Needlescopic cholecystectomy: prospective study of 150 patients.

OBJECTIVE: To evaluate the feasibility and safety of cholecystectomy using miniaturised instruments of 3 mm or less in diameter. DESIGN: Prospective study on patients with gallstones, with or without related complications. SETTING: Private hospital, Hong Kong. PATIENTS: From September 1997 to September 2002, 150 of the 180 consecutive patients managed were included in the present study. MAIN OUTCOME MEASURES: All patients were operated on with a standard four-port technique. Mini-laparoscopes of different sizes were used throughout the study period, which included 2-mm (n=33) fibre-optic laparoscope, and 2.5-mm (n=61) and 3-mm (n=56) laparoscopes of Hopkins rod lens system. The cystic duct and artery were secured either by extracorporeal ties or 10-mm clips passed through the umbilicus. The time taken from dissection to division of the cystic duct and artery, and to complete the operation were documented. RESULTS: The operation was successfully completed with needlescopic instruments in 127 (85%) patients, even though patients with acute cholecystitis and history of common bile duct stones were included. Use of larger-diameter mini-laparoscopes decreased the time needed to divide the cystic duct and artery, to detach the gall bladder from the liver, and to complete the operation. There were no deaths. One minor bile duct injury developed secondary to extensive cauterisation of the gall bladder fossa. CONCLUSION: Needlescopic cholecystectomy with minor technical modification can be completed within a duration comparable to standard laparoscopy at no increased risk for the great majority of patients with gallstones.

Combined laparoscopic and endoscopic approach in patients with cholelithiasis and choledocholithiasis.

BACKGROUND: The Optimal management of common bile duct stones in patients undergoing laparoscopic cholecystectomy remains controversial. METHODS: A prospective study was conducted in 145 of the 481 patients who had a preoperative endoscopic retrograde cholangiogram before their laparoscopic cholecystectomy. RESULTS: Endoscopic retrograde cholangiogram was successful in 138 patients (95%), and common duct calculi were found in 72 (50%) of them. Endoscopic sphincterotomy with ductal clearance was achieved in 62 of 67 patients during a mean of 1.4 sessions (range, 1 to 5). Five (3.4%) patients had complications after endoscopic intervention, all of which resolved uneventfully . Fourteen patients underwent laparoscopic common duct exploration, five had failed endoscopic extraction, five had their common duct stones left intentionally for laparoscopic intervention, and, in addition, four of the seven patients who had a failed endoscopic retrograde cholangiogram had stones identified by intraoperative cholangiogram. Ten of these 14 patients underwent a successful laparoscopic common duct exploration. Laparoscopic cholecystectomy was successfully completed in 134 of the 145 patients, and none had major intraoperative or postoperative complications. The mean postoperative stay was 2.7 days for those patients who underwent a successful laparoscopic procedure. The overall mean number of admissions for completing the treatment was 2.3. CONCLUSIONS: Combined laparoscopic and endoscopic approach is a viable option for patients with gallstones and choledocholithiasis.