Conventional laparoscopic cholecystectomy (CLC) is currently the standard of surgical procedure for gallstone disease. Robotic cholecystectomy (RC) has revolutionized the field of minimally invasive surgery; it is safe and ergonomic, but expensive. The aim of this study is to compare the medical resource utilization and clinical outcomes between the two procedures. This study was conducted retrospectively by assessing data of the clinical outcomes and medical resource of 78 patients receiving RC and 367 patients receiving CLC. We reviewed the data of operation times, length of hospital stay, hospital charges, outpatient department visits, outpatient department service charges, and postoperative complications, which were retrieved from the health information system (HIS) database in this hospital. Patients in both groups had similar demographic and clinical features. The RC group had longer length of hospital stay (p=0.056), significantly longer operation time (p=0.035), and much more hospital charges (p=0.001). The RC group, however, experienced less postoperative complication rates (average 3.8% vs. 20.4%, p=0.001). Conversion rate was 1.9% in the CLC group versus 0% in the RC group (p=0.611). Most complications were mild, and following the Clavien-Dindo classification, there were two cases (2.5%) Grade I for the RC group; 50 cases (13.6%) Grade I and 14 cases (3.81%) Grade II for the CLC group (p<0.001 and 0.001, respectively). Procedure-related complications of Grade IIIa status were encountered in nine patients (2.45%) in the CLC group and none in the RC group (p=0.002).The RC group consumed more medical resources in the index hospitalization; however, they experienced significantly less postoperative complications.

To review and evaluate our experience in laparoscopic cholecystectomy.

A retrospective analysis was performed on data collected during a 13-year period (1992-2005) from 1220 patients who underwent laparoscopic cholecystectomy.

Mortality rate was 0%. The overall morbidity rate was 5.08% (n = 62), with the most serious complications arising from injuries to the biliary tree and the cystic artery. In 23 (1.88%) cases, cholecystectomy could not be completed laparoscopically and the operation was converted to an open procedure. Though the patients were scheduled as day-surgery cases, the average duration of hospital stay was 2.29 d, as the complicated cases with prolonged hospital stay were included in the calculation.

Laparoscopic cholecystectomy is a safe, minimally invasive technique with favorable results for the patient.

Indications for cholecystectomy are limited to clearly symptomatic gallstones. Relatively high failure rates of pain relief are probably caused by incorrect selection of patients for the operation. Contraindications for (laparoscopic) cholecystectomy are related to anaesthesiological considerations. Laparoscopic cholecystectomy was accepted by consensus as the gold standard within 5 years of its introduction. Nevertheless, both the classical open and small-incision cholecystectomies are safe alternatives, and superiority of any one of the three techniques over the others has not been proven. Primary outcome measures (mortality, complications, and symptom relief) seem to be equal for the three techniques. Acute cholecystitis is a complication of gallstones. Generally it is recommended that early cholecystectomy be performed, as delayed cholecystectomy is associated with longer total hospital stay and convalescence due to recurrent cholecystitis episodes. Cholecystostomy is an alternative technique for patients unfit for general anaesthesia. Reported complication and conversion rates in cholecystectomy for acute cholecystitis vary, but are higher than for symptomatic cholecystolithiasis. New developments--such as robot-assisted surgery--are expected to have a significant impact in the near future.

This study is to evaluate the need for preoperative cholangiography during laparoscopic cholecystectomy when endoscopic retrograde cholangiopancreatography (ERCP) is available. Over a period of four years, 1105 consecutive patients had laparoscopic cholecystectomy. All patients, in addition to their clinical assessment, had routine liver function tests (LFTs) and ultrasound (US) examination of the biliary tract. Preoperative ERCP was performed (diagnostic and/or therapeutic) in 107 (9.6%) of the patients. The indications for ERCP were one or more of the following: 1) abnormal liver function test, 74 patients; 2) jaundice, 37 patients; 3) common bile duct (CBD) stone seen in US, 36 patients, and/or CBD dilatation, 46 patients; and 4) pancreatitis, 20 patients. In 41 out of 107 (38%) patients, CBD stones were present and cleared endoscopically. Postoperative ERCP was necessary in eight patients: to remove retained stones in the CBD (two patients), to stop bile leak (two patients), and to investigate the persistent abnormal LFTs in the remaining patients. The number of patients who had evidence of retained CBD stone following laparoscopic cholecystectomy was only two. In both patients, endoscopic removal was successful. Therefore, it is clear that operative cholangiography in laparoscopic cholecystectomy is not essential if there is a reasonable facility for ERCP.

