**1.3 Laparoscopic cholecystectomy – Eric Mühe**

4 Updated Topics in Minimally Invasive Abdominal Surgery

The first truly major surgery on the biliary tract was performed in 1867 in Indiana (USA). John S. Bobbs, professor of surgery at the Medical College of Indiana, operates a tumor in the right upper quadrant in a 30 year old woman, at home and under general anesthesia, resulting in the diagnosis of gallbladder hydrops which was evacuated and drained. It was

Fifteen years later, in 1882, Carl J. Langenbush of Berlin performed the first cholecystectomy by lithiasis, after exercising cholecystectomy in cadavers for several years. However, as more than a century later would happen with the laparoscopy and in the same Germany, Langenbush's communication in the German Congress of Surgery of three cases of cholecystectomy that evolved successfully, was received with apathy and without due

Minilaparotomy was used for several decades for the diagnosis of obstructive jaundice. Through a small incision is valued, in addition to the aetiology, the operability by palpation of the gallbladder and hilum liver and usually the diagnosis included a

In 1982 F. Dubois and B. Berthelot (Dubois & Berthelot, 1982) published the first paper on the minilaparotomy for operations on the bile duct, performing the procedure in 1500 patients, including alongside cholecystectomy, some cases of choledochotomy, sphincterotomy and choledochoduodenostomy. All these interventions were carried out with a transverse or oblique skin incision 3 to 6 cm in length, but the duration of surgery, the authors say, was "twice that of a normal operation". Intervention was carried out with the help of an autostatic (if no more than one assistant was available), a vaginal valve for retraction of the liver, a malleable valve for retraction of the hepatic flexure of the colon and the positioning of two packs for the separation of the colon and stomach, referenced with a

The description of the intervention with this procedure and its duration arise a suspicion of some difficulty with exposure of the structures and the easement of the procedure. However, the authors describe: a minimization of cosmetic damage, solidness of the wall

Moss, in 1983, published the first cases of cholecystectomy with stay less than 24 hours, and in 1986, 100 cases. Later, he operates 160 patients by midline laparotomy, with an incision that "barely allows the surgeon's hand", which were discharged the day after surgery without receiving narcotics, tolerating food intake between 8 and 18 hours and only 3 readmissions. The author concluded in 1996 that the benefits of laparoscopy may be more related to the enthusiasm and expectations for the new technology that in the technique by

In 1985, Morton (Morton, 1985) performs a cost containment study of cholecystectomy with intraoperative cholangiography in 96 patients through an incision of 4 to 5 cm with a mean operating time of 45 minutes. The average stay was 2.5 days and analgesic requirements were lower than in the classical subcostal incision. The period of sick leave decreased

Goco and Chambers in 1988 (Goco & Chambers, 1988) studied the impact of minicholecystectomy in the management of health expenditure, considering the reduction of hospital costs compared to traditional cholecystectomy. The authors conclude, by analyzing 450 interventions, that a 4-cm incision produces an average stay of 1.22 days and that the savings stay was 4.78 days per case. Rating the daily cost at \$ 200 USA in 1988, it is easy to

the first cholecystostomy performed in the history.

**1.2 Development of mini-lap (small-incision) cholecystectomy** 

closure an a reduction of pain and postoperative ileus.

consideration that the time reserved.

cholecistocholangiography.

tape.

itself (Moss, 1996).

significantly.

Laparoscopy has not only caused a revolution in the treatment of cholelithiasis, but that has changed an old surgical proverb: "a large incision, a great surgeon." It seems reasonable to assert that "a smaller incision, less abdominal wall trauma and better aesthetic results." The era of minimally invasive surgery began and laparoscopy has been extended to almost all abdominal surgical operation and almost any procedure has been performed by laparoscopic approach, including resections and all types of gastrointestinal suture.

Interestingly, laparoscopic cholecystectomy was not well received by the German Surgical Society when E. Mühe reported the first operation in 1986. On September 12, 1985, Mühe selected with great care the first patient to perform the first laparoscopic cholecystectomy, almost five years after the first laparoscopic appendectomy by Semm. Like him, Mühe performed the pneumoperitoneum with the Veress needle, inserted the trocar and introduced his own "galloscope" through the umbilicus. Two hours later he concluded successfully the first laparoscopic cholecystectomy (Litynski, 1996). His presentation at the congress was not published and only a summary appeared in Langenbecks Archiv für Chirurgie 1986 (Mühe, 1986). However, with subsequent amendments Mühe concluded that inserting the laparoscope (galloscope) as close as possible to the gallbladder the "cumbersome" pneumoperitoneum could be avoided. After several cholecystectomies without gas, trying to simplify and adapt the technique to be used by most surgeons, he realized that the optical instrument was not necessary, "with or without galloscope, the magic surgical approach could be the same". Soon operated through sheath of the galloscope without the optical instrument with the advantages of minimal incision:


This outlined the bases of minimally invasive surgery. Sadly, Mühe didn´t publish the evolution of his technique for cholecystectomy in any international journal and we haven´t hat notice of it until 1996 with the Litynski´s. book.

