International Surgery Journal

Pateriya A et al. Int Surg J. 2021 Jun;8(6):1767-1771

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DOI: https://dx.doi.org/10.18203/2349-2902.isj20212269
Original Research Article

Open versus laparoscopic cholecystectomy:

a comparative study on patient parameters
Anurag Pateriya, Mathura Prasad Agrawal, Surendra Kumar Samar*

Department of General Surgery, Pacific Institute of Medical Sciences, Udaipur, Rajasthan, India

Received: 04 April 2021

Accepted: 12 May 2021

*Correspondence:
Dr. Surendra Kumar Samar,
E-mail: [email protected]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: The advent of laparoscopic surgeries have heralded a giant leap for minimally invasive surgeries and
are now being used as a primary modality due to its various benefits. The use of laparoscopic surgeries has been
limited only by patient related factors and in certain scenarios by lack of infrastructure availability. The present study
aimed to provide a comparative review of the traditional and minimally invasive modalities.
Methods: The study employed a comparative prospective randomized study model with 100 subjects divided in two
groups based on modality employed. The operative and post-operative parameters were noted and presented.
Results: The study displayed that the advent of post-operative complications as well as hospital stay duration was
higher in traditional laparoscopic cholecystectomy cases.
Conclusions: The study reiterated the long known fact that laparoscopic surgeries in gall stones is favorable from the
patient perspective but is riddled with unavailability due to financial and infrastructure based concerns.

Keywords: Comparative, Cholecystectomy, Laparoscopic, Open method

INTRODUCTION of the patient, reduced hospital stay and better cosmetic

results as compared to the open technique, which have
Cholecystectomy is the process of surgical removal of the further increased its applications.3
gallbladder indicated by reason of symptomatic
gallstones and other gallbladder conditions. It was Carl Epidemiologically speaking an estimated 20 million
Johann August Langenbuch who performed the first people in the United States of America have gallstones.
cholecystectomy procedure in 1882 on a 43 year old man Among these individuals, there are roughly 3 lakh
who was diagnosed with gallstones since almost 16 years cholecystectomies performed annually. An estimated
and established cholecystectomy as an accepted modality 10% to 15% of the affected population round the world
for management.1 From then onwards, open has asymptomatic gallstone disease which either remains
cholecystectomy (OC) was considered as the best hidden or manifests as an accidental finding. Among the
treatment modality along surgical lines for gall stones till 20% cases which are symptomatic, an estimated 1% to
the late 1980s, when a French researcher, Philip Mouret 4% will display complications associated with gallstones,
successfully performed the first laparoscopic such as cholecystitis, gallstone pancreatitis,
cholecystectomy (LC) on an adult subject in 1987.2 choledocholithiasis, gallstone ileus etc.4

Presently, LC enjoys the status of being a safe, reliable The incidence of gallstones is known to increase with an
and routine procedure, preferred by both surgeons and increase in age and demographic studies have
patients due to its minimal access technique which demonstrated that females are more likely to have
includes reduced postoperative pain, faster mobilization gallstones compared to males. It is estimated that

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 Pateria A et al. Int Surg J. 2021 Jun;8(6):1767-1771

