Abstract

Background: Today laparoscopic cholecystectomy is considered the gold standard treatment for gall stone disease. But this facility is not available for common people in many parts of the country due to the high cost of treatment, technical expertise required and non availability of the technology at several district hospitals and other big centres.

Aims: The aim was to study the feasibility of minilaparotomy cholecystectomy against standard open cholecystectomy, where the facilities of laparoscopy are not available. Can minilaparotomy be a solution midway between standard open cholecystectomy and laparoscopic cholecystectomy?

Methods: This study was carried out in two groups of 30 patients each- the standard open cholecystectomy group (OC) and the minilaparotomy cholecystectomy group (MC) done by the fundus first method with a 5-7 cms subcostal incision. Time required for the procedures, average hospital stay, postoperative complication rates etc were noted in both groups.

Results: The average duration of surgery was 131.66 minutes, average hospital stay 10.8 days and postoperative complication rate comparatively more in the standard open cholecystectomy group. The average duration of surgery was 64.66 minutes, average hospital stay 6.4 days and complications less in the minilaparotomy group. Moreover postoperative recovery was early with less requirements for antibiotics and analgesia.

Conclusions: In centres where facilities for laparoscopy are not available, minilaparotomy cholecystectomy is a good and feasible alternative to conventional open cholecystectomy. It can be considered as a procedure which comes close to laparoscopic cholecystectomy considering its benefits over standard open cholecystectomy.

Introduction

Biliary stone disease is a common problem world over. Over past hundred years various therapeutic options have been evolved but cholecystectomy has remained the “Gold Standard” world over. The place of open cholecystectomy has been placed under close scrutiny. Open cholecystectomy has been practiced over 100 years, which has been constantly refined and perfected. Despite benefits of laparoscopic cholecystectomy, there is an alarming rise in biliary tract injuries, missed calculi in common bile duct and missed malignancies. Minilaparotomy cholecystectomy or minor incision cholecystectomy is being rapidly evolved and perfected to offset the shortcomings of laparoscopic cholecystectomy. In the present study the comparison between minilaparotomy cholecystectomy and standard conventional open cholecystectomy in terms of postoperative complications, morbidity, mortality and feasibility of early discharge were studied.

Minilaparotomy cholecystectomy implies performing of cholecystectomy through a 5 cm (± 2 cm) subcostal rectus sparing incision. O’Dwyer1 in 1990 showed that it is associated with short hospital stay in comparison with the standard open method. O’Kelly TJ et al2 confirmed cholecystectomy performed through a small incision is feasible and followed by shorter recovery time than conventional cholecystectomy. Olsen DO3 in 1993 reviewed the literature and concluded that minilaparotomy cholecystectomy is a suitable alternative to laparoscopic cholecystectomy, a technique which has the same benefits without problems inherent in laparoscopic surgery. Majeed et al4 in 1996 concluded that laparoscopic cholecystectomy takes longer to do than minilaparotomy cholecystectomy and does not have any significant disadvantages in terms of hospital stay or postoperative recovery. Supe AN et al5 observed that both are comparable procedures for the treatment of gall stones disease in India. In the present study also the postoperative hospital stay was less in minilaparotomy group as compared to standard open method. There was 10% incidence of sickle cell disease in the present study. From the present study, it was concluded that the small incision of minilaparotomy cholecystectomy produces less trauma, less pain, with subsequent less analgesic requirement. Though the main stress was given to surgical procedure, the common features of gall stone disease were also studied along with.

