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Title: Clinical studies comparing laparoscopic and minilaparotomy cholecystectomy
Author: McMahon, Andrew J.
Awarding Body: University of Glasgow
Current Institution: University of Glasgow
Date of Award: 1993
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Abstract:
Laparoscopic cholecystectomy was first performed by Mouret in France in 1987. Although laparoscopic cholecystectomy has rapidly been introduced into routine practice, there has been no rigorous evaluation comparing it with open cholecystectomy. Use of a small transverse subcostal incision ("minilaparotomy") for open cholecystectomy has been shown to result in a more rapid postoperative recovery than standard incisions 1-7. Therefore a trial was undertaken in which some 300 patients were randomised to laparoscopic (151) or minilaparotomy (148) cholecystectomy over an eighteen months period. Over the first year of the trial, postoperative pain, opiate analgesia consumption, oxygen saturation and pulmonary function (forced vital capacity (FVC), forced expiratory volume in one second(FEV 1), and peak expiratory flow rate (PEFR)) were assessed after laparoscopic (n=67) and minilaparotomy (n=65) cholecystectomy. Laparoscopic cholecystectomy was associated with lower linear analogue pain scores (median 40 v 59 mm, p < 0.001), lower patient-controlled morphine consumption (median 22 versus 40 mg, p < 0.001), a smaller reduction in postoperative pulmonary function (mean PEFR 64% of pre-operative value versus 49%, p < 0.001) and better oxygen saturation (mean 92.9% versus 91.2%, p=0.008) than mini laparotomy cholecystectomy. In the randomised trial as a whole, recovery after surgery was assessed by length of hospital stay, outpatient review at ten days and four weeks, and a modified version of of the SF-36 health survey questionnaire one, four and twelve weeks after surgery. The median operation time was 20 minutes shorter for minilaparotomy (50 versus 70 minutes, p < 0.001), while the median postoperative hospital stay was shorter after laparoscopic cholecystectomy (2 versus 4 days, p < 0.001). The mean hospital cost was £396 greater for the laparoscopic procedure (£1486 versus £1090, p < 0.001). There was a similar incidence of complications after both procedures (minilaparotomy group 2 0%, laparoscopic group 17%). Laparoscopic patients returned to work in the home more rapidly (median 10 versus 15 days, p < 0.001). At one week, laparoscopic patients had significantly better physical and social functioning, less role limitation due to physical problems, less pain, and lower depression scores. At four weeks, only the physical functioning and depression scores were better in the laparoscopic group, and by three months, there were no significant differences. Laparoscopic patients were more satisfied with the overall outcome of their operation, and the appearance of their scars. Compared with minilaparotomy cholecystectomy, laparoscopic cholecystectomy results in moderate benefits in length of hospital stay, post-operative dysfunction, and time to return to normal activity, but an increased cost to the National Health Service. The stress of surgery evokes a wide variety of biochemical and physiological changes, known as the metabolic response to injury. The magnitude of the metabolic response to injury has been shown to be proportional to the degree of the surgical trauma 8-U. As part of the randomised trial, the metabolic response to laparoscopic (n=10) and minilaparotomy cholecystectomy (n=10) was assessed. Venous blood samples were taken at 0, 3, 6, 9, 12, 18, 24, 48, 72 and 168 hours after incision and analysed for C reactive protein, interleukin-6 , cortisol, albumin, transferrin, iron, fibrinogen, fibrin degradation products, polymorphonuclear elastase, neutrophil, and lymphocyte count. 24h urine samples were analysed for urea, creatinine, 3-methylhistidine and catecholamines. The magnitude of the metabolic changes from base-line levels was quantified by calculating areas under each individual curve. A significant metabolic response with a similar time course and magnitude of changes occurred after laparoscopic and minilaparotomy cholecystectomy but with wide inter-individual variation in the magnitude of the response. The laparoscopic technique did not reduce the metabolic response when compared with open surgery using a small incision. Some recent studies have suggested that during laparoscopic cholecystectomy carbon dioxide absorption from the pneumoperitoneum may result in hypercarbia and respiratory acidosis 12-14. in order to clarify these previous findings, ventilatory and arterial blood gas changes were assessed during laparoscopic (n=30) and minilaparotomy (n=30) cholecystectomy as part of the randomised trial. Measurements were made during anaesthesia before commencing surgery, and at the time of removal of the gallbladder. Despite an increase in minute ventilation from a mean (SD) of 5.7 (1.4) litres to 6.1 (1.2) litres (95% Cl of the difference 0.01-0.9), arterial carbon dioxide tension (PaCO2) rose from 5.3 (0.6) to 6.0 (0.9) kPa (95% Cl of the difference 0.3-0.9) during laparoscopic cholecystectomy. Peak airway pressure increased from 17 (4) to 23 (4) cm H2O (95% Cl of the difference 5-7). By comparison, no clinically significant changes in ventilation or blood gas values occurred during minilaparotomy cholecystectomy. Laparoscopic cholecystectomy using a CO2 pneumoperitoneum is associated with a significant increase in carbon dioxide output, requiring a significant but variable increase in minute ventilation to prevent hypercarbia. End-tidal CO2 partial pressure (PE'CO2) monitoring is increasingly used during anaesthesia as an indirect measure of arterial CO2 tension (PaCO2). Therefore the relationship between these two variables was assessed. PE'CO2 had poor precision in predicting PaCO2 (95% limits of agreement -0.61 to +1.93 kPa). The mean (PaCO2 - PE'CO2) did not change significantly during surgery, although there was significant within-patient variation. During laparoscopic cholecystectomy, minute ventilation should be be increased to maintain PE'CO2 towards the lower end of the normal range (4-5 kPa) in order to avoid inadvertent hypercarbia. In some patients with severe cardiac or respiratory disease undergoing laparoscopic cholecystectomy, it may be impossible to eliminate the increased CO2 burden by hyperventilation. Therefore, a study was carried out to assess helium as an alternative to carbon dioxide for creating the pneumoperitoneum. Ventilation requirements, PaCO2 and PE'CO2 were assessed before creating the pneumoperitoneum and at the time of gallbladder removal during laparoscopic cholecystectomy using a helium pneumoperitoneum (n=30). Helium pneumoperitoneum did not result in any significant changes in minute ventilation requirement, although like CO2 pneumoperitoneum, it was associated with a mean rise in peak airway pressure of 7 cm H2O (pcO.OOl, paired t test). There was a 3.2 kPa rise in the alveolararterial oxygen gradient (p=0.006). Four patients had surgical emphysema persisting for five days. Helium may be a suitable alternative for patients with severe cardiorespiratory disease undergoing laparoscopic procedures in whom carbon dioxide insufflation results in excessive hypercarbia and acidosis.
Supervisor: Not available Sponsor: Not available
Qualification Name: Thesis (M.D.) Qualification Level: Doctoral
EThOS ID: uk.bl.ethos.788556  DOI: Not available
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