**9. Conclusion**

34 Updated Topics in Minimally Invasive Abdominal Surgery

operations on 1,300 patients. There were six of these patients who were operated on during pregnancy. They were able to successfully perform the operation on all the six patients and observed that the overall course of the operation is the same with non-pregnant patients. They reported that there were no significant complications to either the patient or the fetus. It was reported later that all the six patients delivered healthy babies and noted no signs of complications. The authors concluded that laparoscopic cholecystectomy can be performed safely in pregnant patients and that it should be considered in any patient who presents

Age is one of the critical factors affecting the mortality and morbidity rates after open cholecystectomy for both acute and chronic cholecystitis [2, 3]. Several series of open cholecystectomy [4, 5] report death as a complication occurring almost exclusively in patients over 60 years of age [6]. Smith and Max [7] found that the morbidity-mortality rate after open cholecystectomy was 25% for patients aged 60-69 as opposed to 50% for patients over 70. Ageing patients with symptomatic cholelithiasis frequently have associated medical disorders. They may be at higher risk of postoperative complications. Evaluation of the results of the laparoscopic approach in the aged would allow patients and surgeons to make

Brunt et al[22] gathered their laparoscopic data for 421 patients from 1989 to 1999 which were extremely elderly or older than 80 years to determine whether extremely elderly patients, age 80 years or older, were at higher risk for adverse outcomes from laparoscopic cholecystectomy than patients younger than 80 years. The patients were divided into two groups: group 1 (age 65-79 years; n = 351) and group 2 (age, 80-95 years; n = 70). The authors noted that the advanced age (group 2) was associated with a higher mean American Society of Anesthesiology (ASA) class and a greater incidence of common bile duct stones, as compared with those of younger age (group 1). Mean operative times in group 2 were 45- 106 minutes as compared with 38 to 96 minutes in group 1, a difference that is not significant. The authors noted that the extremely elderly group had a four times higher rate of conversion to open cholecystectomy and a longer mean postoperative hospital stay of 1.4 to 2.1 days. They also stated that Grades 1 and 2 complications were more common in group 2. They reported that one patient in group 1 had a myocardial infarction 13 days postoperatively, and two deaths occurred in the extremely elderly group within 30 days postoperatively. The authors concluded that laparoscopic cholecystectomy in the extremely elderly is associated with more complications and a higher rate of conversion to open cholecystectomy than in elderly individuals younger than 80 years. The greater chance of encountering a severely inflamed or scarred gallbladder and common bile duct stones as

decisions on the most appropriate treatment for symptomatic cholelithiasis.

well as increasing comorbidities likely account for these differences in outcome.

Mayol et al[24] gathered the outcome of all their laparoscopic cholecystectomy patients between 60 and 70 years of age and patients over 70 who underwent laparoscopic cholecystectomy for symptomatic non-malignant gallbladder disease. They found out that the operative time and conversion rates were similar with both groups. They noted that the overall morbidity rate was 14.5% and there was no perioperative mortality that occurred. There was a recurrent biliary surgery done in two patients from the above 70 group. There were also postoperative endoscopic retrograde cholangiography and sphincterotomy that

with symptomatic cholelithiasis during pregnancy.

**8. Elderly patients** 

**8.1 Case** 

With the success of laparoscopic cholecystectomy on different high risk patients, it is therefore recommended as the treatment of choice. The consequences of this technique including the bile duct injury, influence of pneumoperitoneum on cardiorespiratory system and other complications are outweighed by the benefits that the patients acquire after the surgery and these consequences can be prevented by performing the operation cautiously and skillfully in all the high risk patient groups.

#### **10. References**


**3** 

*Sweden* 

**An Overview** 

**Gallbladder Surgery, Choice of Technique:** 

The first cholecystectomy was performed by Langenbuch in 1882 (1), and the surgical approach changed very little in the next century. However, in the 1980s, reports began to appear that described the removal of the gallbladder through a 3-8 cm, muscle-sparing incision (small-incision cholecystectomy, or minicholecystectomy) (2-17). A few years later, laparoscopic cholecystectomy entered the scene (18, 19). These two minimally-invasive techniques have largely replaced the traditional open cholecystectomy, which used a 10 – 20 cm incision in elective gallbladder surgery (20). In 1993, a consensus conference at the National Institute of Health concluded that the experience of small-incision surgery or minilaparotomy cholecystectomy was limited; and that laparoscopic cholecystectomy could be performed at a treatment cost that was equal to or slightly less than that of open cholecystectomy and offered substantial cost savings to the patient and society by reducing the time off work (21). The alternative to surgical removal of the gallbladder, lithotripsy combined with chemical dissolution of gallstones is restricted to single stone disease and runs a risk of stone recurrence (22, 23). However, it has been found to be associated with

The aim of this review is to discuss factors that influence the choice between cholecystectomy techniques, taking into account the applicability and cost of each technique.

We conducted a literature search, including a search of the Cochrane Library and PubMed (year 2010) with the keyword "cholecystectomy" and used the principles of evidence based

The prevalence of cholelithiasis in European population is currently 10-15%, and it increases with age and female gender (30-33). Patients with cholelithiasis may be asymptomatic or symptomatic. Biliary colic is the only symptom specific to cholelithiasis (34). It is characterised by a high intensity, long duration pain located in the right upper abdominal quadrant; it can be referred, and often appears at night (35). Cholelithiasis may be

**1. Introduction** 

**2. Methods** 

**3. Results and discussion**

*Cholelithiasis, the magnitude of the problem* 

good long-term quality of life in selected patients (24).

medicine in the presentation of the findings (25-29).

E. Nilsson, M. Öman, M.M. Haapamäki and C.B. Sandzén *Department of Surgical and Perioperative Sciences, Umeå University,* 

