Should Subcostal and Lateral Trocars Be Used in Laparoscopic Cholecystectomy? A Randomized,Prospective Study

Introduction

Laparoscopic cholecystectomy (LC) is the standard treatment for symptomatic gallbladder disease. It is well known that LC is superior to open cholecystectomy (OC) in terms of postoperative pain, duration of hospitalization, ability to return to work, and cost. Absolute contraindications for LC are gradually disappearing. Some disadvantages of LC are longer operation time, longer learning curve, and more frequent biliary tract injury, as compared to open methods.^1,2 A trocar is used as a port for the laparoscopic instruments and in maintaining the pneumoperitoneum. An umbilical trocar is used for the laparosopic camera. The camera is extracted and reinserted frequently in order to be cleansed of tissue fluid and electrocauterization smoke intraoperatively. A subxiphoid trocar is used for the dissector, clip applier, hook, scissors, and irrigation system. Many laparoscopic instruments are exchanged through this trocar. Thus, umbilical and subxiphoid trocars are essential in LC. Subcostal and lateral trocars, however, are used for the graspers to retract the fundus and infundibulum of the gallbladder to expose Calot's triangle. The graspers are seldom extracted or exchanged by other instruments, and the function of subcostal and lateral trocars is trivial. It is possible to perform LC without these two trocars.^3–7 The aim of this study was to evaluate the validity of the LC without subcostal and lateral trocars (LCWSL).

Patients and Methods

Sixty patients were prospectively enrolled from June 2006 to June 2007. Inclusion criteria were age 60 years or younger and symptomatic gallbladder disease. Exclusion criteria were: 1) severe cardiopulmonary dysfunction, 2) severe inflammation defined as gallbladder empyema, gangrenous cholecystitis, gallbladder wall thickness >5 mm, or intestinal adhesions diagnosed by preoperative ultrasonography or computerized tomography, and 3) body-mass index (BMI) >40 kg/m². In LCWSL, only two trocars were used at the umbilicus and subxiphoid area. In conventional LC (CLC), four trocars were used at the umbilicus, subxiphoid, right subcostal, and right flank, according to the American method.

Results

The trial profile is shown in Figure 1. A total of 93 patients scheduled for elective LC entered the trial. Of those, 12 patients did not meet the inclusion criteria, 9 patients were eliminated based on exclusion criteria, and 12 patients refused participation. Randomization was accomplished by concealed allocation table. No patients were lost to follow-up. Sixty patients were analyzed. Of the 60 patients, 40 had chronic calculous cholecystitis and 20 had a polypoid lesion of the gallbladder. Fifty-five patients had an American Society of Anesthesiologists (ASA) physical status grade of I and 5 had an ASA grade of II. Two patients had a history of a previous lower abdominal operation. One patient in the LCWSL group had a previous ileocecectomy for cecal diverticulitis and 1 in the CLC group had a previous transabdominal hysterectomy for uterine myoma. It was possible to perform LC in both patients. There were no differences between the two groups in terms of age, sex ratio, BMI, or preoperative comorbidity (Table 1). The operation time of LCWSL was 47.8 minutes and was not different from that of CLC. In the LCWSL group, there was 1 case of gallbladder perforation and 1 case of troublesome bleeding. Two patients in the CLC group had gallbladder perforation. Total blood loss was 23 mL (range, 16–66) in LCWSL. The time to first analgesics was 168 and 156 minutes postoperatively in LCWSL and CLC, respectively. Degrees of pain calculated by VAS were 7.7, 6.4, and 5.7 at 8, 24, and 48 hours postoperatively in the LCWSL group. Degrees of pain in the CLC group were 7.9, 6.7, and 6.1 at 8, 24, and 48 hours, respectively; there were no statistical differences between groups. There were also no statistical differences in terms of time to resume passing intestinal gas, time to return to work, and length of hospital stay. Total lengths of incision were significantly shorter in LCWSL (27.2 versus 38.4 mm) (Table 2). The hospital cost was calculated based on cost reimbursed by the national health insurance system and cost not reimbursed. Patients pay 20% of hospital cost with insurance reimbursement or all of the hospital cost without insurance reimbursement. In the cost with insurance reimbursement, the costs of preoperative workup, surgical operation and anesthetics, medication, and hospital room cost were not different between the LCWSL and CLC groups. However, the cost of laparoscopic instruments in the LCWSL group was cheaper than that of the CLC group by $397 (Table 3). The total hospital cost was $1,195 and $1,592 in LCWSL and CLC, respectively; there was a $397 cost savings in the LCWSL group.

OPEN IN VIEWER

FIG. 1.

Trial profile.

