**3.1 Acute cholecystitis**

6 Updated Topics in Minimally Invasive Abdominal Surgery

4. The commercial pressure has been relentless. Technological research has been overturned in the design and implementation of increasingly sophisticated and safer instruments. Sponsoring of the learning of the technique to the interested surgeons was

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

A review in 1993 (Olsen, 1993) concluded that there are no good studies comparing conventional cholecystectomy by minilaparotomy or by laparoscopy. However, it was apparent that the small incision was better than the big one and that the length of the incision appears to be associated with hospital stay and return to the workplace. The ultimate goal is to achieve a safe surgery with the maximum benefit for the patient, and the keys are: knowledge of anatomy, good surgical view and a proper exposure. This last key to safety, exposure, is a limiting factor for minilaparotomy, which leads the question of how small an incision can still provide a exposure to perform the cholecystectomy safely. For Olsen, the answer is the laparoscopy, which allows for smaller incision, but it is noteworthy that the sum of the incisones made for the insertion of four trocars is about 4 cm and twodimensional view. An incision of this size can provide adequate exposure for

An overview of the Cochrane Hepato-Biliary Group reviews in January 2010 (Keus et al., 2010) revealed the evidence to date of the revisions that assess the effect of differents techniques of cholecystectomy: open, small-incision, or laparoscopic. A total of 5246 patients in 56 randomized trials are included. Total complications of laparoscopic cholecystectomy and small-incision were similar (17%), hospital stay and convalescence were not significantly different, small-incision cholecystectomy operative time was shortest (16.4 minutes) and is less costly. In our study of 1998 (Grau-Talens et al., 1998) small-incision cholecystectomy was \$ 1003 U.S less costly than laparoscopic. The effects of anesthesia and surgery on lung function have been well studied (Lindell & Hendenstierna 1976). There is a reduction in FVC (Forced Vital Capacity) and FEV1 (Forced Expiratory Volume in one second) to 75% of baseline for a separate incision without cutting the muscles, while reducing down to 40-55% in the subcostal incisions and midline laparotomy. An incision that spares the muscular section can prevent postoperative pulmonary complications. The restrictive pattern of lung dysfunction in postoperative abdominal surgery is influenced by several factors and is not well understood. The size, location and direction of the incision are responsible for the alteration of mechanical ventilation, by themselves and the pain. Kind of

anesthetic agent and diaphragmatic dysfunction are also involved (Craig 1981).

5. Finally, the health financier had an opportunity to reduce hospital stays.

**2. Laparoscopic vs. small-incision cholecystectomy** 

cholecystectomy under direct three-dimensional vision.

a strategic objective.

and benefits to the patient.

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 duration of the intervention.

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 stay was 3.1 days.

#### **3.2 Choledocholithiasis**

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%;

Transcylindrical Cholecystectomy for the Treatment


In our Hospital this is the algorithm for suspected choledocholithiasis:

exploration

exploration

al., 1998).


common bile duct exploration.

**4. Transcylindrical cholecystectomy** 

of Cholelithiasis and Its Complications: Cholecystectomy Under Local Anesthesia 9



The first option does not seem reasonable for the reasons already discussed, the last remains reserved for the failures of laparoscopic choledochotomy and retained stones. Conventional open surgery may remain as an option, but at the much higher wall trauma, the greater number of stays, the worse aesthetic outcome and greater disability after surgery. A randomized study demonstrated a greater benefit for the treatment of choledocholithiasis with laparoscopic common bile duct exploration than with postoperative ERCP (Rhodes et

Laparoscopic exploration of common bile duct has been developed in the 90's, almost simultaneously with laparoscopic cholecystectomy, and is performed through the cystic duct or choledochotomy. Laparoscopic choledochotomy is technically demanding, is a difficult procedure that requires a great deal of laparoscopic skill (Kroh & Chand, 2008). In this sense, a simple technique, as is the transcylindrical approach, can have a place in the

