by Vafa Shayani, MD, Lisa Jacobs, MD, Jonathan M. Sackier, MD, FRCS, FACS
Despite its widespread practice in the 1990’s, some still question the role of laparoscopic cholecystectomy (LC) as the primary operative treatment for gallbladder disease.1 Most arguments revolve around the incidence of complications following LC in comparison to that for its open counterpart. Published series, however, demonstrate very low complication rates, comparable or even superior to that reported for open cholecystectomy.2,3 With adequate training and the exercise of good surgical judgment, LC may prove to be the least morbid and the most appropriate surgical management for gallbladder disease.
Although the aphorism - “see one, do one, teach one” - is heard throughout general surgical education, never before has it been taken so literally. In the early 1990’s, general surgeons worldwide signed up for one or two day courses to learn how to perform LC. In many instances, the closest a surgeon ever came to “see” an LC was in the porcine laboratory model, before he or she walked into the operating room to “do one” on a living human being (albeit while proctored by another surgeon who was trying to “teach one” to a colleague).
If the routine practice of LC is to be justified, complication rates need to be minimized, and minimizing complications requires strict training standards. Meeting such standards by the new generation of surgical trainees is a reasonable expectation. Like many other challenging tasks, common laparoscopic procedures such as cholecystectomy may be practiced and mastered during the five years of formal clinical training in general surgery. The proof of improvement in training will become evident as laparoscopic surgery comes of age, and complication rates are compared from one generation of surgeons to another.
Complications of LC can be classified in several fashions. One such classification distinguishes between the complications inherent to abdominal surgery under general anesthesia, the complications of laparoscopic surgery, and those unique to LC. Hereafter, we report the commonly recognized complications of LC using the above classification.
Popularized in the late 1980’s, LC revolutionized hepatobiliary and gastrointestinal surgery. The first LC in man was performed by Muhe in Germany in 1985.4 Reddick and Olsen reported the first series of laparoscopic cholecystectomies in the United States in 1989.5 The initial list of relative and absolute contraindications for LC included such conditions as ascites, coagulopathy, prior abdominal surgery, and acute cholecystitis. However, as general surgeons have gained experience and facility with this operation, almost all benign gallbladder pathology may be considered for an initial laparoscopic approach. An estimated 2% to 5% of laparoscopic cholecystectomies are converted to an open technique.2,6 Indications for conversion include unidentifiable anatomic landmarks, management of common bile duct stones, and management of recognized operative complications. The reported incidence of major morbidity following LC is 2% to 11%, with a mortality rate of 0.1% or less.2,3,7-9 The comparative morbidity and mortality rates for elective open cholecystectomy are 4% to 6% and up to 0.4%, respectively.10-14 It is worth noting that unlike open cholecystectomy, more than half of the fatalities following LC may be attributed to technical complications.2
The gallbladder is a diverticulum of the common bile duct, a midline structure arising from the union of the right and left hepatic ducts, and acts as a reservoir for bile secreted by the liver. The fundulus and the body of the gallbladder lie in the gallbladder fossa in the anteroinferior aspect of the liver, creating an anatomic line of division between the two lobes of the liver. The gallbladder drains via the infundibulum or Hartmann’s pouch into the cystic duct and eventually into the common bile duct. Several mucosal folds are identified within the cystic duct. Though referred to as the valves of Heister, the sphinteric function of these mucosal folds is doubtful. A muscular sac with contractible ability, the gallbladder responds to hormonal stimulation by cholecystokinin and actively releases bile into the common bile duct. Contraction of the gallbladder, coupled with relaxation of the sphincter of Oddi, allows drainage of bile into the duodenum.
Arterial blood is generally supplied to the gallbladder via a single cystic artery arising from the right hepatic artery. Several anatomic variations, however, have been identified (Figure 1). Together with the many aberrant and anomalous variations in the biliary ductal anatomy (Figure 2), the safe identification and division of the cystic duct and artery may pose a technical challenge during LC.
