Contribution of New Approaches (notes and Single Incision Laparoscopic Surgery) to the Outpatient Cholecystectomy

Jose F Noguera, MD, PhD, Angel Cuadrado, MD, PhD, Jose V Roig, MD, PhD

Consorcio Hospital General Universitario de Valencia and Hospital Son Llatzer

Aim: To assess the best minimally invasive approach for outpatient cholecystectomy.

Methods:

120 women with uncomplicated symptomatic cholelithiasis, randomly assigned to one of four study groups and followed prospectively, with the following inclusion and exclusion criteria:

Inclusion criteria:
Indication of minimally invasive cholecystectomy for uncomplicated symptomatic cholelithiasis. Women with age between 18 and 65 years. Perforated hymen

Study groups:
Conventional laparoscopic cholecystectomy (CL)
Minilaparoscopic-Cholecystectomy (ML)
Transumbilical-single port cholecystectomy (TU)
Flexible endoscopic transvaginal cholecystectomy (TV)

No local anesthetics were used. Postoperative pain was treated with metamizol 2 g every 6 hours and Paracetamol 1 g every 6 hours. Antiemetic prophylaxis was used with dexamethasone and ondansetron. Oral intakr was started within 4 hours of surgery.

Discharge criteria were evaluated at 6, 8 and 10 hours after surgery:
Controlled pain, without requiring additional doses. Correct oral intake. Independent deambulation. Spontaneous urination. Correct vital signs.

Results:

The groups were similar in terms of age, anesthetic risk, body mass index and other parameters.

Operating time (minutes).

The operative time was longer for transvaginal and transumbilical approaches. The minilaparoscopic approach was similar to conventional laparoscopy.
The transvaginal approach requires an average of 10 minutes for its creation and closure, while the umbilical approach only increases the time in 5 minutes.

We found significant differences between laparoscopy (47.04 minutes) and the other two techniques (transumbilical 59.80 min and 64.85 min transvaginal).
(Mann-Whitney test, p <0.001).

Conversion to conventional laparoscopic surgery or open surgery

In the transumbilical approach there was a case of conversion (0.83%) to conventional laparoscopy with an additional trocar for proper exposure of the gallbladder.
There was no difference in conversion rate.

Global complications.
No differences between groups. Complications were minor although in some cases conditioned the recommendation not to be discharged early.

Hospital stay

All patients were admitted to the day of the surgery. Although the differences are not significant, is appreciably lower stay for "minimalist" laparoscopy.

Ambulatory-rate.

With the same reflection for hospital stay the approach that allowed a higher percentage of discharge on the day of surgery was the minilaparoscopy.

Causes of hospitalization
Nausea, vomiting, 20 (16.6%)
Uncontrolled pain 12 (10%)
Urinary retention 2 (1.66%)
Alteration vital signs 6 (5%)
Other 6 (5%)

6 months postoperative hernia

After a minimum follow-up of 6 months to all patients, one case of postoperative ventral hernia was detected at 3 months, coinciding with a wound infection in the umbilical access.

Discussion.

The new transvaginal NOTES and single incision transumbilical approaches have proven safe in clinical application, so it can be adopted for outpatient minimally invasive cholecystectomy. They discreetly increase the surgical time but have benefits for patients in medium and long term because of the minimal trauma to the abdominal wall.

Session: Poster Presentation

Program Number: P363