Cholecystectomy: from open surgery to single-incision laparoscopic and transluminal endoscopic surgery

Cholecystectomy is generally accepted as the treatment of choice for symptomatic gallstone disease and is one of the most frequently performed surgical procedures in the world. The first successful procedure was performed in 1882 by Langenbuch and more than a century later Philip Mouret (1987) performed the first laparoscopic cholecystectomy [1]. During the past two decades minimally invasive surgery progressed well and laparoscopic cholecystectomy is currently the gold standard for removal of the gallbladder. Numerous studies, as well as a Cochrane Systematic Review, have reported a shorter hospital stay, shorter period of recovery, reduction of postoperative pain, and better cosmetic results compared with open surgery [2].

Small-incision (open) cholecystectomy (SIC) was introduced as another alternative to open cholecystectomy and indeed has also been shown to be associated with a shorter hospital stay (random effects 2.8 days; 95 % confidence interval – 0.06 to + 0.07) and quicker recovery time compared with open cholecystectomy in a Cochrane meta-analysis of seven randomized controlled trials [3] ^.

Another systematic review comparing the three procedures – open, small-incision or laparoscopic cholecystectomy – showed no difference in mortality and complications; however, laparoscopic cholecystectomy and SIC were preferred over the conventional open cholecystectomy due to faster recovery times [4]. To date, no clear difference could be shown between SIC and laparoscopic cholecystectomy [5]. Despite the lack of evidence of superiority over SIC, the laparoscopic procedure is currently still the method of choice.

Importantly, the introduction of laparoscopic cholecystectomy has revolutionized the methods that surgeons currently use and, due to further innovation of instrumentation ad technology, minimally invasive surgery has developed to even less invasive procedures. The conventional four trocars technique has progressed towards the three ports techniques and more recently the two ports procedure as well as to the introduction of the needlescopic cholecystectomy using small 2-mm instruments to reduce the discomfort from multiple incisions [6] [7].

Another exciting area of development is the natural orifice transluminal endoscopic surgery (NOTES) technique that attempts to eliminate skin incisions, the so-called “scarless surgery” [8] [9] [10]. So far cholecystectomy is the most commonly performed NOTES procedure, particularly via the transvaginal approach in women and the transgastic approach [8] [9] [10].

Surgeons have responded with a competing surgical technique, the single-incision laparoscopic surgery (SILS) or so-called natural orifice transumbilical surgery (NOTUS), which is a new development using only transumbilical incisions. The incision(s) is placed within the umbilicus, thereby eliminating visible abdominal scars [11] [12] [13] [14]. These new techniques are all dependent on further development of appropriate flexible instrumentation. In an attempt to coordinate all of these technological advances in instrument design and new clinical applications the leaders and specialists currently practicing in the field have formed an international multidisciplinary umbrella group, the LaparoEndoscopic Single-Site Surgery Consortium for Assessment and Research (LESSCAR) to advance this field of surgery [15].

Transcylindrical cholecystectomy, a modification of the open SIC procedure, which is reported by Grau-Talens et al. in this issue of Endoscopy [16], should be discussed within the framework of the above-mentioned developments. The transcylindrical cholecystectomy had already been described by the same authors [17] 10 years ago and the present study was performed to assess the feasibility of transcylindrical cholecystectomy under local anesthesia [16].

The authors analyzed a consecutive group of 72 patients with cholelithiasis who underwent transcylindrical cholecystectomy, including a selected group of patients referred for elective surgery. Surgery could be completed under local anesthesia in only 47 / 72 patients (65.3 %); in 12 patients (16.7 %) general anesthesia was used from the start, and 13 patients (18.0 %) were switched to general anesthesia during surgery. Most patients (95 %) could be discharged on the day of surgery, and complications occurred in three of the 60 patients who were included in the final analysis (5 %). The pain score (visual analog scale) at postoperative day 5 was 2.2.

The authors concluded that transcylindrical cholecystectomy is feasible under local anesthesia and might have the added advantage over laparoscopic cholecystectomy of improved patient safety and reduced costs.

The authors chose to study two different aspects of cholecystectomy. First, they did not select the standard laparoscopic procedure but instead used a modification of the open procedure, by performing the well known SIC procedure; in fact they only analyzed the impact of the use of a cylinder. The second aspect was to analyze the feasibility of local anesthesia for SIC with the use of this cylinder modification. Remarkably the authors started the study with 72 patients (a potential first selection bias was to select only elective patients) but finally analyzed 60 patients (12 patients were excluded because general anesthesia was used from the start – a second selection bias). They reported a 78 % success rate rather than the 67 % achieved using an intention-to-treat principle.

Considering the complications, the authors analyzed up to 5 days after surgery but should have reported on a longer follow-up period because bile leakage and bile duct injury will often present later than 5 days post surgery [18].

One should also realize that, as mentioned a decade ago in a comment by Traverso on the first paper on transcylindrical cholecystectomy, the muscle splitting is identical to that done during SIC, and has been used for many years, the only difference being the introduction of a “gas less maxitrocar” [19]. From a theoretical or technical point of view, one could also argue that the cylinder approach could lead to reduced vision within the operative field of the surgeon or assistant and reduce the sensory input of the surgeon compared with SIC and the use of two or three retraction blades, which create a “flexible cylinder.” If the abdomen is already open, the surgeon should use the advantage of sensory input as well as less restriction on the degrees of freedom in movement of the instruments generally used in open surgery.

It might also be questioned whether the advantage of the binocular (restricted) vision via the cylinder, outweighs the disadvantage of not using a camera or pneumoperitoneum for an excellent and probably much better vision of local anatomical details during the procedure.

These technical aspects and potential consequences for outcome should be analyzed in a large, controlled (three-arm randomized) study (SIC compared with cylinder and compared with laparoscopic cholecystectomy), with more details of the operative process and a longer follow-up.

In an attempt not to accept the new, mostly costly, developments in surgery and endoscopy the authors also suggest economic advantages in using the transcylindrical cholecystectomy, but they did not analyze the costs in the present study. Instead, they used costs from a previous study (August 1993 – October 1996) that included only patients with normal clinical admission and only the use of general anesthesia.

Several years ago we showed in a randomized study that day care surgery is feasible for laparoscopic cholecystectomy, with excellent low pain scores and a reduction of costs [20]. Data about the potential reduction of costs associated with local anesthesia in the paper by Grau-Talens [16], were not provided and potential negative aspects (costs and safety) of unprepared acute general anesthesia during the procedure were not analyzed.

I fully echo the opinion of Traverso that authors should be applauded for their attempt to reduce costs, but unfortunately, to date I see no advantage of this new technique over the current gold standard of laparoscopic cholecystectomy and other potential new developments as mentioned above. In fact, the study shows that the progress of this innovation over the past 10 years has been very limited and not followed by other centers. This might be due to the more promising and exciting area of the new single-site laparoscopic and endoscopic approach.

In the context of these critical remarks about the present transcylindrical cholecystectomy study [16] it is worth pointing out that application of the other new procedures such as SILS, NOTUS, and NOTES remains controversial and to date these procedures have not had the impact that was expected, probably due to the limitations of existing instrumentation. All of these new developing procedures should be evaluated by controlled trials with laparoscopic cholecystectomy as the gold standard; the LESSCAR organization might stimulate this exciting process.

Competing interests: None

References

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