Laparoscopic cholecystectomy may be performed in several ways. The patient may be placed either in the supine or synchronous position. With the patient in the supine position, the operating surgeon stands to the left of the patient. Using the synchronous position, the surgeon is positioned between the patient’s lower extremities. The peritoneal cavity is entered either using a Veress needle or Hasson cannula (open technique). The open technique is recommended for patients with prior abdominal surgery and potential adhesion formation near the umbilicus. For similar reasons, the open technique should be considered in the presence of an umbilical hernia. With pneumoperitoneum pressure at or near 1.5 mm of mercury, other trocars are inserted under direct laparoscopic visualization. Laparoscopic cholecystectomy is generally performed using four laparoscopic cannulae, although, for complicated cases, additional cannulae may facilitate the procedure. The camera is inserted through the umbilical cannula, and the fundus of the gallbladder is grasped and retracted cephalad through a cannula inserted subcostally along the right anterior axillary line. A different technique of retracting the fundus may be employed through a cannula in the left upper quadrant. Hartmann’s pouch is maneuvered through a second subcostal cannula inserted along the right midclavicular line. The maneuvering of Hartmann’s pouch can be done by the primary surgeon or an assistant. The dissection of cystic duct, cystic artery, and gallbladder are performed through a cannula in the epigastrum, positioned between the xiphoid process and umbilicus.
Just as in open cholecystectomy, the cystic duct is a guide to the common bile duct. It is worth noting that the purpose of identifying the cystic duct is not to visually identify the common bile duct; rather, this identification is intended to help avoid the common bile duct (as well as to ultimately ligate and divide the cystic duct). In addition, an intraoperative cholangiogram obtained through the cystic duct will provide the surgeon with an indirect view of the common bile duct, which will further make it possible to avoid this structure. Therefore, an early task during LC is identification of the cystic duct. A safe method of identifying the cystic duct is to incise the peritoneal reflection along the medial and the lateral aspects of Hartmann’s pouch (Figure 3). By lifting Hartmann’s pouch off the liver bed, the cystic duct can be retracted superiorly and anteriorly, allowing safe identification of the junction of cystic duct with Hartmann’s pouch. At this time, an intraoperative cholangiogram, through a cystic duct incision, will confirm ductal anatomy as well as the presence or absence of common bile duct stones. In addition, identification and ligation of an accessory duct (duct of Luschka) at the time of cholangiography may prevent postoperative bile leak from an unrecognized and severed duct. In the absence of common bile duct stones, the cystic duct is ligated proximally and distally and divided. The cystic artery is similarly ligated and divided. Identifying anomalous ductal anatomy (Figure 2) should alert the surgeon of a possible anomalous arterial system as well (Figure 1). Following division of the cystic duct and cystic artery, the gallbladder is dissected from the gallbladder fossa and delivered through one of the laparoscopic cannulae. The removal of all cannulae should be visualized laparoscopically to check for abdominal wall bleeding. The fascia of all 10 mm or larger cannulae should be closed to avoid postoperative incisional hernia.
Perhaps the single most important measure for preventing complications during LC is recognition of the limitations of laparoscopy. Although many surgeons find laparoscopic visualization superior to laparotomy, lack of a three dimensional view impairs recognition of anatomic relations. In addition, inability to palpate structures may further limit structural identification during laparoscopy. It is important for the surgeon to recognize these facts and convert to a laparotomy if he or she cannot safely complete the operation laparoscopically.
