Mini-cholecystectomy: a personal series in acute and chronic cholecystitis

Abstract

Background

Minimally invasive techniques in the surgical treatment of gallbladder disease include laparoscopic cholecystectomy (LC) and mini-cholecystectomy (MC). Reports of LC in acute or chronic inflammation of the gallbladder are common, but those of MC are much more limited, particularly in complicated cases.

Methods

Thirty-six consecutive patients with gallstone disease who underwent mini-cholecystectomy (MC) were included in this study. Twenty-four were female, median age 62 years (range 23–82) and median body mass index (BMI) was 23.4 (range 17.0–28.4). Seventeen of 36 patients had an acutely inflamed gallbladder, one with septicaemia, and six had gangrenous cholecystitis. Three patients presented with acute pancreatitis. MC was performed by a standardised technique. Operative time, frequency of postoperative analgesic injections, time to start oral diet after operation and length of postoperative hospital stay were compared between patients with chronic and acute cholecystitis.

Results

The median operative time was 92.5 minutes (range 35–130). There was no difference in operative time between patients with chronic and acute cholecystitis: 80 minutes (range 35–120) vs 95 minutes (range 60–130). The frequency of postoperative analgesic injections was also similar in the two groups. Oral diet could be started within 24 h of operation in all except one patient with chronic cholecystitis but in only 8 of 17 with acute cholecystitis. Postoperative hospital stay was shorter in patients with chronic cholecystitis: 2 days (range 2–5) vs 4 days (range 2–14), p =0.0009.

Conclusions

MC is an effective surgical procedure for an inflamed gallbladder regardless of the degree and type of inflammation. Patients with chronic cholecystitis recover more quickly and have a shorter hospital stay.

Introduction

Minimally invasive surgical procedures for gallbladder disease include laparoscopic cholecystectomy (LC) and mini-cholecystectomy or mini-laparotomy cholecystectomy (MC). MC was first described more than two decades ago by Dubois and Berthelot ¹, and the favourable results were reported at the same time as LC was introduced into the UK in 1990 ²,³,⁴. Subsequently, four randomised clinical trials have compared LC and MC in the elective treatment of gallbladder stones ⁵,⁶,⁷,⁸. The results varied between the series, and at present it is sensible to conclude that no concrete advantage has been proved for either procedure in elective cholecystectomy.

The role and results of LC in both chronic and acute cholecystitis and other emergency conditions of the gallbladder and those of MC in chronic cholecystitis have frequently been reported ²,³,⁵,⁶,⁷,⁸,⁹,¹⁰, but the applicability and efficacy of MC in acute cholecystitis have not been properly evaluated. The aim of this study was to assess and compare the results of MC in the treatment of gallbladders with either acute or chronic inflammation related to gallstone disease.

Patients and methods

Patients

Thirty-six consecutive patients with gallstone disease who underwent MC between January 1999 and December 2002 were included in this study. There were 24 women, and the median age was 62 years (range 23–82). Nineteen patients had gallstones without any evidence of acute inflammation of the gallbladder, whereas 17 had acute cholecystitis (6 of these 17 had gangrenous cholecystitis). One diabetic patient with severe acute cholecystitis had sepsis and shock on admission, requiring emergency MC; blood culture was positive for Klebsiella. Three patients who presented with acute biliary pancreatitis had endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy (ERCP + ES) 1–3 days before MC. Twenty-two patients had co-morbid conditions: hypertension (11 patients), diabetes (9), hyperlipidaemia (4), ischaemic heart disease (3), chronic obstructive pulmonary disease (2) and chronic viral B hepatitis (2). Eight patients had more than one associated medical illness.