Discussion

Previously, some surgeons have introduced the technique of LCWSL. Slim et al. originally succeeded in performing a three-trocar LC. ³ They used umbilical, subxiphoid, and subcostal trocars. Among 710 patients, the use of the lateral trocar was necessary in only 55 cases (8%); 26 laparoscopies were converted to open procedures (3.6%). Their results were similar to results when using the “classic” four-trocar technique. Moreover, it was less expensive and resulted in one less scar. ¹ Several studies have reported similar results.^2–5 Some researchers have reported their experience with LCWSL. Lomanto et al. performed LCWSL in 25 patients. After inserting the umbilical and subxiphoid trocars, two stitches with nonabsorbable sutures were passed through the fundus to pull up the gallbladder and at the neck of the gallbladder to expose the structures of Calot's triangle. Their technique offered better results in terms of postoperative pain, cosmetic outcome, and cost effectiveness. ⁸ Mori et al. also performed a similar technique. The researchers used umbilical and subxiphoid trocars, and the fundus of the gallbladder was ligated and lifted up by a loop prepared with one string and one cannula. ⁹ Recently, Cuesta et al. used two 5-mm trocars, one for the telescope and the other for laparoscopic instruments, and inserted both through the umbilicus to hide the scar. ¹⁰ A wire (1 mm) was introduced in the subcostal area and, once in the abdominal cavity, was bent by a device introduced through the umbilical trocar. By means of this hook the gallbladder was gently pulled in an upright direction to visualize Calot's triangle. ⁸ Contrary to CLC, another procedure to retract the gallbladder is necessary in LCWSL. This is quite different from three- and four-trocar LC. Moreover, the fundus of the gallbladder is sometimes fixed and is impossible to pull it in the desired direction. This results in some surgeons' hesitation in the use of LCWSL. But, it is clear that reducing the number of trocars has better cosmetic and economic results. Usually, three to four trocars are used in CLC; the subxiphoid trocar is used for the dissector, scissors, clip applier, and extraction of the resected gallbladder. This trocar is important and essential in LC. However, the trocars of the right subcostal and lateral area are used almost invariably for grasper forceps to hold the fundus and infundibulum of the gallbladder to unfold Calot's triangle. It is seldom necessary to change the instruments through these trocars. Based on this, we tried to insert the graspers directly without using the subcostal and lateral trocars to reduce the total number of trocars. Three-millimeter graspers were easily inserted into the peritoneal cavity and were capable of retracting a minimally inflamed gallbladder. Therefore, in these cases, it was not necessary to expose Calot's triangle with methods such as ligation of the gallbladder or using a hook wire, as reported previously in LCWSL. This is clear if we looked at the total operating time of our methods. Seventy minutes were required in LCWSL as previously performed. The mean operation time of our methods was 47.8 minutes; this is the same operative time reported with CLC. There is no difference in the operative procedure, except the insertion of the subcostal and lateral graspers directly into the abdominal cavity without trocars; thus, this procedure could be applied without a steep learning curve. Usually, subcostal or lateral trocars are used as an exit site for the suction drain tube after extraction of the gallbladder. In a previous study, placing the drain tube through the right flank was reportedly difficult, and this difficulty has been described in the literature.^8–10 In spite of not using the trocar, it is possible to pull the drain tube from abdominal cavity in our trial because the grasper effectively takes up the drain tube. Direct insertion of a grasper without a trocar seems to be a more time-saving, easy, and effective technique when performing LCWSL, rather than suturing the gallbladder, making a hook, etc. We used a Veress needle to enlarge the hole to insert the 5-mm grasper in case of severe inflammation of the gallbladder because it was impossible to grasp the gallbladder with a 3-mm grasper. But, direct insertion of a 5-mm grasper without enlarging the preformed hole made by the 3-mm grasper seemed to be possible. This would reduce operation time.

The high cost of LC is an important problem in some countries.^9,10 This phenomenon, in part, comes from unique medical insurance systems that are quite different from the United States. Unfortunately, medical insurance providers of some countries do not reimburse for laparoscopic instruments. However, the hospital-room cost is cheap, compared to the cost of laparoscopic instruments. In our country, the cost of a laparoscopic trocar is $120∼150 USD, while the hospital-room cost for one day is $50∼100 USD. In the countries having similar circumstances, new techniques to cut the cost of CLC are needed. Champault reduced the cost by nearly half by using an open method for the pneumoperitoneum, reusable trocars, reusable instruments, bipolar coagulation of the cystic artery, intracorporeal ligature of the cystic duct, no use of suction lavage apparatus, and use of a surgical glove as a bag to extract the gallbladder. This technique seems to be very attractive in view of cost effectiveness and appears to be the most effective method to reduce the total cost of LC. However, it bears some risks of morbidity due to the methods of ligating the cystic duct and artery, although there were none in their study.

Conclusions

In LC, trocars have the highest cost, and it is wise, from a safety perspective, not to change the surgical procedure, but to instead reduce the numbers of trocars and apply reusable trocars. Using only two reusable trocars and the same technique as in conventional CLC, this modified LCWSL cut the total hospital cost by nearly $400 USD. No additional procedures are needed, unlike previously reported two-trocar LC procedures. We assure that this modified technique will give cost-saving benefits without technical difficulty in countries having similar insurance systems.