During LC, it is prudent to utilize intraoperative cholangiography to compensate for the limitations of laparoscopy (Figure 4). Cholangiography not only allows for the diagnosis and management of common bile duct stones, it also provides a road map of ductal anatomy. In the majority of cases, cholangiography will provide enough information to safely ligate and divide the cystic duct and avoid injuring the common bile duct. In a small percentage of cases, cholangiography will identify injury to the common bile duct (Figure 5) and make it possible for the surgeon to manage the injury at time of the original operation, minimizing morbidity. It is our opinion that all patients undergoing LC will benefit from intraoperative cholangiography.15
COMPLICATIONS INHERENT TO ALL MAJOR OPERATIONS
Laparoscopic cholecystectomy harbors similar physiological risks as does major open abdominal operations. “Minimally invasive surgery” is a phrase applied to laparoscopic procedures including LC. However, considering the intraoperative cardiovascular and hemodynamic effects of carbon dioxide insufflation,16-19 one can conclude that there is nothing minimal about the invasive nature of LC.
The potential complications involving general anesthesia with endotracheal intubation are many. Adverse effects of anesthetic agents include allergic reactions, malignant hyperthermia, and significant cardiopulmonary depression. A thorough preoperative history and physical examination should provide the surgeon and anesthetist with adequate information to identify those patients at risk for general anesthesia.
Some authors have suggested performing a variety of laparoscopic operations under regional block;20-23 however, elimination of general anesthesia may actually increase the risks of LC. Adequate exposure during laparoscopy with pneumoperitoneum requires complete relaxation of the abdominal muscles, a feat that usually mandates general anesthesia. Prolonged carbon dioxide pneumoperitoneum may result in transient hypercarbia, a condition that is easily managed with patients under general endotracheal anesthesia. Abrupt shifts in cardiopulmonary parameters are better controlled with patients under general endotracheal anesthesia. Finally, patient positioning in steep reverse Trendelenburg, gastric decompression with a nasogastric tube, and anxiety provoking communications between surgeon, anesthesiologist and operating room staff are much better tolerated by patients under general anesthesia. Therefore, elimination of general endotracheal anesthesia is unlikely to reduce the incidence of complications.
Like open cholecystectomy, LC may result in operative blood loss requiring transfusions, postoperative wound infection and dehiscence, and incisional hernia formation. Postoperative pulmonary complications such as atelectasis, pneumonia and pulmonary emboli may result in significant morbidity and mortality. Cardiovascular complications including cardiac dysrhythmias, myocardial ischemia, and myocardial infarction are potential complications. Other complications not specific to LC include fever, nausea, vomiting, urinary retention, urinary tract infection, thrombophlebitis, and postoperative pancreatitis. The prevention and management of many of these complications are discussed in the next two sections.
COMPLICATIONS INHERENT TO ALL LAPAROSCOPIC PROCEDURES
George Kelling reported the first laparoscopic examination of the abdominal cavity using a Nitze cystoscope in 1901.24 Modern laparoscopy using automatic insufflation devices for monitoring gas flow and intra-abdominal pressures was introduced by Semm in the 1960’s.24 Considering the vast experience of gynecologists with laparoscopy, the gynecologic literature is perhaps the best source for common complications of laparoscopy. Despite the astronomic growth of technology and introduction of safer laparoscopic devices, complications related to laparoscopic instrumentation have not been eliminated.
Complications attributed to the use of laparoscopic equipment include the risk of inadvertent perforation of small or large bowel upon introduction of the Veress needle. Other potential targets for the Veress needle include distended stomach or urinary bladder. Therefore, decompression of the stomach and the urinary bladder, with endogastric tube and urinary catheter, respectively, is advisable. In addition, careful and controlled insertion of the Veress needle while retracting the abdominal wall anteriorly may reduce the incidence of such visceral injuries. Finally, the use of Hasson cannula for entry into the peritoneal cavity has the potential to reduce the risk of injury from the Veress needle and should be considered for patients with prior abdominal surgery and increased risk of intra-abdominal adhesions.