approximately 20% of women and 5% of men in the age The subjects who consented to inclusion in the study
bracket of 50 to 65 years have gallstones. Overall, 75% of were provided with a detailed participation information
gallstones are composed of cholesterol and the other 25% sheet explaining the need for the study and that their
are pigmented. Despite the differences in composition of refusal for participation at any stage will not affect their
gallstones and the variance among genders, the clinical treatment. The subjects were subjected to thorough
signs and symptoms of the disease manifest similarly.5 history taking and general examination process. The
routine investigations as well as radiology imaging were
Despite its widely propagated advantages, the pitfalls of performed prior to the surgery. Other protocols were
LC are also well known. The lack of three dimensional followed as per standardized regulations prevailing in the
imaging can lead to a limited surgical view and a lower institution.
discrimination of organelles. It is an obvious contra
indication for patients who cannot sustain or are The study pool comprised of 100 subjects, divided in two
permitted general anaesthesia. In patients with cardiac groups of 50 subjects each. The division was done on the
illnesses, the carbon dioxide insufflation can induce basis of the procedure to be employed for
arrythmias. Also the poor structural visualization can lead cholecystectomy viz LC or OC. Pre-operative checkups
to the increased risk of hemorrhage and bile duct damage and admission were similar for both cases.
or leakage. Coupled with the elevated cost of equipment,
the use of laparoscopic procedures in poorer set ups is a The duration of surgery was noted as the time from
troublesome task.6-8 initiation if skin incision, up to the time till final closure
of sutures. Pain was measured using a visual analog scale
This led to the formulation of a plan for the present study, (VAS). Blood loss was calculated using by gravimetric
which aims to compare the LC and OC in parameters method by swab weighing. In LC it was measured by the
such as duration of procedure, blood loss and volume of irrigation fluids and subtracted from volume
requirements, post-operative pain and analgesia, duration from the fluid collected in suction bottles to estimate the
of hospital stay, financial load on patient and finally final blood loss.
patient response. We hope to provide a conclusion that
will advise on the effectiveness and possible use of a The details of the study parameters were filled in a MS
particular procedure, LC or OC as preferential for excel sheet and subjected to statistical analysis in
patients. consultation with institutional statistician using SPSS
version 12 software.
METHODS
RESULTS
The present study was a comparative prospective
randomized study done in a period of one year from The study sample comprised of 100 adult subjects
September 2019 to September 2020 in the department of including 61 males and 39 females. The average age of
general surgery of Pacific institute of medical sciences, the study subjects was 45.21±14.6 years. There were
Udaipur, Rajasthan. The research proposal was submitted statistically significant differences among the average age
and approved by research committee and institutional between males and females of the study population. The
ethics committee prior to commencing the study. majority of the individuals (n=72) were from a rural
residential area, while the rest of the subjects (n=28) were
The study was done among the outpatient and inpatient from urban area. The predominant occupation among the
wards of the hospital. study subjects were agriculture and livestock related.
Other professions included shopkeepers, mine workers
Inclusion criteria and housewives or unemployed. Educational
qualifications were predominantly high school
Inclusion criteria for the study was age above 20 and level(n=52), with 27 subjects holding bachelor’s degrees,
below 70 years, radiological confirmation of gall bladder while 21 were school dropouts.
calculi done by ultrasonography, individuals who have
provided a written valid consent for inclusion in the The clinical presenting complaints of subjects was varied.
study. Only elective cases were included. Maximum had a chief presenting complaint of abdominal
pain or discomfort, followed by nausea/vomiting,
Exclusion criteria indigestion and dyspepsia (Figure 1). There was no
statistical difference in the chief complaints between the
Individuals refusing consent or unable to provide valid two groups.
consent, emergency cases requiring surgery, cases with
history of previous abdominal surgery in past year, In terms of operative characteristics, it was evident that
individuals with associated co morbidities like cancers, the blood loss was statistically higher in open
oesophageal strictures which can impair pain assessment cholecystectomy cases (Figure 2). The same was seen in
were excluded from the study. total duration of stay and average pain scores among the
subjects.

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 Pateria A et al. Int Surg J. 2021 Jun;8(6):1767-1771

both the groups in the study. The complications were

70 higher among the open cholecystectomy cases (Figure 3).
60
Financially, the cumulative average cost of OC was lower
50
with a value of ₹12,145 as compared to LC having an
40
average cost of ₹14,230. This was statistically significant.
30 Patient response was variable as regards to the procedure.
20 All patients were asked to submit a response on their
10 operative and post-operative care and none of the subjects
0 reported any adverse comments.

DISCUSSION

The present study was conducted with a study population

of 100 subjects which were dominantly male. The
disparity was due to the fact that in the study duration, the
Figure 1: Chief complaints. authors had a lower female turnout in outpatient wards.
The mean age of the subjects was 45.21 years. This is in
concurrence to studies reported by Doke et al and Shukla
Blood Loss >100 ml et al wherein the authors had a similar age group in their
(Frequency) study sample.9,10 The notable difference is the fact that
they had a more uniform distribution of males and
Time to Oral Feed (Hrs) females.

Stay Duration (Days) The commonest presenting complaint was abdominal

pain and discomfort in both the groups. There was no
Avg. Pain Score (VAS) statistically significant difference in the chief presenting
complaints in our study. This is similar to studies by
various authors, wherein the commonest complaints are
Duration of surgery (Mins)
abdominal pain and distension.8-12
0 20 40 60 80 100
The present study comprised mostly of individuals from a
Group LC Group OC rural household, owing to the location of the institution,
which is on the outskirts of the city and caters to the large
rural populace in the vicinity.
Figure 2: Operative parameters.
The mean duration of surgery in the LC group was 86.8
minutes as compared to a lower time for open surgery
Hernia which held at 66.3 minutes by average. This difference
was statistically significant. The study shows a lower
Bleeding time in OC cases and is similar to studies by Doke et al,
Shukla et al and Chattopadhyay et al wherein the authors
Infections reported a lower duration of surgery thought the
difference in duration was varied.9,10,13 This variance can
Jaundice be attributed to surgeon skill and anaesthetic
requirements. However the common denominator exists
Distension
that all OC cases take a relatively lower time.
Nausea/Vomitting
The average blood loss in OC cases was higher, with 31
0 10 20 30 40 50 subjects reporting a loss of over 100 ml blood compared
to only 6 cases in LC group. This is in concurrence with
Group LC Group OC studies by Shukla et al, Sheikh et al and Poggio et
al.10,14,15 The authors in their studies reported a lower loss
of blood. This is attributed to the fact that laparoscopy
Figure 3: Post-operative complications. being a minimally invasive procedure is likely to have a
lower blood loss.
The commonest post-operative complication observed
was nausea and vomiting, followed by abdominal The pain in the post-operative period was lower in LC
distension, jaundice, wound infection and bleeding. There groups as compared to the OC group, owing to the fact
was a statistically significant difference seen between that being a minimally invasive procedure, the likelihood

