:

The present study included  50 patients with symptomatic cholelithiasis proved by ultrasonography admitted  to the department of surgery at the Main University Hospital and the Medical Research Institute, University of Alexandria. Patients were randomized into either of 2 groups by the closed envelope technique.

GroupA (25 patients): the laparoscopic

cholecystectomy  group (LC).

GroupB (25patients): the mini-laparotomy cholecystectomy  group (MLC).

Exclusion criteria:

-History of jaundice and or history ofbiliary pancreatitis.

- Elevated liver enzymes and or elevated serum bilirubin.

- Elevated alkaline phosphatase.

- Ultrasonographic evidence of common bile duct stones or dilated common  bile duct

>8mm.

- BMI >30.

Laparoscopic cholecystectomy was done using the American approach.8

Technique   of     mini-laparotomy

cholecystectomy9: to  describe in  short. a- Pre-operative ultrasonographic marking of the site of the gall bladder and its position

was marked on the skin.

b- The patient was placed in the supine position with  a  bridge under the   lower ribs.

c- Nasogastric tube was inserted for deflation of the stomach and removed at the end of operation.

d- Transverse epigastric skin incision was made

over  the  lateral portion of  the  rectus abdominis muscle.

e- The incision was kept between 4 and 5cm. f- The operating room lights were turned off and the primary  surgeon  utilized  a head light to illuminate the small opening in the

abdomen.

g- The instrumentation required included three small narrow Deaver retractors, medium sized haemoclips and a clip applier with long tip.

h- Next, a longitudinal  incision was made in the anterior  rectus sheath and the rectus abdominis muscle was split in the process.

i- Another longitudinal  incision was made in the posterior rectus sheath and peritoneum.

j- The patient was rotated to the left side with the right side up.

k- After the above maneuver and retraction of the liver bed in the supero-lateral direction with a narrow Deaver retractor the Calot's triangle became visible.

1- The cystic  duct and artery  were  clamped with   stainless steel   clips or  ligated.

m- The gall bladder was dissected of the liver bed.

n-  The  skin  was  closed with  subcuticular sutures.

o- No drain was inserted.

Results:

Patient's demographics:

Both groups were found to be matching, with

no statistically significant difference, in their

preoperative assessment.

Operative data:

Conversion: In  the laparoscopic cholecystectomy group,  the procedure was converted to an open one in one patient (4%); the cause of conversion was the presence of cholecysto-duodenal fistula  in addition to excessive adhesions. Consequently; this patient was excluded from  the study. In the  mini­ laparotomy cholecystectomy group, the wound was widened in one patient (4%) due to the occurrence of uncontrollable  bleeding which couldn't be managed from the small incision. Widening of the wound up to 12 em was done and the bleeding  which was from an injured cystic artery was successfully controlled.  A sub-hepatic tube drain  was inserted in this patient; consequently this patient was excluded from the study.

Table (1): Comparison of operative time in both groups in minutes.

There was no statistically significant difference between the operative time in both groups

(p=0.601).

Table (2): Operative data in both studied groups.

Postoperative data:

No statistically significant difference was found between the mean postoperative pain score in both groups (p= 0.952). The number of analgesic ampoules (diclophenac sodium

75mg) required during the 1st postoperative

24 hours in both groups was recorded. As regards postoperative analgesic consumption,

no statistically significant difference was found between both groups (p=0.843). Resumption of oral feeding  and hospital  stay were not statistically significant between both groups (p= 0.658, 0.509). There was no statistically significant difference between the overall postoperative complication mtes inboth studied groups (p=0.552).

In group A; return to normal activities postoperatively ranged between six and ten days with a mean of7.57±1.28 days, while in group B; patients returned to normal activities after six to twenty one days with a mean of

8.36±3.82 days (the patient who developed external biliary fistula returned to his normal daily activities after 3 weeks). There was no statistically significant difference between both groups as regards return to normal daily activities (p =0.472).

Inthe laparoscopic cholecystectomy group,

all patients were  satisfied with  their postoperative fine scar, while in the mini­ laparotomy cholecystectomy group, all except two patients were satisfied with  their postoperative fine  scar.  There  was no statistically significant difference between both groups as  regards   patient's satisfaction (p = 0.482).

Discussion:

Laparoscopic cholecystectomy is the gold

standard treatment modality for symptomatic calcular cholecystitis, patients who are unfit for laparoscopy such as elderly patients with severe cardiopulmonary  disease,  mini­ laparotomy cholecystectomy may be a good alternative to laparoscopic cholecystectomy with nearly  the same  outcome  as regards operative time, hospital stay, return to normal daily  activities  and   post-operative complications.5-7 As regards the financial cost mini-laparotomy cholecystectomy may be a good choice in developing countries where cost             containment   is     critical.l

Our results as regards operative time was in accordance with what was reportedby Sylvanus et aLlo Vagenas et al, J Harju et al, found in their studies that the mean operative time of laparoscopic cholecystectomy was significantly longer than  that  of mini-laparotomy cholecystectomy_ll,l2 Syrakos et al in their study reported a longer operating time for laparoscopic cholecystectomy versus mini­ laparotomy cholecystectomy (median values were  61 minutes versus 46 minutes respectively).13 Setting  up and testing  of laparoscopic equipments usually add minutes to the performance time. The shorter operative time of laparoscopic cholecystectomy in this study may be attributed to increased familiarity and experience with the laparoscopic technique, absence of acute attacks and absence of unclear anatomy.