Other mechanisms of injury to the hollow organs include damage from electrosurgery. Although the principles of electrosurgery are the same for open and laparoscopic procedures, the prevention of complications resulting from electrosurgery during laparoscopy demands in-depth knowledge of the science of electrosurgery. To avoid inadvertent grounding to other structures, it is vitally important to fully visualize the laparoscopic instrument used for electrosurgery prior to start of electroconduction. One also needs to recognize the inverse relationship between the surface area of electrosurgical instrument and electrical current generated, explaining greater heat intensity generation by instruments with small surface area. Therefore, using an electrosurgical instrument with a broader surface will minimize the risk of inadvertent damage of structures, including the gallbladder and the common bile duct. Finally, to avoid inadvertent puncture of abdominal viscera, like all other laparoscopic instruments, each and every insertion and removal of the electrosurgical instrument should be directly visualized using the laparoscope.
The overall incidence of bowel injury during LC is estimated as 0.14%.2 These injuries are often unrecognized at the time of surgery. Typically, the patient presents at a later time with sepsis, peritonitis, abdominal abscess, and enterocutaneous or colocutaneous fistulae. Less common visceral injuries include punctures of the uterus, kidney, ovarian cysts and diaphragm by the Veress needle.
The retroperitoneum and major blood vessels are other potential targets for the Veress needle or trocars (Figure 6). Injuries to the mesenteric vessels, aorta, vena cava, iliac vessels, and portal vessels have all been reported with an overall incidence of 0.25%.1 Early recognition of vascular injury and conversion to a laparotomy will allow timely repair of the vessel and prevention of long-term morbidity. However, when undetected, serious complications, including death from exsanguination, may ensue.2 Even injuries to smaller vessels such as the inferior epigastrics, when undetected, may result in fatalities.25
Insufflation of the abdominal wall by inserting the Veress needle into the preperitoneal space may result in subcutaneous emphysema. This emphysema may extend distally to the fascia lata and scrotum, and proximally to the soft tissues of the neck with potential for airway compromise. Careful monitoring of pressures recorded by the insufflator may allow recognition of the erroneous positioning of the Veress needle. Once recognized, the needle should be removed and repositioning attempted. In the event of multiple failed attempts, the open technique (using the Hasson cannula) should be considered.
Leakage of carbon dioxide around poorly secured laparoscopic cannulae may also result in development of subcutaneous emphysema. Although the use of threaded guides may reduce the risk of insufflation of subcutaneous tissue, careful attention during insertion and removal of instruments will reduce the inadvertent movement of laparoscopic cannulae, reducing the risk of subcutaneous emphysema. In most cases, subcutaneous emphysema resolves spontaneously and is associated with minimal morbidity.
Pneumoperitoneum may result in pneumothorax or pneumomediastinum.26 These complications are attributed to passage of insufflating gas through weak points or defects in the diaphragm. Careful monitoring of the patient’s physiologic parameters while under general anesthesia, including changes in transcutaneous oxygen saturation and mean airway pressure, may alert the surgeon and anesthetist to the development of pneumothorax. Safe treatment of a large pneumothorax often requires placement of a thoracostomy tube. Pneumomediastinum often resolves spontaneously.
Air embolism may result from direct insufflation of carbon dioxide into a vein or absorption of intraperitoneal carbon dioxide.27 Outcomes range from self-limiting slight increases in arterial and alveolar CO2 and in central venous pressure, to fatal respiratory and hemodynamic compromise. To minimize the risk of infusing CO2 directly into a vein and causing a massive air embolism, the initial abdominal insufflation should be minimized to 1.5 l/min, while closely monitoring the patient’s vital signs.