Material and Methods

This prospective study carried out over a period of 2 years in two groups. Group OC includes patients with conventional open cholecystectomy and Group MC includes patients with minilaparotomy cholecystectomy. All the patients of cholelithiasis in the present study were thoroughly investigated after the admission. Detailed history was recorded. Investigations included complete haemogram, blood sugar (fasting, and post meal) renal function tests, liver function tests, coagulation profile, sickling (early and late) with Hb electrophoresis and blood grouping. Percutaneous transhepatic cholangiography, Endoscopic retrograde cholangiopan-creatography etc. were not done in this study because only selective gall stone cases were included in this study. The cases included in this study were:

• USG proven symptomatic cholelithiasis
• USG proven acalculus cholecystitis
• Non malignant pathology

The patients excluded from the study were:

• Patients unfit for anaesthesia or surgery
• Patients who have refused participation in this clinical study
• Patients with choledocholithiasis

This study includes patients of both sexes and the age group ranges from 9 to 70 years. Patients from both the groups were operated under general anaesthesia. In group OC, standard open cholecystectomies were performed through various incisions depending upon the choice of the surgeon. These incisions were standard subcostal Kocher’s incision, right paramedian incision and midline incision. Cholecystectomies were done by both fundus first or retrograde method.

All the patients in the MC(minilaparotomy cholecystectomy) group were done by the fundus first method. A 5-7 cm right subcostal incision centring the tip of 9th costal cartilage was taken. After opening the abdomen, Deaver’s retractors were used for deep retraction. If gall bladder was tense, it was aspirated. After dissection from the liver bed, junction of CBD and cystic duct was identified. Cystic artery was identified and ligated with 2-0 vicryl suture. Cystic duct stump was also ligated with vicryl. If difficulty encountered in identifying anatomical landmarks, then the length of the incision was extended as per the need. Gel foam was kept over the gall bladder fossa. Selective intraperitoneal drainage was done and wound closed. Patients were ambulated as early as possible. Oral fluids were started depending on the presence of bowel sounds. Sutures were removed on the 7th to 10th postoperative day depending on the wound conditions and patients age.

Results

In all, 60 cholecystectomies were done during this study; 30 in the conventional open and 30 in the minilaparotomy group. The incidence of gall stones was higher in 4th to 5th decade. The age range of patients was 9 to 70 years. The mean age incidence was 41.55 yrs. Male:female ratio was 1:2.75. There were 6 patients (10%) in this study who were having haemolytic anaemia, 4 were having sickle cell trait (AS pattern) and other 2 having sickle cell disease (SS pattern). In all these cases pigment stones were recovered. Pain in the right hypochondrium (40%) and epigastrium (40%) were the commonest symptoms, followed by dyspepsia (42%). Liver functions were normal except in one patient, who was known case of sickle cell disease where the bilirubin was 7.3 mg%. Coagulation profile was deranged in 4 cases, which was corrected before surgery. None of the patients in the present series showed radio opaque gall stones on X-ray abdomen. Ultrasonography diagnosed stones approximately in 98% patients. Only in one patient whose ultrasound suggested cholelithiasis with dilated common bile duct was found to have normal common bile duct intraoperatively. After clinical examination and investigations, it was observed that 40% cases presented as chronic cholecystitis. Only in two cases of minilaparotomy group the length of the incision was extended and minilaparotomy converted to standard open cholecystectomy. In the first patient there was intraoperative difficulty to achieve cholecystectomy and in the other gall bladder was accidentally opened while dissecting from the liver bed as it was very much inflamed. No intraoperative difficulties encountered with the standard open group. Blood transfusion was not required in any case in this study.

The average duration of surgery in the standard open group was 133 minutes whereas it was 64 minutes in the minilaparotomy group. Antibiotic requirement was comparatively less in the minilaparotomy group. It was 3.03 days in minilaparotomy group and 8.26 days in the standard open group. Analgesic requirement was also less in the minilaparotomy group i.e. 4.33 days compared to 7 days for the standard open group. Minilaparotomy incision i.e. 5 cm (± 2 cm) subcostal incision allowed faster recovery and produced comparatively less pain. The post operative complication rate was 10% in minilaparotomy group compared to 30% in the standard open cholecystectomy.

The incidence of biliary leak was 3.33% in each group. It lasted for 10 days in the minilaparotomy group and 7 days in standard open group and were managed conservatively. Wound infection rate was 3.33% in the minilaparotomy group compared to 13.33% in the standard open group. The incidence of fever in the standard open method was 16.66% while it was 6.66% in the minilaparotomy group. There was no mortality in this study (Tables 1 and 2).