Operation

A personal standardised technique for MC was established after a 3-year experience of performing the operation in patients with chronic cholecystitis. The incision was started approximately 3 cm to the right of the midline and ran obliquely parallel to and 3 cm below the right costal margin. The initial length of the incision was either 4 or 5 cm, depending on the size of the patient and the degree of gallbladder distension; it was extended if necessary but did not exceed 6 cm. The rectus muscle was cut with diathermy. In a patient with a markedly distended gallbladder (e.g. acute gangrenous cholecystitis), decompression of the gallbladder was the first step after entering the abdominal cavity. All except four patients had retrograde or ‘cystic duct-first’ cholecystectomy. The four patients with antegrade or ‘fundus-first’ cholecystectomy had acute gangrenous cholecystitis. The stumps of the cystic duct and cystic artery were ligated with non-absorbable suture material (instrument-assisted ligation); surgical clips were never used to control these structures. Only the one patient with preoperative sepsis who had an appreciable amount of pericholecystic fluid collection had a Jackson-Pratt drain placed in the right subhepatic space; the others did not require a drain. After closing the surgical wound, field block was routinely performed with 0.25% bupivacaine injection deep into the plane of the intercostal nerve (beneath the anterior rectus sheath). The term ‘operative time’ was defined as the period starting at ‘knife to skin’ and finishing at ‘last stitch’.

Statistical Analyses

Data are presented as median and range. Comparisons of operative time, frequency of postoperative analgesic injections and length of hospital stay were done by means of the Mann–Whiney U test. Differences in time to start oral diet and complication rate were evaluated by the χ² test. Differences were considered to be significant when the probability value was <0.05.

Results

The results of the comparison between patients with chronic and acute cholecystitis are shown in Table 1. There was no difference in age between patients with chronic cholecystitis and those with an acutely inflamed gallbladder: 57 years (range 26–80) vs 67 years (range 23–82), p = 0.26. The median body mass index (BMI) was 23.4 (range 17.0–28.4), with no difference between the two groups (23.3 (range 17.0–28.4) vs 23.5 (range 17.6–28.4)- There was no operative mortality. Two patients with acute cholecystitis developed complications (morbidity rate 5.6%); one had wound infection and the other a retained common bile duct stone that was treated successfully by ERCP + ES 7 days after MC. The median operative time was 92.5 minutes (range 35–130); 80 minutes for patients with chronic cholecystitis (range 35–120) and 95 minutes for those with an acutely inflamed gallbladder (range 60–130), p = 0.16. No patients required conversion to a standard open cholecystectomy. The two groups required similar doses of postoperative parenteral analgesics (1 dose, range 0–4)). Oral diet was started within 24 h of operation in 18 of 19 patients with chronic cholecystitis but in only 8 of 17 patients with acute cholecystitis (p = 0.28). The median hospital stay was 3 days overall (range 2–14); patients with chronic cholecystitis had a shorter hospital stay, i.e. 2 days (range 2–5) vs 4 days (range 2–14), p < 0.001. Two patients in the group with acute inflammation had a prolonged hospital stay. One was the diabetic patient with sepsis on admission (discharged 13 days postoperatively), and the other had acute gangrenous cholecystitis associated with severe hypertension (discharged 14 days postoperatively).

Table 1. Comparison of mini-cholecystectomy in chronic cholecystitis and acute cholecystitis .

	Operative time (min)	Number of analgesic injections	Oral diet within 24 h (%)	Postoperative hospital stay (days)	Complications
Whole series (n=36)	92.5	1 (0–4)	72.2	3 (2–14)	2
Chronic inflammation (n=19)	80 (35–120)	1 (0–4)	94.7	2 (2–5)	–
Acute inflammation (n=17)	95 (60–130)	1 (0–4)	47.1	4 (2–14)	2
p value	0.16	0.75	0.28	<0.001	<0.001

Discussion

More than 2000 cases of MC have been reported worldwide without any deaths or major common bile duct injuries since the first report in 1982 ¹,²,³,⁵,⁷,⁸,¹¹,¹²,¹³,¹⁴,¹⁵. Although three randomised controlled trials showed better results for LC than MC with gallbladders that were not acutely inflamed in terms of shorter hospital stay, reduced postoperative analgesia requirements or earlier return to normal activities ⁵,⁶,⁷, a more recent study from Majeed and colleagues showed that LC took longer to perform than MC and had no significant advantage in terms of hospital stay or postoperative recovery ⁸. The two procedures have been accepted as effective minimally invasive surgical procedures for non-acute gallstone disease.