Perhaps the most common adverse effects associated with laparoscopy are the intraoperative hemodynamic and respiratory changes associated with pneumoperitoneum. Pneumoperitoneum results in an increase of intra-abdominal pressure. Abdominal hypertension will result in elevation of the diaphragm and consequent changes in pulmonary parameters, including an increase in mean airway pressure and a decrease in residual volume and vital capacity. Changes in pulmonary function, in conjunction with the absorption of carbon dioxide, may result in elevation of end tidal CO2, hypercarbia and respiratory acidosis. In addition, abdominal hypertension may reduce venous return to the heart, decrease the cardiac preload, and lower cardiac output, resulting in metabolic acidosis. Most of the cardiovascular and respiratory complications of pneumoperitoneum are preventable and easily manageable in a mechanically ventilated and paralyzed patient. However, occasionally, the pneumoperitoneum has to be released to allow normalization of these parameters during laparoscopic cases.
Long-term complications of laparoscopy include those related to the abdominal incisions made by laparoscopic trocars. Rectus sheath hematoma is a potentially morbid complication of laparoscopy. This complication, which is more likely in the face of coagulopathy, may be avoided by using abdominal wall transillumination technique to identify and avoid grossly visible vessels in the abdominal wall. In addition, all trocar sites should be laparoscopically inspected at the end of the operation. Even the smallest site of active bleeding should be identified and arrested if a return to the operating room is to be avoided. Bleeding from abdominal wall vessels into the abdominal cavity may not spontaneously tamponade and may result in hemodynamically significant blood loss. Occasionally, especially with injury to the epigastric vessels, full thickness abdominal wall suture ligatures may be used to control the bleeding.
Few incidents of trocar site dehiscence and resulting evisceration of omentum and small bowel in the immediate postoperative period have been reported28 (as well as Jacobs, et al., personal communication). Most of these incidents involve 10 mm or larger trocar sites that were not closed at the level of the fascia at the end of the operation. Therefore, as a general practice, an attempt should be made to approximate the fascia for all 10 mm or larger trocar sites. Several laparoscopic instruments have been designed for this purpose, but none have gained universal acceptance.
Late breakdown of the fascial layer may result in development of a trocar site hernia. The incidence of trocar site hernia after LC has not been accurately established. This is in part due to an unknown population of patients with asymptomatic trocar site hernias. Bowel incarceration with resulting obstruction,29 as well as, strangulation requiring resection have been reported.30 In otherwise asymptomatic patients, trocar site hernias may be electively repaired under general or local anesthesia.
Wound infection can present as wound abscesses or soft tissue inflammation (cellulitis) without purulent collection. The umbilical trocar site frequently used for gallbladder retrieval is the most commonly infected site. The estimated incidence of wound infections range from 0% to 3.2% and compares favorably to that reported for open cholecystectomy.31 Since spillage of bile from the gallbladder may increase the risk of colonization of the laparoscopic incisions, in select cases, use of a retrieval bag may minimize the risk of wound infections.
All patients undergoing major abdominal surgery under general anesthesia are at increased risk for development of deep venous thrombosis (DVT).32 In addition, pneumoperitoneum and the reverse Trendelenburg position may contribute to venous stasis in the lower extremities.33,34 The incidence of deep venous thrombosis and pulmonary embolus formation in LC are not well established; however, significant morbidity and mortality associated with these complications have been reported.2,35 Therefore, patients undergoing LC should be considered for DVT prophylaxis.
COMPLICATIONS SPECIFIC TO LAPAROSCOPIC CHOLECYSTECTOMY
Like any new technique, there is a learning curve for LC, during which the risk of technical complications is higher.36 Improvements in the complication rate is in part attributable to the evolution of the technique of LC. For instance, an early practice during LC involved visualization of the junction of the cystic duct and common bile duct. This could result in unnecessary dissection in the area of the common bile duct, with potential ischemic injury to the common bile duct and the late development of common bile duct stricture. In addition, the use of electrosurgery near the common bile duct has been implicated as a potential source for injury to this structure. Therefore, the practice of dissecting and visualizing the common bile duct has since been abandoned. Instead, the junction of Hartmann’s pouch and cystic duct should be identified, allowing safe performance of cholangiography and radiographic identification of the common bile duct.