Operative procedures on the gallbladder and biliary ducts have undergone a profound transformation since the introduction of laparoscopic techniques in general surgery. As the benefits of minimally invasive procedures become universally known, patients are seeking surgery at an earlier stage, resulting in an increased number of cases for elective surgery and a considerable reduction in emergency operations, morbidity, need for intraoperative cholangiography (IOC), fewer common bile duct (CBD) explorations, shortened hospital stay, and reduced overall costs. The early criteria for IOC and the need for CBC explorations must be reevaluated in view of the observed changes and appropriate modifications made. Looking at the present trends, it seems that the routine use of IOC is not justified in the average patient who presents for laparoscopic cholecystectomy with no history of jaundice or pancreatitis, normal liver function tests, and a normal-size CBD on ultrasonography. Under those conditions, the chance of leaving an unsuspected stone in the CBD is less than 1%; and if it happens the stone can be easily retrieved by endoscopic sphincterotomy as an outpatient procedure.

Laparoscopic cholecystectomy (LC) though a very safe operative procedure does have its own morbidity and mortality. The present study was undertaken to analyze the morbidity and mortality of this procedure in an institutional setting. Between October 1992 and October 1995 a total of 433 patients received LC. Conversion to open cholecystectomy was required in 62 patients (14.3%). The decision to convert was made because the surgeon was forced to convert (3.7%) or the conversion was the operator's choice (10.6%). There was no difference in the conversion rate of consultants versus residents (14.4% vs. 14.2%). Major intraoperative and postoperative morbidity was encountered in 8.3% of patients. One patient required reexploration. The incidence of common bile duct (CBD) injury was 2.5%. There was no operative or 30 days mortality. However, two patients died in the follow-up period due to procedure-related complications. Low threshold for conversion, early recognition of morbidity, and prompt and judicious management of such complications under guided supervision is necessary in order to avoid major postoperative problems. The experience in a teaching hospital training program is different from that of an individual surgical setup.

Abdominal surgery, especially upper abdominal surgical procedures are known to adversely affect pulmonary function. Pulmonary complications are the most frequent cause of postoperative morbidity and mortality. This review article aimed to analyse the incidence and risk factors for postoperative pulmonary morbidity and their prevention. The most important means for preoperative assessment is the clinical examination; pulmonary function tests (spirometry) are not reliably predictive for postoperative pulmonary complications. Age, type of surgical procedure, smoking and nutritional state have all been identified as potential predictors for postoperative complications. However, usually there is not enough preoperative time available to obtain beneficial effects of stopping smoking and improvement of nutritional state. In patients with COPD, a preoperative multidisciplinary evaluation including the primary care physician, pulmonologist/intensivist, anesthesiologist and surgeon is required. Consensus as to preoperative physiologic state, therapeutic preparation, and postoperative management is essential. Simple spirometry and arterial blood gas analysis are indicated in patients exhibiting symptoms of obstructive airway disease. There are no values that contra-indicate an essential surgical procedure. Smoking should stop at least 8 weeks preoperatively. Preoperative therapy for elective surgery with antibiotics, beta2-agonist, or anticholinergic bronchodilator aerosols, as well as training in cough and lung expansion techniques should begin at least 24 to 48 hours preoperatively. Postoperative therapy should be continued for 3 to 5 days. Usually, anaesthesia is responsible for early complications, whereas surgical procedures are often associated with delayed morbidity. Laparoscopic procedures are recommended, as postoperative morbidity and hospital stay seem reduced in patients without COPD. Regional anaesthesia is given as having less adverse effects on pulmonary function than general anaesthesia. However, for unknown reasons these benefits are not associated with a decrease in postoperative respiratory complications. Moreover, the quality or the type of postoperative analgesia does not influence postoperative respiratory morbidity. Postoperatively, oxygen administration increases SaO2, but cannot abolish desaturation due to obstructive apnea. The various techniques of physiotherapy (chest physiotherapy, incentive spirometry, continuous positive airway pressure breathing) seem to be equivalent in efficacy; but intermittent positive pressure breathing has no advantages, compared with the other treatments and could even be deleterious. Chest physiotherapy and incentive spirometry are the most practical methods available for decreasing secretion contents of airways, whereas continuous positive airway pressure breathing is efficient on atelectasis. In stage II or III COPD patients, admission in a intensive therapy unit and prolonged mechanical ventilation may be required.