Many reasons can be considered to explain the success of laparoscopic cholecystectomy:


Transcylindrical Cholecystectomy for the Treatment

**3.1 Acute cholecystitis** 

duration of the intervention.

stay was 3.1 days.

**3.2 Choledocholithiasis** 

of Cholelithiasis and Its Complications: Cholecystectomy Under Local Anesthesia 7

In some studies, laparoscopic cholecystectomy has shown lower spirometric reductions when compared to open cholecystectomy (Frazee et al., 1991) and to mini-lap (McMahon et al., 1994) although the latter with incisions between 5 and 10 cm. Presumably, a reduction in the length of the incision could be rewarded by a smaller reduction in the impairment of lung physiology, ie, an incision of 4.5 cm, uniform to all layers of the abdominal wall could improve postoperative spirometric results as happened in our study (Grau-Talens et al.,1998) wich shows that the reduction of spirometrics values were similar in laparoscopic and small-incision cholecystectomy, ie over 20% of preoperative value for FVC and 25% for

Early cholecystectomy is the best treatement for acute cholecystitis. Laparoscopic cholecystectomy was a relative contraindication in acute cholecystitis, but now is the preferred aproach for most patients. The first articles appear in the early 90´s (Cooperman, 1990) (Yamashita et al., 2007). However, in our experience, cholecystectomy in this way was not easy: the difficulties are related to the inflammatory process, with greater difficulty for dissection and recognition of structures, the possibility of further contamination of the cavity (not the surgical wound), the need for instruments to 10 mm in diameter, greater difficulty in haemostasis and, of course, a greater proportion of conversions (35%) and

With these preliminary considerations we began to operate the acute cholecystitis by early transcylindrical cholecystectomy (within 72 hours or more of admission), thinking that the abdominal wall injury should not be higher than laparoscopy, even using the cylinder of 5 cm in diameter, that manipulation of the gallbladder (gripping, aspiration, recovery of stones etc.) could be done in a simpler way than by laparoscopy, and that contamination of the surgical wound could be avoided by the protective and insulating effect of the cylinder. We have only found an article of acute cholecystitis treated by minilaparotomy in the context of a randomized study comparing minilaparotomy with conventional laparotomy (Assalia et al., 1997). The authors show figures contrasting results in a very favourable way, not only with traditional laparotomy, but with the laparoscopic approach. In this article the average time (+ /-SD) of the intervention was 69.1 (+ / - 17.0) minutes and mean hospital

The choledochotomy was first performed in 1884 by Kummel and in 1889 by Thornton and Abbe, who made the first ideal suture of the choledochotomy. In the late nineteenth and early twentieth century the common bile duct exploration was guided by the subjective clinical impression of the surgeon, until the introduction of intraoperative cholangiography by Mirizzi in 1937. In the Massachusetts General Hospital (Bartlett & Waddell, 1958) were reviewed 1000 choledochotomy for suspected choledocholithiasis with a mortality of 1.8% (three times higher than simple cholecystectomy) and 16% global choledocholithiasis. In the presence of previous pancreatitis, stones were found at choledochotomy in 12% of the patients; in the presence of jaundice or a reliable history of jaundice, 35%; in the previous situation more palpable stone in 99%; with bile duct larger than 1 cm diameter, 58%;

FEV1. The results obtained by keus et al. are similar to ours (Keus et al 2008).

**3. Treatment options in biliary lithiasis complications** 


Given all the above mentioned facts it is obvious that the introduction of the technique is an undeniable fact and that, at present, nobody doubt that laparoscopy is the technique of choice for cholecystectomy. However, the advantages of laparoscopic cholecystectomy have been put in evidence, deliberately, with the open cholecystectomy with a generous wound of about 15 cm. But what if the comparison is made against a technique that uses an incision of 5 cm or smaller? It is possible that the above mentioned advantages were less obvious and that the assessment had to be made over other aspects than aesthetics, postoperative pain, parietal trauma, hospital stay, re-employment, etc., entering the field of cost, security and benefits to the patient.
