Laparoscopic cholecystectomy in the new millennium

Laparoscopic cholecystectomy has become the gold standard for the treatment of symptomatic cholelithiasis. Many authors-including investigators at our institution, who reported one of the initial experiences with laparoscopic cholecystectomy in July 1992-have documented a definite learning curve associated with this procedure. We present a follow-up study of our experience with laparoscopic cholecystectomy and compare these data to an earlier study of the initial experience with laparoscopic cholecystectomy at the Beth Israel Medical Center.

We retrospectively reviewed 300 consecutive patients from March 1998 through March 1999. The patient population was epidemiologically similar to that of the original study with regard to age, sex, and American Society of Anesthesia (ASA) classification. However, whereas the initial population included only patients with chronic disease, in our study 13.7% of the patients had been admitted through the emergency room with acute stone disease of the biliary tract.

We found a 5.7% conversion rate, a 1% rate of major complication, and a 5.7% rate of minor complication rates, as compared to the initial study's rates of 12%, 4%, and 10%, respectively. Whereas none of the patients in the original study left the hospital on the day of surgery and only 49% were discharged within 1 day, in our group, 29 patients (10%) underwent ambulatory procedures and an additional 186 patients (62%) were discharged on the 1st post-operative day. The average duration of the operation was 90 min, which did not represent a statistical improvement over the time of 93 min reported in the earlier study.

Since 1992, both the conversion rate and length of stay have declined at our hospital, but operative time has remained essentially the same. These findings probably reflect a bimodal learning curve, the increase in the number of cholangiograms and additional intraoperative procedures now performed, the greater severity of gallbladder disease currently treated with laparoscopic cholecystectomy, and increases in the number of attending physicians as well as the level of residents who perform this procedure.