The most devastating complications of LC are bile duct injuries. The incidence of bile duct injury for open cholecystectomy is estimated as 0% to 0.4%, and for LC as 0% to 2%.2,37 Less than 50% of bile duct injuries are detected intraoperatively.2 A delay in diagnosis of bile duct injury may result in significant morbidity including bile duct stricture, bile leak resulting in biloma formation, and peritonitis with potential mortality. Injury to the common bile duct is usually a result of misidentification of ductal structures. Inadvertent transection of the common bile duct, mistaken for cystic duct, is often encountered in cases of acute cholecystitis with significant inflammatory tissue near the ductal structures. This potentially avoidable injury may also occur when the cystic duct is short or has a posterior entry into the common bile duct (Figure 2). The most effective maneuver for avoiding this injury is to begin the dissection of the cystic duct by incising the peritoneal reflection along the medial and lateral aspects of Hartmann’s pouch. This technique allows safe identification of Hartmann’s pouch and cystic duct junction. In addition, obtaining an intraoperative cholangiogram by placing the cholangiogram catheter high in the cystic duct, near its junction with Hartmann’s pouch, will allow the identification of all ductal structures before complete transection of any duct.
Other possible causes for bile duct injury include the use of electrosurgery near ductal structures, as well as, iatrogenic injuries caused by cannulation of the cystic duct and the common bile duct with a cholangiogram catheter. Once injury to the common bile duct is recognized intraoperatively, options for management depend on the severity of the injury. Complete transection of the common bile duct requires re-establishment of biliary-enteric communication. This is most commonly achieved using roux-en-Y choledochojejunostomy or hepaticojejunostomy, although primary anastomosis and T-tube drainage may be considered. Minor injuries to the common bile duct may be managed by direct repair of the duct, closure over a T-tube, or creation of a choledochoduodenostomy.
Cystic duct avulsion is another potential complication related to the ductal structures. Management options are similar to those for injuries to the common bile duct, ranging from simple repair of the duct to conversion to laparotomy and creation of a roux-en-Y choledochojejunostomy.
Undetected ductal injury may lead to postoperative bile leak. Among the 77,604 cases reported by Deziel et al., delayed bile leak was recognized in 0.29% of patients.2 A number of perioperative events may lead to bile leaks. The cystic duct is the most frequent source for postoperative bile leaks. Cystic duct stump blowout may be caused by ischemic necrosis of the cystic duct stump, or by the buildup of pressure in the common bile duct as a result of retained common bile duct stones. Following manipulation of the common bile duct and ampulla of Vater (such as during laparoscopic common bile duct exploration), periampullary edema may result in transient common bile duct obstruction with resulting increase in the common bile duct pressure and blowout of the cystic duct. External drainage of Morrison’s pouch following common bile duct exploration may eliminate postoperative biloma formation.
Other sources of postoperative bile leak and biloma formation include undetected injuries to the common bile duct or the cystic duct proximal to its transection. In addition, a transected accessory duct of Lushka can result in bile leak and biloma formation. Most of these injuries are avoidable if an adequate intraoperative cholangiogram is obtained prior to dividing any ductal structures. Postoperative biliary leaks and collections are often drained using the percutaneous technique with or without a sphincterotomy and stenting of the outflow tract. Many such patients require eventual laparotomy for definitive management of their ductal injuries.
Spillage of bile and gallstones from the gallbladder are common during LC. In most instances, these are inconsequential events. However, unlike open cholecystectomy, laparoscopic retrieval of spilled stones may be challenging and, unlike spilled bile, irrigation alone will have no effect on spilled stones. There have been reports of morbid complications including generalized peritonitis, peritoneal and retroperitoneal abscess formation, draining umbilical sinuses, and penetration of internal organs by spilled gallstones.2,38-40 In an unusual case, Thompson et al. reported a case of cholelithoptysis (expectoration of gallstones) following erosion of spilled gallstones through the diaphragm and into the thoracic cavity.39 Therefore, at the conclusion of the LC, it is reasonable to remove as many of the spilled stones as possible and thoroughly irrigate the peritoneal cavity. However, one must avoid excessive perseverance and not jeopardize patient safety by unreasonably prolonging the operation. In addition, one may obtain a specimen of bile with a suction trap for identification of organisms and directed antimicrobial therapy. Drain placement and detailed documentation of the operative events are equally important.