Most of the patients of minilaparotomy group could be ambulated the same evening as compared to the next morning i.e. on the first postoperative day in patients of the standard open group. Oral fluids were started

Table 1: Table showing postoperative complications in Group A (standard open)

on the first post operative morning in minilaparotomy group while it was on 2nd postoperative day in the standard open group after the presence of bowel sounds were confirmed. Average hospital stay was 10.8 days in the standard open group and 6.4 days in minilaparotomy group. The prolonged hospital stay was because of biliary leaks, fever, wound infection and wound gape in the standard open group while only in one patient of minilaparotomy group it was because of biliary leak and fever.

Discussion

The age incidence of present series is comparable with the studies of other Indian authors. Malhotra6 reported mean age incidence of 39 years in Central Indian population. In contrast to Western countries, the Indian patients are younger in age. Various factors like shorter life span, racial, socioeconomic and dietary factors have been implicated by Indian authors. The male : female ratio of 1 : 2.75 in the present series compares well with the study of Ananth krishnan et al7 and Ganey et al.8 There is consistent evidence that the gall bladder diseases are more common in females in all age groups. Down et al9 in 1983 reported that it is the progesterone rather than oestrogen which is responsible for cholelithiasis.

Table 2: Table showing postoperative complications in Group B (minilaparotomy)

Heaton10 claimed that; there is increased prevalence of gall stones in the patients of diabetes mellitus. In the present study there was only one patient who was a known case of diabetes. The present series reports 10% incidence of haemolytic disorders. This is comparable with the study of Barrett and Connor et al11 (10%) and Billa et al12 (10.37%). William Pokorny13 reported 50% incidence of haemolytic disorders in cases with cholelithiasis in children below 19 years. Pain was present in 50% of cases in the present series, while it was 93% in the study by Anathkrishnan et al7 and 94.9% in a series of Wani et al.14 Incidence of dyspepsia was 70% in the present series. The incidence of jaundice in the present series was 13.33% while it was 8.66% reported by Wani et al.14 Ultrasonography diagnosed 98% of patients correctly in the present study. The reliability of this investigation is more than 90% in patients with chronic calculus cholecystitis and 80% in patients with acute calculus cholecystitis. It has 90-95% accuracy in identifying calculi. The incidence of chronic cholecystitis was 40% in the present study. These were 6 patients in the present study who presented as acalculus cholecystitis based on clinical findings and ultrasound. As we did not have the facility for HIDA scan, it could not be done in our patients.

The main stress in this study was on surgical procedure. In the present study 60 patients underwent conventional open cholecystectomy (OC) and 60 minilaparotomy cholecystectomy (MC). There was intraoperative difficulty in 2 cases in the minilaparotomy group. The first case was excessively obese with a micronodular cirrhotic liver. It was difficult to ligate the cystic duct and cystic artery in depth, hence the incision was extended and procedure completed. In the other case the incision was slightly more on one side not centring the fundus hence it was extended. Hence the conversion rate to standard open method was 3.33% in present series (Table 3).

The causes of conversion to standard conventional open method were different in different studies. They include acutely inflamed gall bladder, emphysema of gall bladder, common bile duct stones, bile duct injury, primary haemorrhage, intrahepatic gall bladder, difficulty in defining anatomical landmarks and morbid obesity.

Table 3: Table showing conversion rate to open method in different series

The average duration of operation in the standard open method was 131.66 min and in the minilaparotomy group was 64.66 minutes, which is significantly less, a contradictory finding as in most of the studies, the average duration in the two groups was same or slightly less in open than minilaparotomy group. It can be explained on the basis that all the minilaparotomies were performed by senior surgeon who was trained in the skill of minilaparotomy cholecystectomy. Obviously the smaller incision of minilaparotomy will also save some time in opening as well as during closure of the incision.