In 1992, we started laparoscopic cholecystectomy in the Hospital Verge del Toro (Mahon, Menorca, Spain) after a training period at another hospital. The technique quickly settled in the hospital, in a time of full discussion of the validity of this approach and the need for prior training. We conducted a series of 11 laparoscopic cholecystectomy, until the absence of capnography and other circumstances prevented continuation of the procedure The laparoscopic view of Calot's triangle, with the camera close enough to the structures, as it's

jaundice and only cystic dilated (greater than 4 mm), 50%; when occurred only jaundice and small stones (<0.5 cm) in 34%. In patients without jaundice, the presence of stones in the choledochotomy was as follows: If calculation palpable, 89%; if dilated common bile duct, 53%; if the cystic duct dilated, 29%; and in the presence of small stones, 16%.

With the arrival of cholangiography the negative common bile duct exploration decreased from 50% to 6%, the incidence of retained stones also fell from 25% to 11%. Moreover, although it was not popular until the 70, the introduction of rigid choledochoscope in 1941 by McIver reduced the incidence of retained stones. A big progress in the treatment of retained stones was the introduction of endoscopic sphincterotomy in 1974 by german and japanese authors (Classen &Demling, 1974) with a success rate of 95%, 15% morbidity and mortality from 0.2 to 1.5% ( Escorrou et al., 1984), relativized the problem of retained stones and its treatment and compared favourably with surgical sphincterotomy, whose mortality was 2.9 to 4.4%.

With the introduction of laparoscopic cholecystectomy, surgery for gallstones changed and preoperative endoscopic retrograde cholangiography became the rule in the care of patients suspected of gallstones in the bile duct to avoid open choledochotomy. In experienced centres, the success rate of ERCP in the extraction of common duct stones is 90% but 1% overall mortality and complication rate of 6% to 10% (Fink, 1993). The risk of mortality and morbidity should be added to the subsequent laparoscopic cholecystectomy. If we accept a risk of death of 0.3% and 5% complication rate for laparoscopic cholecystectomy, the overall mortality of the sum of the two procedures can be 1.3% and morbidity of 11 to 15% (Tomkin, 1997).

Other notable aspects of this sequence of treatments (first ERCP and posterior cholecystectomy) are: the cost and the negative ERCP, ie, discriminating which patients have choledocholithiasis preoperatively. A study by Koo and Traverso (Koo &Traverso, 1996) revealed that the history is the best predictor of choledocholithiasis, but was only able to predict 45% of cases, surpassing the biochemistry of liver function and ultrasound. For this reason, preoperative ERCP is rewarded with the discovery of choledocholithiasis in no more than 50% of cases, which are obviously exposed to morbidity and mortality, and raise the cost of surgical practice. In another recent study, ERCP was performed only if the patient had any of the following criteria: dilatation of the bile duct by ultrasound, gallstone pancreatitis or abnormalities of liver function tests (Katz et al., 2004). ERCP was performed in 41 patients and stones were found in 22 (53.7%). The authors conclude that dilatation of the bile duct along with liver function abnormalities are the most useful, with a yield of 82% correct in detecting choledocholithiasis.

In the last decade has improved radiological assessment of patients with suspected common bile duct stones. Transabdominal ultrasounds are not very sensitive in detecting common bile duct stones, but if ultrasounds are negative and liver function is normal, the chances of choledocholithiasis are minimal. Magnetic resonance cholangiopancreatograpy and endoscopic ultrasonography have high sensitivity and specificity (grater than 90%) and are the best options as preoperative assessment (Werbesey & Birkett 2008). There are different diagnostic and therapeutic options to address the common bile duct, but not an algorithm that can be considered the standard criterion. The management of this disease depends on the experience and the possibilities of available technology of each working group. The therapeutic approaches are:


jaundice and only cystic dilated (greater than 4 mm), 50%; when occurred only jaundice and small stones (<0.5 cm) in 34%. In patients without jaundice, the presence of stones in the choledochotomy was as follows: If calculation palpable, 89%; if dilated common bile duct,

