comparision between laproscopic and open cholecystectomy

1. By
Dr Aravind

3.  Complete Surgical Removal of Gallbladder
 Most commonest abdominal surgery
 First described by Langenbuch in 1882
 First endoscopic cholecystectomy was performed by
Mühe of Böblingen, Germany in 1985
 The National Institutes of Health (NIH)
Consensus Development Conference in 1992
recognized Laproscopic Cholecystectomy as the
new "gold standard" for the treatment of
gallstone disease

4. Anatomy
 Classic anatomy of the biliary tree is present in
only 30%
 Anomalies are the rule, not the exception
 Calot's triangle
 Boundaries
Cystic duct,
Cystic artery, and
The common hepatic duct

6. Indications
 Chronic Cholecystitis.
 Cholelethiasis.
 Acute on Chronic Cholecystitis.
 Acute Cholecystitis with complications.
 Empyema Gallbladder.
 Gangrenous Gallbladder.
 Perforated Gallbladder.
 Trauma to Gallbladder.
 Choledocholesthiasis.
 As a part of other procedure like Whipple Procedure.
 Carcinoma Gallbladder.
 Direct Invasion of Hepato-cellular carcinoma.
 Metastasis to gall bladder.
 Prophylactic Cholecystectomy in high risk patients.
 Parasitic Infestation of Gallbladder like in Ascariasis.
 In Bariatric surgery

7. Preoperative Considerations:
 Consent
 Nil by mouth for 8 hrs.
 Intravenous Fluids.
 Prophylactic Broad Spectrum Antibiotics.
 Anaesthesia fitness for General Anaesthesia
especially with related to respiratory function.
 Control of Hypertension & DM in affected patients.
 Arrangement of 1-2 pints of cross-matched blood.
 Correction of Any bleeding or clotting disorder.

8. Open Cholecystectomy
 Right subcostal (Kocher) incision
 Midline or Paramedian incision
 Placement of Retractors and
abdominal Sponges
 Adhesions of omentum or viscera
adjacent to the gallbladder are
divided
 Fundus held by a sponge holder and
retracted towards surgeon
 Dissection to identify cystic duct, its
entry into the common bile duct, and
the cystic artery

9. Dissection in Calot’s Triangle
 Ligation of the cystic duct in close proximity to
its junction with the common bile duct has long
been considered an essential component of OC.
 For preventing poscholecystectomy syndrome
 The cystic artery should be dissected, secured,
and divided near the surface of the gallbladder
 Intraoperative cholangiography
 Drains are not mandatory

12.  After adequate Hemostasis & removal of
abdominal packs closure of posterior rectus
sheath with absorbable sutures.
 Anterior Rectus Sheath is closed in continuous
fashion by Non-Absorbable sutures.
 Skin closed

13. Postoperative Management
 Nil by mouth till bowl sounds are present.
 Continue Intravenous fluids till patient is oral free.
 Adequate Analgesia.
 Continue Intravenous Antibiotics for 72 hours and then change
to oral for one week.
 Change of dressing if soaked early otherwise after 72 hours.
 Removal of drain when drainage is minimal.
 Removal of Sutures when wound is healed.
 Anti-ulcer therapy if needed.
 DVT Prophylaxis.
 Send specimen for Histopathology and stones for chemical
Analysis if present.

14. Laproscopic Cholecystectomy
 Traditional approach is 4 port but SILS
has become available as well now a days.
 Has become a gold standard approach for
gallbladder removal.
 If fails then convert to Open Procedure.
 Difficult to perform in Patients with
Previous open Abdominal Surgeries.
 Carries some increased risk of extra-
hepatic duct injuries.
 Recovery is better and early than open
surgery.
 Needs specialized equipment & training
of personnel.
 Usually avoided in cases of suspected
malignant Disease.

15.  Infundibulum is grasped, placing traction on the
gallbladder in a lateral direction to disalign the cystic
duct and common bile duct (CBD)
 Identify the structures forming the sides of Calot's
triangle
 Infundibulum of the gallbladder given traction
superior and medial direction
 Unnecessary and potentially harmful to dissect the
cystic duct down to its junction with the CBD
 The neck of the gallbladder is thus dissected away
from its liver bed, leaving only two structures
entering the gallbladder—the cystic duct and artery
 Both cystic duct and cystic artery are divided
between metal clips
 Intraoperative cholangiography (IOC)
 Dissection is done from infundibulum to fundus
 Gall bllader is extracted from one of larger port

17. Advantages and Disadvantages
Advantages Disadvantages
 Less pain
 Smaller incisions
 Better cosmesis
 Shorter hospitalization
 Earlier return to full
activity
 Decreased total costs
 Lack of depth perception
 View controlled by camera
operator
 More difficult to control
hemorrhage
 Decreased tactile
discrimination (haptics)
 Potential CO2 insufflation
complications
 Adhesions/inflammation limit
use
 Slight increase in bile duct
injuries

18. Journals

19.  Randomized clinical trial of open versus laparoscopic
cholecystectomy in the treatment of acute cholecystitis
 By M. Johansson1,*, A. Thune1, L. Nelvin1, M.
Stiernstam1, B. Westman2 andL. Lundell2
 Published on 6 DEC 2004 in British Journal of Surgery
 Background:
 The aim of this prospective trial was to determine whether
surgical approach (open versus laparoscopic) had an impact
on morbidity and postoperative recovery after
cholecystectomy for acute cholecystitis.
 Methods:
 Seventy patients who met the criteria for acute
cholecystitis were randomized to open or laparoscopic
cholecystectomy. The type of operation was unknown to
the patient and all hospital staff involved in the
postoperative care.

20.  Results:
 There were no significant differences in rate of
postoperative complications, pain score at discharge and
sick leave.
 In eight patients a laparoscopic procedure was converted
to open cholecystectomy.
 Median operating time was 90 (range 30–155) and 80
(range 50–170) min in the laparoscopic and open groups
respectively (P = 0·040).
 The direct medical costs were equivalent in the two groups.
 Although median postoperative hospital stay was 2 days in
each group, it was significantly shorter in the laparoscopic
group (P = 0·011).
 Conclusion:
 Cholecystectomy for acute cholecystitis can be performed
by either laparoscopic or open techniques without any
major clinically relevant differences in postoperative
outcome. Both techniques offer low morbidity and rapid
postoperative recovery

21.  A population-based cohort study comparing
laparoscopic cholecystectomy and open
cholecystectomy
 By Steven L Zacks MD, MPH1, Robert S Sandler MD,
MPH1,3, Robert Rutledge MD2 and Robert
S Brown Jr MD, MPH
 In The American Journal of Gastroenterology (2002)
 OBJECTIVES:
 Laparoscopic cholecystectomy (LC) has become a
popular alternative to open cholecystectomy (OC).
Previous studies comparing outcomes in LC and OC
used small selected cohorts of patients and did not
control for comorbid conditions that might affect
outcome. The aims of this study were to characterize
the morbidity, mortality, and costs of LC and OC in a
large unselected cohort of patients.

22.  METHODS:
 We used the population-based North Carolina Discharge
Abstract Database (NCHDAD) for January 1, 1991, to
September 30, 1994 (n = 850,000) to identify patients
undergoing OC and LC
 Compared length of stay, hospital charges, complications,
morbidity, and mortality between OC and LC patients
 RESULTS
 The OC patients had longer hospitalizations, generated
more charges required home care more often
 CONCLUSIONS:
 The introduction of LC has resulted in a change in the
management of cholecystitis. Despite a higher proportion
of patients with acute cholecystitis, the risk of dying was
significantly less in LC than in OC patients, even after
controlling for age and comorbidity. Based on lower costs
and better outcomes, LC seems to be the treatment of
choice for acute and chronic cholecystitis

23.  Thirty-day complications after laparoscopic or open
cholecystectomy: a population-based cohort study in Italy
 By Nera Agabiti1, Massimo Stafoggia1, Marina Davoli1, Danilo
Fusco1, Anna Patrizia Barone1, Carlo Alberto Perucci2
 Published in BMJ open in 2013
 Objective
 The objective of the study is to evaluate short-term
complications after laparoscopic (LC) or open cholecystectomy
(OC) in patients with gallstones by using linked hospital discharge
data.
 Design
 Population-based cohort study.
 Setting
 Data were obtained from the Regional Hospital Discharge
Registry Lazio Region in Central Italy (around 5 million
inhabitants) in 2007–2008

24.  Outcome measures
 30-day surgical-related complications’ defined as any
complication of the biliary tract
 30-day systemic complications’
 Results
 13 651 patients were included; 86.1% had LC, 13.9% OC.
2.0% experienced surgical-related complications (SRC),
2.1% systemic complications (SC).
 In relation to SRC, the advantage of LC was consistent
across age categories, severity of gallstones and previous
upper abdominal surgery
 No advantage among people with emergency admission and
very old people
 Conclusions
 This large observational study confirms that LC is more
effective than OC with respect to 30-day complications.
Population-based linkage of administrative datasets can
enlarge evidence of treatment benefits in clinical practice

25.  Role of antibiotics on surgical site infection in
cases of open and laparoscopic cholecystectomy:
A comparative observational study
 By Pankaj Gharde1, Manish Swarnkar1,
Lalitbhushan S Waghmare2, Vijay Manohar
Bhagat3, Dilip S Gode4, Dhirendra D Wagh1,
Pramita Muntode3, Hrituraj Rohariya1, Anoop
Sharma1
 In Journal of Surgical technique and Case report in 2014
Aims and Objectives:
 To study the effect of antibiotics on superficial
SSI in the cases of open and laparoscopic
cholecystectomy.

26.  Results
2 cases got SSI in LC group and 2 cases got SSI
in OC group
 Discussion
Antibiotic prophylaxis has no role in SSI, even if
you provide antibiotics for longer duration they do
not assist in the prevention of infection
 Conclusion
Our study concludes that there is no difference
in outcome of patients in the cases of
laparoscopic and open cholecystectomy whether
you give antibiotics or not. The SSI rate remains
the same.

27.  Laparoscopic cholecystectomy after a quarter
century: why do we still convert?
 By Balazs I. Lengyel, Dan Azagury, Oliver Varban,
Maria T. Panizales, Jill Steinberg, David C. Brooks,
Stanley W. Ashley, Ali Tavakkolizadeh
 In Surgical Endoscopy February 2012
 Background
 Laparoscopic cholecystectomy (LC) is the gold
standard procedure for gallbladder removal. However,
conversion to open surgery is sometimes needed
 this study aimed to identify the main reasons for
conversion and ultimately to develop guidelines to help
reduce the conversion rates

28.  Methods
 Using the National Surgical Quality Improvement Program
(NSQIP) database and financial records, the authors
retrospectively reviewed 1,193 cholecystectomies performed at
their institution from 2002 to 2009 and identified 70
conversions.
 Results
 In 91% of conversion cases, the conversion was elective. In 49%
of these conversions, the number of ports was fewer than four
 Of the six emergent conversions (9%), bleeding and concern
about common bile duct (CBD) injury were the main reasons. One
CBD injury occurred
 Conclusions
 In 49% of the cases, conversion was performed without a
genuine attempt at laparoscopic dissection. Considering this new
insight into the circumstances of conversion, the authors
recommend that surgeons make a genuine effort at a
laparoscopic approach, as reflected by placing four ports and
trying to elevate the gallbladder before converting a case to an
open approach.

29.  Bile duct injuries during open and laparoscopic
cholecystectomy in the laparoscopic era:
alarming trends
 By Jukka Karvonen, Paulina Salminen, Juha M.
Grönroos
 In Surgical Endoscopy in September 2011
 Background
 After the introduction of laparoscopic
cholecystectomy (LC), scientific discussion and
concern about iatrogenic bile duct injuries (BDIs)
have been limited mostly to BDIs sustained in LC
 BDI,s in all cholecystectomies have not been the
center of attention.

30.  Results
 Altogether 75 BDIs were encountered in a total of 8349
cholecystectomies
 Twenty BDIs (15 Amsterdam type A and 5 type B, C, or D)
occurred in the 1616 OCs (incidence rate = 1.24%)
 55 (26 type A and 29 type B, C, or D) in the 6733 LCs (incidence
rate = 0.82%)
 All the BDIs in the OCs were missed while 11/29 of the major
BDIs in the LCs were detected at the time of surgery
 Fifty-four of 59 type A, B, and C BDIs could be treated
endoscopically.
 Conclusions
 In the laparoscopic era, OC is associated with a high number of
BDIs, if minor BDIs are included. Excluding some major LC BDIs,
BDIs are, as a rule, missed at the time of surgery. More than
90% of Amsterdam types A, B, and C BDIs can be treated
endoscopically, whereas type D BDI remains an absolute
indication for surgery.

31.  Single-incision laparoscopic surgery (SILS) vs.
conventional multiport cholecystectomy: systematic
review and meta-analysis
 By S. R. Markar, A. Karthikesalingam, S. Thrumurthy,
L. Muirhead, J. Kinross, P. Paraskeva
 In Surgical Endoscopy May 2012
 Background
 Single-incision laparoscopic surgery (SILS) has gained
increasing attention due to the potential to maximize
the benefits of laparoscopic surgery.
 The aim of this systematic review and pooled analysis
was to compare clinical outcome following SILS and
standard multiport laparoscopic cholecystectomy for
the treatment of gallstone-related disease

32.  Results
 In total, 375 cholecystectomy operations from 7 randomised
controlled trials were included, 195 by single-incision (SILS) and
180 by conventional multiport
 Operating time was significantly longer in the SILS group
compared to the standard multiport laparoscopic
cholecystectomy group
 There was no significant difference in the incidence of
postoperative complications, postoperative pain score (VAS), or
the length of hospital stay between the two groups.
 Conclusion
 The results of this meta-analysis demonstrate that single-
incision laparoscopic cholecystectomy is a safe procedure for the
treatment of uncomplicated gallstone disease, with postoperative
outcome similar to that of standard multiport laparoscopic
cholecystectomy. Future high-powered randomized studies
should be focused on elucidating subtle differences in
postoperative complications, reported postoperative pain, and
cosmesis following SILS cholecystectomy in more severe biliary
disease.

33. Comparison
Open Cholecystectomy Laparoscopic Cholecystectomy
 Easy.
 Can be done in peripheral
centers.
 May have more post operative
respiratory complications.
 Cosmetically not good.
 Hospital Stay is longer.
 Usually Reserved for failed
laparoscopic cases &
malignant Disease.
 Needs special equipment &
training of personnel.
 Learning Curve & Good Hand
eye coordination needed.
 Cost is higher.
 Hospital stay is shorter.
 Lesser post operative
complications.
 Avoided in Malignant Disease.
 If fails then have to proceed
towards open approach.
 Has become Gold standard
treatment for Gall bladder

35. Thank You