Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Laparoscopic cholecystectomy was more effective than minilaparotomy

ACP J Club. 1994 July-Aug;121:16. doi:10.7326/ACPJC-1994-121-1-016


Source Citation

McMahon AJ, Russell IT, Baxter JN, et al. Laparoscopic versus minilaparotomy cholecystectomy: a randomised trial. Lancet. 1994 Jan 15;343:135-8.


Abstract

Objective

To evaluate morbidity and hospital costs for laparoscopic compared with minilaparotomy cholecystectomy.

Design

Randomized control trial with 12-week follow-up.

Setting

5 hospitals (1 university and 4 general hospitals) in Scotland.

Patients

299 patients with symptomatic cholelithiasis as an indication for elective cholecystectomy. Exclusion criteria were common bile duct stones; extensive previous upper abdominal surgery; or abnormal liver function tests or dilated common bile duct with an abnormal preoperative cholangiogram.

Intervention

Laparoscopic cholecystectomy (n = 151), done by a 4-trocar technique with electrocautery dissection, or minilaparotomy (n = 148) done through a 5- to 10-cm transverse subcostal incision. Both groups received antibiotic prophylaxis, subcutaneous heparin, and local anesthetic wound infiltration at the end of the procedure.

Main outcome measures

Median duration of postoperative hospitalization, costs, and patient satisfaction 1, 4, and 12 weeks after surgery.

Main results

15 patients (10%) assigned to laparoscopic cholecystectomy required open cholecystecomy, and 14 patients (10%) assigned to minilaparotomy required an incision of > 10 cm. Patients who received laparoscopic cholecystectomy, compared with patients who received minilaparotomy, had a longer mean operation time from skin incision to closure (71 vs 57 min, P < 0.001) and a shorter median hospital stay (2 vs 4 d, P < 0.001). After 1 week, patients receiving laparoscopic cholecystectomy had better physical and social function, less pain, and less depression compared with those receiving minilaparotomy (P for linear trends < 0.05). No difference existed at 12 weeks. Patients with laparoscopic cholecystectomy also returned earlier to leisure and social activities (median 7 vs 12 d, P < 0.01). The groups did not differ for time to return to work. Hospital costs were higher for the laparoscopic procedure (£1486 {U.S. $2170}* vs £1090 {U.S. $1591}*, P < 0.001). The rate of complications was similar in the groups (laparoscopic cholecystectomy 17%; minilaparotomy 20%).

Conclusions

Compared with minilaparotomy, laparoscopic cholecystectomy led to reduced postoperative pain and pulmonary dysfunction; shorter but costlier hospitalization; an earlier return to normal activities but not to paid employment; and somewhat greater short-term satisfaction.

Source of funding: Chief Scientist Office of the Home and Health Department of the Scottish Office.

For article reprint: Mr. P.J. O'Dwyer, University Department of Surgery, Western Infirmary, Glasgow G11 6NT, Scotland, United Kingdom. Fax 44-141-211-1972.

*Conversion rate used was for March 1993, the end of recruitment for the study [U.S. $1 = £0.685].


Commentary

The study by McMahon and colleagues is one of the few that compares minilaparotomy with laparoscopic cholecystectomy. Even without rigorous evaluation, laparoscopic cholecystectomy has taken the surgical field by storm since its introduction late in 1989. By 1990, 25% of cholecystectomies were done by laparoscope, and 80% were done in this way in 1992.

This study compared laparoscopic cholecystectomy with minilaparotomy using a randomized controlled design and addressed not only complications but also direct hospital costs, patient satisfaction, and at least 1 indicator of indirect cost—return to work. Direct hospital costs were higher for laparoscopic cholecystectomy, even with the decrease in hospital stay. The higher cost per procedure is especially important because of the substantial increase in the overall rate of cholecystectomies done because of the increased use of laparoscopic cholecystectomy (1-3). Although patients were more satisfied and able to return to leisure activities sooner after a laparoscopic cholecystectomy, these differences were not statistically significant at 3 months and patients did not return to work faster.

This and other studies indicate that laparoscopic cholecystectomy has a similar complication rate (1) and decreased mortality (3) when compared with open cholecystectomy. For the individual patient, the shorter recovery, increased short-term satisfaction, and decreased mortality warrant the increased costs. From a societal perspective, however, these considerations need to be balanced against a probable change in threshold for doing a cholecystectomy, higher direct costs of laparoscopic cholecystectomy, and a suggestion of comparable indirect cost for laparoscopic cholecystectomy and minilaparotomy in terms of time lost from work.

Claudia A. Steiner, MD, MPH
Johns Hopkins UniversityBaltimore, Maryland, USA


References

1. Legoretta AP, Silber JH, Constantino GN, Kobylinski RW, Zatz SL. Increased cholecystectomy rate after the introduction of laparoscopic cholecystectomy. JAMA. 1993;270:1429-32.

2. Orlando R 3d, Russell JC, Lynch J, Mattie A. Laparoscopic cholecystectomy. A statewide experience. The Connecticut Laparoscopic Cholecystectomy Registry. Arch Surg. 1993;128:494-9.

3. Steiner CA, Bass EB, Talamini MA, Pitt HA, Steinberg EP. Surgical rates and operative mortality for open and laparoscopic cholecystectomy in Maryland. N Engl J Med. 1994;330:403-8.