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 Pateria A et al. Int Surg J. 2021 Jun;8(6):1767-1771

of tissue damage is less. This in turn leads to lower pain 4. Blythe J, Herrmann E, Faust D, Falk S, Edwards-
score and reduces usage of analgesics as well as hastens Lehr T, Stockhausen F, et al. Acute cholecystitis-a
recovery time. These parameters are consistent with cohort study in a real-world clinical setting (ReWO
studies by Doke et al, Shukla et al, Chattopadhyay and study, ncT02796443). Pragmat Observat Res.
Karim et al who reported that the mean pain score, 2018;9:69.
recovery time and time for resumption of normal 5. Kose SH, Grice K, Orsi WD, Ballal M, Coolen MJ.
activities was lower in case of LC as compared to Metagenomics of pigmented and cholesterol
traditional method.8,9,13,16 gallstones: the putative role of bacteria. Sci Rep.
2018;8(1):1-3.
The number of subjects with postoperative complications 6. Choy I, Kitto S, Aryee N, Okrainec A. Barriers to
was higher in OC group in the present study. The the uptake of laparoscopic surgery in a lower-
commonest complication was nausea and vomiting, middle- income country. Surg Endosc.
followed by distension and jaundice. The limiting factor 2013;27(11):4009-15.
was the fact that only OC group had features or 7. Lundberg O, Kristoffersson A. Open versus
complaints of wound infection. This is similar to studies laparoscopic cholecystectomy for gallbladder
by Anmol et al and Coccolini et al where the authors carcinoma. J Hepatobiliary Pancreat Surg.
concluded that post-operative complications and 2001;8(6):525-9.
morbidity was significantly lower in case of laparoscopic 8. Pessaux P, Regenet N, Tuech JJ, Rouge C,
cholecystectomy as compared with the traditional open Bergamaschi R, Arnaud JP. Laparoscopic versus
method.17,18 open cholecystectomy: a prospective comparative
study in the elderly with acute cholecystitis. Surg
CONCLUSION Laparosc Endosc Percutan Tech. 2001;11(4):252-5.
9. Doke A, Gadekar N, Gadekar J, Dash N, Unawane
The aim of the study was achieved in the fact that we S. A comparative study between open versus
were able to determine that despite the advantage of a laparoscopic cholecystectomy. Sch J App Med Sci.
lower cost and less surgical time, OC is not a very patient 2016;4(1):57-61.
friendly procedure. With a higher rate of complications, 10. Shukla A, Seth S, Ranjan A. A comparative study
an enhanced duration of stay, and more time required for between laparoscopic and open cholecystectomy in
resuming normal activities, this is definitely not a feasible cases of cholecystitis with cholelithiasis: one year
option for many individuals. However, its necessity does experience in tertiary care center. Int Surg J
arise in cases where access to minimally invasive surgery 2017;4(3):903-7.
is hampered owing to infrastructural and skill availability 11. Gadaon TR, Talamzii MA. Traditional versus
issues. In rural India, access of high end healthcare is laparoscopic cholecystectomy. Am J Surg.
limited and if available is expensive. Here the OC does 1999;161(3):336-8.
play a role in imparting a substitute. 12. Singh SP, Gupta P, Sharma AK, Mishra M, Singh P,
Mishra SP. Comparison of patient response to
Our study does suffer from limitations. Firstly the laparoscopic versus open cholecystectomy: A study
demographic sample is skewed in favor of males. from a rural center in india. Intl J Sci Res Pub.
Secondly, it would not be a true representative sample 2015;5(6):1-9.
owing to its limited sample size, which we intend to 13. Chattopadhyay K, Das R. Laparoscopic and open
overcome by undertaking a longer more substantiative cholecystectomy: a comparative study. International
study with a broader sample size. J Surg Sci. 2020;4(1):427-30.
14. Sheikh U, Azam S, Mallah MQ, Laghari QA,
Funding: No funding sources Choudhry AM. Comparative study of morbidity of
Conflict of interest: None declared laparoscopic versus open cholecystectomy in
Ethical approval: The study was approved by the complicated gallstone disease. GOMAL J Med Sci.
Institutional Ethics Committee 2011;9(2):200-3.
15. Poggio JL, Rowland CM, Gores GJ, Nagorney DM,
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