Sylvanus et al and J Harju et al in their studies reported that there was no statistically significant difference between mini-laparotomy cholecystectomy and  laparoscopic cholecystectomy as regards  postoperative pain.lO,12 Vagenas et al in their study reported that laparoscopic cholecystectomy significantly reduced postoperative pain compared to mini­ laparotomy cholecystectomy.ll In our study the use of muscle splitting technique significantly reduced  postoperative pain following mini-laparotomy cholecystectomy. Postoperative hospital stay after laparoscopic cholecystectomy and mini-laparotomy cholecystectomy is another controversial issue. Squirell et al and Sylvanus et al, in prospective randomized comparisons oflaparoscopic versus

found  no significant difference as regards postoperative hospital stay  between both groups),lO  On the other hand, Rose et al and Barkun et al claim that  laparoscopic cholecystectomy is associated  with a shorter convalescence period than mini-laparotomy cholecystectomy_l4,15 In a prospective randomized study,  Kunz  et al reported that there was no statistically significant difference between  laparoscopic and mini-laparotomy cholecystectomy as regards  operative time, postoperative hospital stay, and peri-operative complications. Syrakos et al in their study did not find any significant difference between laparoscopic and mini-laparotomy cholecystectomy groups as regards postoperative hospital stay.13 In our study there was  no  statistically significant difference between both groups as regards postoperative hospital stay. The short postoperative hospital stay following both procedures in our study is attributed to the use of fast track surgery. In this study, there was no statistically significant difference between the  laparoscopic cholecystectomy group and the mini­ laparotomy cholecystectomy group as regards patient's satisfaction with  the procedure. Vagenas et al in their  study  found  that  as regards aesthetic  result, punctures  from fine caliber laparoscopic instruments were superior to small  surgical incisions. However, data shows  no significant long  term  difference between both groups as regards the aesthetic results.n

One  obvious  advantage of laparoscopic cholecystectomy over   mini-laparotomy cholecystectomy is  that   laparoscopy is exploratory and can detect any other pathology in the abdominal cavity.In the mini-laparotomy cholecystectomy, abdominal exploration couldn't be performed from the small incision.

Conclusion and recommendations:

• Results of mini-laparotomy cholecystectomy are  comparable to that  of laparoscopic cholecystectomy as regards operative time, postoperative pain  score,  postoperative analgesic requirement, postoperative complications, hospital stay,  return  to normal daily activities and  patient's satisfaction   with  the    procedure.

good alternative to  laparoscopic cholecystectomy in developing  countries where laparoscopy is not available and in patients who are not fit for laparoscopy such as patients with severe cardiopulmonary disease.

• Mini-laparotomy cholecystectomy is a safe,

cost-effective procedure  associated  with smooth  postoperative period  and  early convalescence.

• One obvious disadvantage of laparoscopic

cholecystectomy is  that  if  it's widely adopted a generation of younger surgeons will emerge  who are not experienced in open biliary surgery which will be needed inabout 2-2.8% of patients. Surgeons who perform mini-laparotomy cholecystectomy will retain their open operating skills and thus will be less likely to have operative mishaps.

•  For  mini-laparotomy cholecystectomy emphasis on good illumination (the use of head light) and experienced  surgeon with open biliary surgery is important, the use of funds 1st technique is more safe but it's a matter of surgeon preference.

References:

1- Squirrell DM, Majeed AW, Troy G, et al: A randomized, prospective, blinded comparison of post-operative pain, metabolic response, and perceived health after  laparoscopic and  small  incision cholecystectomy. Surgery 1998; 123: 485-

495.

2- McMahon AJ, Russell IT, Ramsay G, et al: Laparoscopic and mini-laparotomy cholecystectomy: A  randomized trial comparing post-operative pain  and pulmonary function. Surgery 1994; 115:

53-59.

3- Kum CK, Wong CW, Goh PM, et al: Comparative study  of pain  level  and analgesic requirement after laparoscopic and open cholecystectomy. Surg Laparosc Endosc 1994; 4: 139-141.

4- ChanHS, Ha XF, Ooi PJ, et al:A prospective

comparative study between conventional and  laparoscopic cholecystectomy. Singapore Med  J 1995; 36:  406-409.

5- lshizaki Y, Bandai Y, Shimomura K, et al: