Open Cholecystectomy

Vs
Laparoscopic Cholecystectomy
By
Dr Aravind
Complete Surgical Removal of Gallbladder
Most commonest abdominal surgery
First described by Langenbuch in 1882
First endoscopic cholecystectomy was performed by
Mhe of Bblingen, 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
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
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
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.
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
Dissection in Calots 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
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
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.
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.
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
Advantages and
Disadvantages
Advantages Disadvantages
Lack of depth perception
View controlled by camera
operator
More difficult to control
Less pain hemorrhage
Smaller incisions Decreased tactile discrimination
Better cosmesis (haptics)
Potential CO2 insufflation
Shorter hospitalization
complications
Earlier return to full Adhesions/inflammation limit use
activity Slight increase in bile duct
Decreased total costs injuries
Journals
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.
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 30155) and 80 (range 50
170) min in the laparoscopic and open groups respectively ( P =
0040).
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 =
0011).
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
A population-based cohort study comparing laparoscopic
cholecystectomy and open cholecystectomy
By Steven LZacksMD, MPH1, Robert SSandlerMD, MPH1,3,
RobertRutledgeMD2 and Robert SBrownJrMD, 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.
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
Thirty-day complications after laparoscopic or open
cholecystectomy: a population-based cohort study in Italy
By Nera Agabiti1, Massimo Stafoggia1, Marina Davoli1, Danilo Fusco
1, 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
Outcome measures
30-day surgical-related complications defined as any complication of
the biliary tract
30-day systemic complications
Results
13651 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
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 Bhagat
3
, 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.
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.
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
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.
Bile duct injuries during open and laparoscopic
cholecystectomy in the laparoscopic era: alarming
trends
By Jukka Karvonen, Paulina Salminen, Juha M. Grnroos
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.
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.
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
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.
 Comparison
Laparoscopic
Open Cholecystectomy
Cholecystectomy

Easy. Needs special equipment &

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.
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
Thank You