Raising the outcome standards for conventional open cholecystectomy

Postcholecystectomy length of stay declined after the introduction of laparoscopy in 1987. Technology deserves some credit for reducing iatrogenic trauma. However, the improved outcome primarily resulted from setting higher surgical standards. What goals were (and are) achievable with the conventional "open" technique?

One surgeon performed 160 consecutive open cholecystectomies from 1983 to 1987. The patients averaged 46 years of age (range 13 to 100), 62% were female, and 20% presented acutely. Five (3.1%) had common bile duct exploration. Each patient was prepared to accept early discharge. Prompt ambulation followed minimal tissue handling and use of long-acting local anesthesia. Enteral feeding at 300 kcal plus 12 g AAs/ hour began immediately, with swallowed air and potential excess removed automatically by efficient more proximal aspiration.

160 patients were discharged the next day, 158 of 160 (99%) without receiving any narcotics. They absorbed (on average) 3,350 kcal plus 130 g AAs the initial 8 to 16 hours. Serum branched-chain amino acids (BCAA) levels rose above basal within 4 hours. Three patients (1.9%) were readmitted. One (0.6%) had a sterile biloma drained percutaneously. A single acute cholecystitis patient developed sepsis (0.6%), a subphrenic abscess that resolved after drainage. The sole mortality (0.6%) was caused suddenly 27 days postoperatively by a pulmonary embolus.

Laparoscopy is a valuable surgical tool whose actual incremental benefits are yet to be determined. Shorter length of stay after cholecystectomy may primarily reflect the altered expectations and overall improved surgical performance associated with this innovation.