The possibility of conversion to open cholecystectomy (OC) always exists while performing a laparoscopic cholecystectomy (LC). This study has been performed with the aim of identifying factors predicting conversion to OC. From October 1992-April 1994, LC was attempted in 150 patients and conversion to OC was required in 29 (19%) patients. Ten preoperative factors were analyzed retrospectively to identify parameters significantly correlating with conversion to OC. Preoperative factors analyzed were age, sex, duration of symptoms, BMI (Body Mass Index), past history of jaundice, previous abdominal surgery, associated medical risk factors, palpable lump on clinical examination, USG, and OCG findings. Univariate and multiple stepwise regression analysis identified male sex, USG finding of contracted/thick-walled gall bladder, and a palpable gall bladder lump on examination as significant preoperative factors predicting conversion to OC.

New instrumentation and techniques have enabled laparoscopic surgeons to perform complicated reconstructive procedures. Few centers have attempted these procedures because of the excessive time involved with laparoscopic suturing. The Endo stitch suture device was developed to facilitate suture placement. We clinically compared conventional intracorporeal suturing and Endo Stitch suturing for laparoscopic suture placement and knot tying.

Intracorporeal suturing was used to complete laparoscopic dismembered pyeloplasties and bladder neck suspensions. Sutures were placed with either needle holders and graspers or the automatic suture device. A total of 85 maneuvers were assessed. Operative videotapes were reviewed to assess accuracy of suture placement, knot tying, and time to place suture and tie knots. All suturing was performed by an experienced laparoscopist.

Accuracy of stitch placement and knot tying were equivalent. The average time for stitch placement with the Endo Stitch was 43 +/- 27 seconds (n = 41). This was significantly less than the average stitch placement time for conventional suturing, which was 151 +/- 24 seconds (n = 14). The Endo Stitch knot tying was completed in an average of 74 +/- 50 seconds (n = 17), whereas knot tying with the conventional technique took 197 +/- 70 seconds (n = 13). The needle is automatically loaded in the Endo Stitch after each suture and is immediately ready.

The Endo Stitch device reduced the amount of time needed for placement of stitches and knot tying. Reconstructive laparoscopic procedures requiring multiple suture placement may be completed in a shorter time period using this instrument.

Although the upper urinary tract resides at an extraperitoneal location, the traditional laparoscopic approach to these organs has been transperitoneal. Several investigators have advocated using a direct approach to the retroperitoneum to minimize risks associated with transperitoneal surgery. We performed autopsy and radiographic studies in an effort to define the location of the retroperitoneum relative to surface anatomy. These investigations indicate that the peritoneal reflection was consistently anterior to the posterior axillary line. Moreover, when a patient was placed in the lateral position, the anteroposterior extent of the potential retroperitoneal space increased 2-fold. Based on these studies, a technique for direct retro-peritoneoscopy was initiated and successfully performed in 21 of 23 patients. Direct access to the retroperitoneum can be performed in a reliable and safe manner.

Laparoscopic surgery holds great promise as a technique for reducing hospital stay and convalescence. Although advantages in hospital cost cannot be shown for all such procedures, improvements in technique and operator experience will undoubtedly improve the situation. Analysis of the pertinent physiologic aspects and complication rates indicates that laparoscopy is not minimally invasive, but rather exposes the patient to many of the risks normally incurred by open procedures. Enthusiasm for the use of these techniques must be tempered by good judgment and scientific evidence supporting equivalent or better long-term results at equal or lower rates of morbidity and mortality.

This study evaluated the selective use of endoscopic retrograde cholangiopancreatography (ERCP) in the context of laparoscopic cholecystectomy (LC) while minimizing the use of operative cholangiography.

There has been a long-standing debate between routine and selective operative cholangiography that has resurfaced with LC.

Prospective data were collected on the first 1300 patients undergoing LC at McGill University. Preoperative indications for ERCP were recorded, radiologic findings were standardized, and technical points for a safe LC were emphasized.

A total of 106 patients underwent 127 preoperative ERCPs. Fifty patients were found to have choledocholithiasis (3.8%), and clearance of the common bile duct (CBD) with endoscopic sphincterotomy was achieved in 45 patients. The other five patients underwent open cholecystectomy with common duct exploration. Intraoperative cholangiography (IOC) was attempted in only 54 patients (4.2%), 6 of whom demonstrated choledocholithiasis. Forty-nine postoperative ERCPs were performed in 33 patients and stones were detected in 17 (1.3%), with a median follow-up time of 22 months. Endoscopic duct clearance was successful in all of these. The incidence of CBD injury was 0.38%, and a policy of routine operative cholangiography might only have led to earlier recognition of duct injury in one case. The rate of complication for all ERCPs was 9% and the associated median duration of the hospital stay was 4 days. The median duration of the hospital stay after open CBD exploration was 13 days.

LC can be performed safely without routine IOC. The selective use of preoperative and postoperative ERCP will clear the CBD of stones in 92.5% of patients.