In the emergency setting of acute cholecystitis, LC is gaining popularity rapidly and good results have been reported ¹⁶,¹⁷. However, the conversion rate to open cholecystectomy is still high, varying between 16% and 35% ¹⁶,¹⁷. By contrast, only a few studies on the applicability and efficacy of MC in acute cholecystitis have been published ¹⁸,¹⁹. Assalia and colleagues compared MC (30 patients) with conventional open cholecystectomy (CC, 30 patients) and showed no differences with regard to operative time, operative difficulty or complication rate. However, significantly lower analgesic requirements as well as shorter hospital stay were found in the MC group. Moreover, 22 patients (73%) in the MC group returned to normal daily activities 2 weeks after the operation as opposed to 12 (40%) in the CC group ¹⁹. The present study shows clearly that MC is effective not only in chronic cholecystitis, but also in an acutely inflamed gallbladder.

Although a transverse incision in the right upper quadrant is the most popular approach for MC ⁵,⁶,⁷,⁸,²⁰,²¹ and is less painful than a vertical incision ²², the author prefers to use a small oblique incision. It should be noted that most previous reports of MC involved patients with a non-inflamed gallbladder. Since the size of the gallbladder was usually normal or even small, a transverse incision could cover its full extent from fundus to cystic duct. By contrast, the gallbladder of a patient with acute cholecystitis is usually distended, and dissection to identify the cystic duct and cystic artery in Calot's triangle is much more difficult than that in chronic cholecystitis. While gaining experience of MC before the start of this study, an oblique incision was found to provide better exposure, particularly in patients with acute inflammation of the gallbladder. The incision can obviously be extended to a standard Kocher's incision if necessary. Moreover, decompression of the gallbladder can be done without difficulty because the fundus can be accessed easily. Special retractors, such as the Harrington-Pemberton or Bookwalter retractor, are recommended by some surgeons ²¹,²³, but the author finds retraction by the simple instruments to be completely satisfactory.

The median operative time for MC in the present study was 92.5 minutes (80 minutes in chronic cholecystitis and 95 minutes in acute cholecystitis), and was slightly longer than that of previous reports of 40–74 minutes ⁵,⁶,⁷,⁸,¹⁴,¹⁹,²⁰. In the present study operative time was measured between ‘knife to skin’ and ‘last stitch’, whereas it is usually not defined in other studies. Moreover, most previous reports involved elective operations for which the operative time should be shorter than that in an emergency situation. Postoperative hospital stay in the present series was in agreement with other reports ⁵,⁶,⁷,⁸,¹⁴,¹⁹,²⁰, although in some centres, MC is now performed as day-case or ambulatory surgery ²¹. The results of MC in acute cholecystitis in this study compare favourably with those reported for LC ⁹,¹⁶,¹⁷, but the costs are lower ⁶,²¹. Avoiding the need for special instruments improves the cost-effectiveness of MC.

The following conclusions can be drawn from the data from this study. 1) MC is an effective minimally invasive surgical procedure for both acute and chronic cholecystitis, with a low morbidity rate (5.6%), an early return to oral diet, few doses of postoperative analgesic and a short postoperative hospital stay. 2) A small right subcostal incision is the appropriate choice for MC in either a normal-sized or distended gallbladder. 3) MC can be performed without the use of special instruments, thus reducing the expense. 4) Since not every case is suitable for LC and MC is cheaper, MC should be considered in every case of gallstone disease, particularly in a developing country in which the health-care budget is limited. However, special training is essential to become familiar with the technique.