Migration of cystic duct clips resulting in a nidus for subsequent development of common bile duct stones is a rare, but reported, complication of LC.41 Although not unique to LC, the incidence of clip migration is believed to be higher for laparoscopic than for open cholecystectomy.41 The use of absorbable ligatures instead of metal clips is the only technique that will eliminate the risk of clip migration. This complication may be diagnosed by plain abdominal roentgenograms or computed axial tomography scans and is confirmed by endoscopic retrograde cholangio pancreatography (ERCP). Sphincterotomy with extraction of the clip and stones is the management of choice, and surgical procedures are rarely necessary.
Hemodynamically significant blood loss is very rare during LC. However, anomalous arterial anatomy can result in cystic artery transection prior to its ligation (Figure 1). Similarly, anomalous anatomy of the right and left hepatic arteries may result in inadvertent ligation or division of these vessels which may result in significant hepatocellular injury or blood loss. In general, identification of the cystic duct, in conjunction with an adequate intraoperative cholangiogram, may help with the correct identification of the vasculature and reduce the incidence of vascular injuries.
Trauma to the hepatic vessels can result in pseudoaneurysm formation with subsequent rupture and hemobilia.42 Cystic artery pseudoaneurysm formation following LC has been reported.43,44 Other bleeding complications associated with LC include bleeding from the liver and gallbladder fossa, resulting in intraoperative blood loss or postoperative hematoma formation.
Another rare but reported complication of LC is traction injury to the liver as a result of cephalad retraction of the fundus of the gallbladder. Fusco and colleagues attributed laceration of the quadrate lobe of the liver to placement of the epigastric trocar through the falciform ligament.45 If the falciform ligament cannot be avoided and the liver edge is found under tension, division of the falciform ligament may help avoid liver injury.
Finally, the early reports on LC included conversions to laparotomy in their complications. We now know that regardless of the learning curve, a minority of cholecystectomies are best and most safely managed using the open technique. Persistence in laparoscopic completion of an operation may result in major operative complications with associated morbidity and mortality. Therefore, a surgeon who recognizes the limitations of the equipment and the art and science of laparoscopy is to be commended, rather than being penalized for converting a difficult and unsafe laparoscopy to a necessary laparotomy.
In 1997, LC is considered by many to be the primary treatment for symptomatic cholelithiasis and cholecystitis. Like many other laparoscopic procedures, LC requires a great degree of technical finesse and refinement as well as good surgical judgment. Perhaps the most important decision to be made by the surgeon during LC is when to consider the laparoscopic access unsafe and convert to an open approach for gallbladder removal. Although LC has been attributed a greater complication rate than open cholecystectomy, adequate training in laparoscopic surgery and the exercise of good judgment should lower the incidence of complications comparable to, or lower than, open cholecystectomy.
1. Majeed AW, Troy G, Nicholl JP, Smythe A, Reed MWR, Stoddard CJ, et al. Randomized, prospective, single-blind comparison of laparoscopic versus small-incision cholecystectomy. Lancet. 1996;347:989-994.
2. Deziel DJ, Millikan KW, Economou SG, Doolas A, Ko ST, Airan MC. Complications of LC: a national survey of 4292 hospitals and an analysis of 77604 cases. Am J Surg. 1993;165:9-14.
3. Jatzko GR, Lisborg PH, Pertl AM, Stettner HM. Multivariate comparison of complications after laparoscopic cholecystectomy and open cholecystectomy. Ann Surg. 1995;2