Laparoscopic Surgery in the Elderly: Personal Experience in 141 Cases

Abstract

Introduction:

As life expectancy increases, the number of elderly patients presenting with surgically correctable diseases will rise as well. For advantages, which are well recognized in young patients, laparoscopic surgery has been proposed also for older patients. Because of underlying chronic diseases, however, elderly patients have been considered at high risk for the laparoscopic approach. Several studies have pointed out the risks related to cardiac, respiratory, or general comorbidities when elderly patients are proposed for laparoscopic treatment of their surgical disease.

Patients and Methods:

In this study, we reported our experience in 141 patients older than 65 years who were submitted to laparoscopic procedures for several indications. According to American Society of Anesthesiologists (ASA) score, patients were classified as ASA I in 70.9% of cases, ASA II in 27.6%, and ASA III in 1%.

Results:

No mortality has been reported. Conversion rate was 5.3% for bleeding in 4 cases or intraoperative hypotension in 2 cases. Mean hospital stay was 5 days. Postoperative complication was reported in 1 case and consisted of a hearth attack.

Conclusions:

Laparoscopic surgery in the elderly is a safe procedure, if preoperative selection of the patients is accomplished. An experienced surgical team and multidisciplinary approach are mandatory.

Introduction

After its introduction in 1987 by Mouret,¹ laparoscopic surgery has been widely accepted. For advantages, namely the reduction of postoperative pain, reduced hospitalization, and costs, laparoscopic techniques are today performed routinely in many indications and reduced alterations in postoperative hemostatic and immunologic changes.² With the increasing age of the general population, who needs surgery more frequently than in the past, laparoscopic surgery has recently been proposed for elderly patients.³ These patients, whose functional capacity and reserve are commonly compromised, could benefit of the mini-invasive approach, since it could induce less perioperative physiopathologic changes.^4,5 However, for the high incidence of comorbidity conditions, consisting mainly of associated cardiopulmonary, immunologic, or kidney diseases, which can negatively interfere with the postoperative outcome,^6,7 laparoscopic surgery in elderly patients is still debated and its routine use is controversial. Risks, complications, and mortality of laparoscopic surgery in elderly patients are still under evaluation in the literature. In this study, we retrospectively reviewed our experience in laparoscopic surgery performed in patients older than 65 years of age, and we analyzed our data in order to assess safety and feasibility and to eventually help selecting elderly patients for these mini-invasive procedures.

Patients and Methods

The charts of 237 patients older than 65 years of age were retrospectively reviewed. Laparoscopic surgery was accomplished in 141 of 237 patients. All patients were treated in the same surgical unit and operated on by the same surgeon (RV) from June 1995 to may 2009. Male-to-female ratio was 0.8, with a mean age of 71.7 (range, 65–96) (Table 1). Laparoscopic procedures included (Table 2) laparoscopic cholecystectomy in 72 cases (in 7 cases associated with common bile duct exploration by the transcystic or choledocotomy approach, in 1 case associated with umbilical hernia repair, and in 1 case associated with liver biopsy), laparoscopic splenectomy in 14 cases, laparoscopic left colectomy with anterior resection of the rectum in 16 cases (in 1 case associated with an incidental splenectomy, in 1 case with a protective ileostomy, and in 1 case associated with a cholecystectomy), laparoscopic right colectomy in 2 cases, laparoscopic atypical resection of liver tumor in 1 case, laparoscopic radiofrequency ablation of liver primary or secondary tumors in 5 cases, diagnostic laparoscopy in 5 cases, laparoscopic bioptic removal of abdominal or retroperitoneal lymphonodes in 6 cases, laparoscopic repair of bilateral or unilateral inguinal hernia, respectively, in 5 and 2 patients, laparoscopic crural hernia repair in 1 case, umbilical hernia or incisional abdominal hernia, respectively, in 1 and 4 patients, left adrenalectomy in 3 cases, laparoscopic gastrojejunal anastomosis in 1 case of unresectable pancreatic tumor, laparoscopic renal cystectomy in 2 cases, and the laparoscopic repair of iatrogenic perforation of uterus and small bowel in 1 case.

Table 1.

Personal Experience in Laparoscopic Surgery in the Elderly

Number of patients	141
Period of study	January 1995 to May 2009
Male/Female	8/10
Mean age (range)	71.7 years (65–96)

Table 2.

Laparoscopic Procedures Performed

Cholecystectomy	63 patients
Cholecystectomy + common bile duct exploration	7
Cholecystectomy + umbilical hernia repair	1
Cholecystectomy + liver biopsy	1
Right colectomy	2
Left colectomy + anterior rectal resection	16
Splenectomies	14
Atypical resection of liver tumor	1
Radiofrequency ablation of liver	5
Diagnostic laparoscopy	5
Bioptic removal of abdominal lymphonodes	6
Repair of bilateral inguinal hernia	5
Repair of unilateral inguinal hernia	2
Crural hernia repair	1
Umbilical hernia repair	1
Incisional hernia repair	4
Gastrojejunal and loop anastomosis	1
Renal cystectomy	2
Repair of iatrogenic perforation of uterus and small bowel	1
Left adrenalectomy	3

Preoperative workup of the patients for the evaluation of the preoperative risk included, in all cases, a routine lab test, electrocardiography (ECG), echocardiography, and chest X-ray. Ambulatory blood-pressure monitoring was accomplished in 39 patients with anamnestic hypertension. Holter ECG monitoring was analyzed preoperatively in 20 cases with anamnestic cardiac arrhythmias. According to American Society of Anesthesiologists (ASA) scores, patients submitted to laparoscopic procedures were classified as ASA I in 70.9% of cases, ASA II in 27.6%, and ASA III in 1%. The techniques we use for the laparoscopic procedures are reported elsewhere.^8–11

Results

Table 3 summarizes the results in this series of patients. Operative time depended on the laparoscopic procedure performed. Overall, mean operative time was 180 minutes (range, 50–300). Conversion to open surgery was necessary in 5.3% of patients, mainly for intraoperative bleeding (4 cases) or for intraoperative hypotension in 2 patients. Mean hospital stay was 5 days, ranging from 2 to 10 days in relation to the complexity of the operation with patients with colon resection hospitalized for longer time.

Table 3.

Results

Conversion to open surgery	5.3%
Intraoperative bleeding	4 patients
Intraoperative hemodynamic hypotension	2 patients
Mean hospital stay (range)	5 days (2–10)
Postoperative complications	1 patient (heart attack)
Mortality	0

For the evaluation of postoperative complications, all the patients, after discharge from the hospital, were observed weekly for a follow-up period of 1 month. Postoperative complications were observed in only 1 case. The patient developed a heart attack on postoperative day 4 and was admitted to the cardiac unit and successfully treated by medical therapy. No mortality was reported in the first month after the operation.

Discussion

Throughout the 1990s, no aspect of surgery has grown faster than the field of operative laparoscopy. Long recognized for its diagnostic utility, laparoscopy vaulted to the forefront of surgical intervention shortly after reports of a safe, efficient method for laparoscopic cholecystectomy were published.¹ There has since been a vast expansion of the field of laparoscopic surgery, with application designed not only for general and gynecologic surgery, but also for endocrine, vascular, orthopedic, and urologic surgery. Minimally invasive operations were developed to achieve the same goals of open operations, but with reduced physiologic consequences. Many benefits of laparoscopic procedures have been recognized,^4,12 and it has been shown to reduce postoperative pain and length of hospital stay, provide faster recovery, and to be cost-effective, in comparison to open surgery.

Most western societies have undergone a progressive aging of their population in the last century. In the United States alone, life expectancy has increased by an average of 5 years in the last 25 years,¹³ and this trend is expected to continue. Health trends will be determined mainly by the aging of the world's population. With improved life expectancy, the proportion of people surviving their 80s is predicted to rise dramatically in Western countries,¹³ while elective and emergency interventions in elderly patients are expected to rise likewise.

Elderly patients pose several unique challenges to their surgeons. As the body ages, there is a decline in the normal function of most organ systems.¹⁴ Age-related decline in organ function is highly variable and occurs at different rates for different people. Moreover, each change in organ function has the potential to become clinically significant, when subjected to the physiologic stress of major surgery. The presence of comorbid conditions further affects the natural aging process by reducing the recuperative reserve of older patients following surgical stress. Numerous diseases are associated with advancing age. The incidence of hypertension, atherosclerosis, and chronic pulmonary disease are often elevated in older patients.¹⁵ In our report, according to ASA scores, we classified as ASA I 100 patients, ASA II 39 cases, and ASA III 2 patients. Comorbidity conditions, however, did not interfere in any cases with the choice of laparoscopic approach when indications for surgery had been established.

It is important, however, to mention that laparoscopic surgery is associated with physiologic changes that are rarely observed during open surgery.^16–18 Some studies^16,17 demonstrate that peritoneal insufflation with moderately increased intra-abdominal pressure results in moderate alterations in hemodynamic parameters. The pneumoperitoneum causes an increase in mean arterial pressure, systemic vascular resistance, and inferior caval vena pressure. Initially, after insufflation, there is an increase in cardiovascular pressure and pulmonary wedge pressure, although these values tend to fall gradually while the pneumoperitoneum is maintained. Stroke volume generally decreases, while cardiac output is generally preserved and cardiac heart rate increases. Elevated partial pressure of carbon dioxide (PaCO₂) may further augment heart rate when carbon dioxide (CO₂) is the gas of insufflation. Concerning cardiac output, however, conflicting results have been shown with cardiac output, which has been demonstrated to increase,¹⁸ decrease,^19–21 or remain unchanged.^22,23 Some of these differences may probably be explained by different degrees of cardiac disease at the time of operation. In addition, using transthoracic bioimpedance, Critchley et al.,²⁴ contrary to the statements of other researchers^18–20 demonstrated the stability of cardiac index and stroke volume during intra-abdominal insufflation. Moreover, Cunnigham et al.,²⁵ using transesophageal echocardiography, observed changes in the loading conditions during laparoscopy and demonstrated that preload, assessed by the left ventricular end-diastolic area, and left ventricular ejection fraction, were not influenced, either by the pneumoperitoneum (IAP = 15 mm Hg) or by the patient's position on the operating table. In addition to circulatory changes, in aged patients, laparoscopy may induce also a physiologic alteration of ventilation.¹⁷ In fact, elevation of the diaphragm induced by the pneumoperitoneum and limited lung expansion decrease functional residual capacity and lung compliance and increase dead space with the worsening of acidosis and hypercapnia.

Interestingly, patient positioning may play a role in the hemodynamic changes during laparoscopic surgery. The Trendelenburg position, for example, may increase right-sided filling pressures and, therefore, may augment a patient's effective volume status, although, under these conditions, cardiac function has been shown both to improve and decline as a result.^18,19 Concerning the effect of age on pulmonary gas exchange during laparoscopy in Trendelenburg position, Takahata et al.²⁶ has reported an increase in P(aET)CO₂ during CO₂ insufflation in the Trendelenburg position in the elderly age group and this change was increasing with pneumoperitoneum pressure. These researchers proposed a monitoring of P(aET)CO₂ with caution in elderly patients. These physiopathologic modifications explain the higher rates of intraoperative cardiopulmonary complications of laparoscopy versus open surgery, which, as reported by Popken et al.,²⁷ are, respectively, 15.8 versus 7.7%. Rishimani and Gautman²⁸ have proved that an abdominal pressure of 6 mm Hg or less versus 14 mm Hg elicits a lower increase of mean arterial pressure (24.9 versus 41.5%), airway pressure (10 versus 44.3%), and end-tidal CO₂ (10.6 versus 20.5%).

It is our opinion that some technical details during laparoscopic surgery may not interfere with adverse cardiopulmonary physiologic changes. In our cases, in elderly patients, we always induce the pneumoperitoneum gradually up to 8 mm Hg. Never do we change the positioning of patients during the insufflation of CO₂. Cardiopulmonary monitoring is of help during these initial phases of laparoscopy. Using this approach, we did not observe any serious trouble during laparoscopy, and, in our experience, only in 2 cases had we converted to an open procedure for adverse intraoperative hemodynamic changes.

With increasing experience in laparoscopic surgical techniques for nearly all abdominal diseases, the choice of a laparoscopic approach in the elderly has become a reality in many indications. Many surgeons^4,5 believe that these procedures are ideally suited for older patients, and age alone is no longer considered a contraindication for most surgical procedures. It is our opinion that laparoscopic cholecystectomy in the elderly should be recommended as the standard procedure. Selection of the patient is, however, mandatory to reduce morbidity and mortality. We included, as an indication for laparoscopic surgery, patients mainly classified as ASA I or II. Sicker patients, since their increased hemodynamic risks with increased abdominal pressure during laparoscopy, were operated on with open surgery. No comparison, therefore, could be done between the nonhomogeneous open and laparoscopic groups of our patients over 65 years of age. In our experience, however, in laparoscopic elective cholecystectomy, the morbidity and mortality was similar to those reported in young patients and in open surgery. Conversion rate was not different to the one observed in the young population.

Besides gallbladder surgery, laparoscopic colorectal surgery is an attractive alternative to open approach. Law et al.,²⁹ in their study, included a sizable number of elderly patients with open and laparoscopic colorectal resection. The postoperative mortality of patients treated with laparoscopic colorectal resection was only 1.5%, which was less than that of open surgery (5.6%), although it did not reach a statistically significant level. The overall morbidity rate of the patients was 33.8%. These results were comparable with other series with elderly patients,³⁰ and the researchers considered these findings not high when taking into account the prospective documentation of the morbidities, the high incidence of comorbid conditions of the patients, and the high proportion of patients with rectal cancer. He concluded that the laparoscopic approach is a safe option for the elderly. Peters and Fleshman³¹ prospectively evaluated the outcome of minimally invasive colectomy in 103 patients aged 65 years or older; 81 procedures were completed laparoscopically. The complication rate did not differ significantly between the groups (25% in the laparoscopic group versus 23% in the converted group), but postoperative hospitalization was significantly shorter in the laparoscopic group (5.3 days), in comparison with the converted group (8.1 days).

To assess objectively the role of laparoscopic colorectal surgery in the elderly, Reissman et al. compared their results in patients older than 60 years (n = 36; mean age, 73 years) to a younger, procedure matched cohort (n = 36; mean age, 44 years); 38% of the older patients had comorbid conditions. There were no statistically significant differences between the younger and older cohort in complications (11% in the younger group versus 14% in the older group) or conversion (8 versus 11%). Length of postoperative ileum (2.8 versus 4.2 days) and hospital stay (5.2 versus 6.5 days) did not differ significantly between the groups by age. Their data dearly demonstrated that advanced age should not be a contraindication for laparoscopic colorectal procedures. Our experience is in favor of the laparoscopic approach in old patients who need colorectal surgery. Although procedure-related complexity results in an increased duration of surgery, and extreme positioning of patients is often required, laparoscopic colorectal surgery, in recent experience, have been our procedure of choice unless comorbidity conditions contraindicated the pneumoperitoneum. Reduced CO₂ pressure, in our opinion, is mandatory during long-lasting procedures, such as colorectal resections, since it is, in addition to the other above-mentioned technical pearls, probably responsible for the low incidence of intraoperative troubles which we reported in this series.

Conclusions

Laparoscopic surgery is a safe procedure also in elderly patients. Selection of cases is mandatory to reduce the incidence of intra- or postoperative complication. Hemodynamic and respiratory preoperative evaluation is essential to rule out, from the laparoscopic procedure, patients who can develop trouble for an intraoperative pneumoperitoneum. Performance of the laparoscopic procedure with low intra-abdominal pressure (not high than 8 mm Hg) is of help to complete the procedure without need for a conversion to open surgery. Experienced surgical team and multidisciplinary approach are recommended.

Disclosure Statement

No competing financial interests exist.

References

Mouret

. How I developed laparoscopic cholecystectomy. Ann Acad Med Sing, 1996; 25:744–747.

Vecchio

, Cacciola

, Martino

, Cacciola

, MacFadyen

. Modifications of coagulation and fibrinolytic parameters in laparoscopic cholecystectomy. Surg Endosc, 2003; 17:428–433.

Senagore

, Madbouly

, Fazio

, Duepree

, Brady

, Delaney

. Advantages of laparoscopic colectomy in older patients. Arch Surg, 2003; 138:25–26.

Fried

, Clas

, Meakins

. Minimally invasive surgery in the elderly patient. Surg Clin North Am, 1994; 74:375–387.

Lujan

, Sanchez Bueno

, Parrilla

et al. Laparoscopic versus open cholecystectomy in patients aged 65 and older. Surg Laparosc Endosc, 1998; 8:208–210.

Margotta

Jr. , Howitz

, Willis

, Wallack

. Cholecystectomy in the elderly. Am J Surg, 1988; 156:509–512.

Watters

, McClaran

. The elderly surgical patient. Wilmore

, Cheung

, Harken

et al. American College of Surgeons Scientific American Surgery. New York: Scientific American, 1999; 2–31.

Vecchio

, Gelardi

, Barbaros

, Intagliata

, Cacciola

. How to prevent intraoperative risks and complications in laparoscopic splenectomy. Giorn Chirurg(in press).

Vecchio

, Gelardi

, Intagliata

, Swehli

, Vicari

. Laparoscopic left colectomy: From the perfect knowledge of surgical anatomy to the proper surgical technique. Giorn Chirurg(in press).

10.

Vecchio

, MacFadyen

. Laparoscopic common duct exploration. Langenbecks Arch Surg, 2002; 387:45–54.

11.

Vecchio

, Di Martino

, Lipari

, Sambataro

. Previous appendicitis may affect peritoneal overlap of the mesh in laparoscopic inguinal hernia repair. Surg Endosc, 2002; 16:359.

12.

Frazee

, Roberts

, Symmonds

et al. What are the contraindications for laparoscopic cholecystectomy. Am J Surg, 1992; 164:491–495.

13.

Stewart

, Stitz

, Lumley

. Laparoscopic-assisted colorectal surgery in the elderly. Br J Surg, 1999; 86:938–941.

14.

Weeks

, Nelson

, Gelber

et al. Short-term quality-of-life outcomes following laparoscopic-assisted colectomy vs. open colectomy for colon cancer: A randomized trial. JAMA, 2002; 287:321–328.

15.

Schwandner

, Schiedeck

THK

, Bruch

H-P

. Advanced age—indication or contraindication for laparoscopic colorectal surgery? Poster presentation at the 115th Congress of The German Society Dis Colon Rect, 1999; 42:356–362.

16.

Iwase

, Takao

, Watanabe

, Tanaka

, Kido

, Ogawa

, Ono

, Yoshitake

. Intra-abdominal venous pressure during laparoscopic cholecystectomy. HPB Surg, 1994; 8:13–17.

17.

Wittgen

et al. Analysis of the hemodynamic and ventilatory effects of laparoscopic cholecystectomy. Arch Surg, 1991; 126:997–1001.

18.

Westerband

, Van De Water

, Amzallag

, Lebowitz

, Nwasokwa

, Chardavoyne

, Abou-Taleb

, Wang

, Wise

. Cardiovascular changes during laparoscopic cholecystectomy. Surg Gynecol Obstet, 1992; 175:535–538.

19.

Harris

, Ballantyne

, Luther

, Perrino

. Alteration of cardiovascular performance during laparoscopic cholecystectomy: A combined hemodynamic and echocardiographic analysis. Anesth Analg, 1996; 83:482–487.

20.

Ninomiya

, Kitano

, Yoshida

, Bandoh

, Baatar

, Matsumoto

. comparison of pneumoperitoneum and abdominal wall lifting as to hemodynamics and surgical stress response during laparoscopic cholecystectomy. Surg Endosc, 1998; 12:124–128.

21.

Jakimovicz

, Stultiens

, Smulders

. Laparoscopic insufflation of the abdomen reduces portal venous flow. Surg Endosc, 1998; 12:129–132.

22.

Myre

, Smith

, Buanes

, Stokland

. Haemodynamic changes during laparoscopy. Br J Anaesth, 1994; 72,Suppl 1:18.

23.

Dhoste

, Lacoste

, Karayan

, Lehuede

, Thomas

, Fusciardi

. Haemodynamic and ventilatory changes during laparoscopic cholecystectomy in elderly ASA III patients. Can J Anaesth, 1996; 43:783–788.

24.

Critchley

LAH

, Critchley

JAJH

, Gin

. Haemodynamic changes in patients undergoing laparoscopic cholecystectomy: Measurement by transthoracic electrical bioimpedance. Br J Anaesth, 1993; 70:681–683.

25.

Cunningham

, Turner

, Rosenbaum

, Rafferty

. Transoesophageal echocardiographic assessment of haemodynamic function during laparoscopic cholecystectomy. Br J Anesth, 1993; 70:621–625.

26.

Takahata

, Kunisawa

, Nagashima

, Mamiya

, Sakurai

, Fujita

, Fujimoto

, Iwasaki

. Effect of age on pulmonary gas exchange during laparoscopy in the Trendelenburg lithotomy position. Acta Anaesthesiol Scand, 2007; 6:687–692.

27.

Popken

, Küchle

, Heintz

, Junginger

. Cholecystectomy in high-risk patients. A comparison between conventional and laparoscopic procedures. Chirurg, 1998; 69:61–65.

28.

Rishimani

ASN

, Gautam

. Hemodynamic and respiratory changes during laparoscopic cholecystectomy with high and reduced intra-abdominal pressure. Surg Laparosc Endosc Percut Tech, 1996; 6:201–204.

29.

Law

, Chu

, Tung

. Laparoscopic colorectal resection: A safe option for elderly patients. J Am Coll Surg, 2202 Dec 195,6:76873.

30.

Spivak

, Vandemaele

, Friedman

, Nussbaum

. Colorectal surgery in octogenarians. J Am Coll Surg, 1996; 183:46–50.

31.

Peters

, Fleshman

. Minimally invasive colectomy in elderly patients. Surg Laparosc Endosc, 1995; 5:477–479.