The analgesic requirement in minilaparotomy group in present study is well comparable with the study of O’Kelly et al.2 The analgesic requirement in the present study with the conventional open method was for 7 days and in the minilaparotomy group it was for 4.33 days. Tramadol was used in both the groups. Hence, it shows that a small incision with less trauma produces less pain with subsequent less analgesic requirement while a bigger incision with more trauma produces more pain and subsequent more analgesic requirement.(Table 4).

Table 4: Table showing comparative parameters of minilaparotomy cholecystectomy in different series.

The major complications in the present study in the standard open method were biliary leak (3.33%) and wound infection (13.33%), well comparable with the study by Raza et al.19 The complications in the minilaparotomy group in this study were biliary leak (3.33%) and wound infection (3.33%), comparable with the study reported by Reddic EJ et al.16 It is obvious that the complications in the minilaparotomy group was less than the open cholecystectomy group. With laparoscopic cholecystectomy major complications are reported in many studies such as bile duct injuries, slipped clip of cystic duct, slipped clip of cystic artery or major viscus perforation intraoperatively. In the present study bile duct injury is not recorded in both the groups. We used simple ligatures to ligate the cystic duct and artery. In laparoscopic cholecystectomy there are definite contraindications like intraabdominal sepsis, massive intestinal dilatation and pregnancy.

Open cholecystectomy is largely free of all these complications. More over laparoscopic cholecystectomy has a definite learning curve irrespective of previous experience of open cholecystectomy. But laparoscopic cholecystectomy has definite advantages like shorter hospital stay; less postoperative dysfunction and quicker return to normal activities; but is more costly.

The antibiotic requirement in minilaparotomy group was less as compared to open cholecystectomy group without increasing the rate of infection. The average postoperative hospital stay of the minilaparotomy group was 6.4 days compared to 10.8 days in the conventional group, which was slightly more than average postoperative hospital stay in different studies. However, in the present series 20 cases of minilaparotomy who were local residents were discharged within 2-4 days. Hence, it could be feasible to discharge the patients of minilaparotomy early if the patient is a local resident. The patients from distant places were not ready to accept the early discharge with the fear that it will be difficult for them to approach the hospital in case of any difficulty after discharge. As oral fluids were tolerated early in patients of minilaparotomy, intravenous fluids were omitted from the first post operative day itself whereas oral fluids were tolerated late in patients of conventional open cholecystectomy. Also, there was feasibility of early ambulation in the minilaparotomy group without any problem. Full recovery was possible in 10-15 days in patients of minilaparotomy cholecystectomy with good satisfaction of a small scar. Direct cost of therapy in minilaparotomy method was less to that of the standard open group. Moreover it does not require any special instruments like a laparoscope. Analgesic and antibiotic requirement, duration of hospitalization, post operative complications were all less as compared to the conventional open group. Return to full activity is early and hence the indirect cost of therapy was also less as compared to open cholecystectomy group. Hence minilapar-otomy is cost effective and a better alternative to conventional open cholecystectomy.

Though minilaparotomy cholecystectomy is not comparable to laparoscopic cholecystectomy because of small cosmetic incisions, reduced postoperative pain, rapid return to full activity and shorter hospital stay; in places where facility for laparoscopy is not available, minilaparotomy cholecystectomy is a good alternative to standard conventional open cholecystectomy. Whenever intraoperative difficulty arises, minilaparotomy can be safely converted to standard conventional open cholecystectomy. The duration of surgery can be significantly reduced in minilaparotomy method with continuous practice or if it is done by the seniors. It is definitely a better procedure for the patients as compared to standard open method, especially where the facilities for laparoscopy are not available. For the accurate placement of the incision in minilaparotomy cholecystectomy, the exact site of gall bladder can be marked preoperatively with the help of ultrasonography.

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*Associate Professor and Unit Head, **Lecturer, ***Senior Resident, Department of Surgery, Govt. Medical College, Nagpur, India.