With the arrival of cholangiography the negative common bile duct exploration decreased from 50% to 6%, the incidence of retained stones also fell from 25% to 11%. Moreover, although it was not popular until the 70, the introduction of rigid choledochoscope in 1941 by McIver reduced the incidence of retained stones. A big progress in the treatment of retained stones was the introduction of endoscopic sphincterotomy in 1974 by german and japanese authors (Classen &Demling, 1974) with a success rate of 95%, 15% morbidity and mortality from 0.2 to 1.5% ( Escorrou et al., 1984), relativized the problem of retained stones and its treatment and compared favourably with surgical sphincterotomy, whose mortality

With the introduction of laparoscopic cholecystectomy, surgery for gallstones changed and preoperative endoscopic retrograde cholangiography became the rule in the care of patients suspected of gallstones in the bile duct to avoid open choledochotomy. In experienced centres, the success rate of ERCP in the extraction of common duct stones is 90% but 1% overall mortality and complication rate of 6% to 10% (Fink, 1993). The risk of mortality and morbidity should be added to the subsequent laparoscopic cholecystectomy. If we accept a risk of death of 0.3% and 5% complication rate for laparoscopic cholecystectomy, the overall mortality of the sum of the two procedures can be 1.3% and morbidity of 11 to 15% (Tomkin,

Other notable aspects of this sequence of treatments (first ERCP and posterior cholecystectomy) are: the cost and the negative ERCP, ie, discriminating which patients have choledocholithiasis preoperatively. A study by Koo and Traverso (Koo &Traverso, 1996) revealed that the history is the best predictor of choledocholithiasis, but was only able to predict 45% of cases, surpassing the biochemistry of liver function and ultrasound. For this reason, preoperative ERCP is rewarded with the discovery of choledocholithiasis in no more than 50% of cases, which are obviously exposed to morbidity and mortality, and raise the cost of surgical practice. In another recent study, ERCP was performed only if the patient had any of the following criteria: dilatation of the bile duct by ultrasound, gallstone pancreatitis or abnormalities of liver function tests (Katz et al., 2004). ERCP was performed in 41 patients and stones were found in 22 (53.7%). The authors conclude that dilatation of the bile duct along with liver function abnormalities are the most useful, with a yield of 82%

In the last decade has improved radiological assessment of patients with suspected common bile duct stones. Transabdominal ultrasounds are not very sensitive in detecting common bile duct stones, but if ultrasounds are negative and liver function is normal, the chances of choledocholithiasis are minimal. Magnetic resonance cholangiopancreatograpy and endoscopic ultrasonography have high sensitivity and specificity (grater than 90%) and are the best options as preoperative assessment (Werbesey & Birkett 2008). There are different diagnostic and therapeutic options to address the common bile duct, but not an algorithm that can be considered the standard criterion. The management of this disease depends on the experience and the possibilities of available technology of each working group. The

53%; if the cystic duct dilated, 29%; and in the presence of small stones, 16%.

was 2.9 to 4.4%.

1997).

correct in detecting choledocholithiasis.



therapeutic approaches are:


The first option does not seem reasonable for the reasons already discussed, the last remains reserved for the failures of laparoscopic choledochotomy and retained stones. Conventional open surgery may remain as an option, but at the much higher wall trauma, the greater number of stays, the worse aesthetic outcome and greater disability after surgery. A randomized study demonstrated a greater benefit for the treatment of choledocholithiasis with laparoscopic common bile duct exploration than with postoperative ERCP (Rhodes et al., 1998).

Laparoscopic exploration of common bile duct has been developed in the 90's, almost simultaneously with laparoscopic cholecystectomy, and is performed through the cystic duct or choledochotomy. Laparoscopic choledochotomy is technically demanding, is a difficult procedure that requires a great deal of laparoscopic skill (Kroh & Chand, 2008). In this sense, a simple technique, as is the transcylindrical approach, can have a place in the common bile duct exploration.

In our Hospital this is the algorithm for suspected choledocholithiasis:
