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Introduction: In order to improve the outcome of classical laparoscopic cholecystectomy (CLC), surgeons have attempted to minimize tissue trauma. The aim of this study is to describe the technique of mini-laparoscopic cholecystectomy (MLC) and to report the outcome of this approach when used as a routine procedure., Methods: Since January 2012, all consecutive patients undergoing MLC were included in this study. Operative and perioperative data were prospectively collected. Additionally, cost analysis was performed., Results: From 2012 to 2015, 200 MLC were performed (F/M: 132/68, mean age 45±16 years). Mean operative duration was 97±32min for the first 50 patients and 75±25min for the subsequent 150 patients (P<0.0001). Modifications in the number or size of trocars were necessary in nine of the first 50 procedures and in seven of the subsequent 150 procedures (P=0.003). Perioperative morbidity included gallbladder perforation (n=28) or moderate (<50mL) bleeding (n=6). Postoperative morbidity was 4%. The mean global cost for a MLC procedure was 1757±1855 euros. This cost decreased from 2946±3115 euros in the first 50 patients to 1390±1278 euros in the subsequent 150 patients (P=0.001)., Conclusion: Mini-laparoscopy can be used for routine elective cholecystectomy. This approach is associated with low morbidity and good cosmetic results., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Our objective was to determine the probability threshold for recurrent symptoms at which elective cholecystectomy compared to observation in older patients with symptomatic cholelithiasis is the more effective and cost-effective option. We built a decision model of elective cholecystectomy versus observation in patients >65 presenting with initial episodes of symptomatic cholelithiasis that did not require initial hospitalization or cholecystectomy. Probabilities for subsequent hospitalization, emergency cholecystectomy, and perioperative complications were based on previously published probabilities from a 5 % national sample of Medicare patients. Costs were estimated from Medicare reimbursements and from the Healthcare Cost and Utilization Project. Utilities (quality-adjusted life years, QALYs) were obtained from established literature estimates. Elective cholecystectomy compared to observation in all patients was associated with lower effectiveness (-0.10 QALYs) and had an increased cost of $3,422.83 per patient at 2-year follow-up. Elective cholecystectomy became the more effective option when the likelihood for continued symptoms exceeded 45.3 %. Elective cholecystectomy was both more effective and less costly when the probability for continued symptoms exceeded 82.7 %. An individualized shared decision-making strategy based on these data can increase elective cholecystectomy rates in patients at high risk for recurrent symptoms and minimize unnecessary cholecystectomy for patients unlikely to benefit.

Background: Clinicians must choose a treatment strategy for patients with symptomatic cholelithiasis without knowing whether common bile duct (CBD) stones are present. The purpose of this study was to determine the most cost-effective treatment strategy for patients with symptomatic cholelithiasis and possible CBD stones., Study Design: Our decision model included 5 treatment strategies: laparoscopic cholecystectomy (LC) alone followed by expectant management; preoperative endoscopic retrograde cholangiopancreatography (ERCP) followed by LC; LC with intraoperative cholangiography (IOC) ± common bile duct exploration (CBDE); LC followed by postoperative ERCP; and LC with IOC ± postoperative ERCP. The rates of successful completion of diagnostic testing and therapeutic intervention, test characteristics (sensitivity and specificity), morbidity, and mortality for all procedures are from current literature. Hospitalization costs and lengths of stay are from the 2006 National Centers for Medicare and Medicaid Services data. The probability of CBD stones was varied from 0% to 100% and the most cost-effective strategy was determined at each probability., Results: Across the CBD stone probability range of 4% to 100%, LC with IOC ± ERCP was the most cost-effective. If the probability was 0%, LC alone was the most cost-effective. Our model was sensitive to 1 health input: specificity of IOC, and 3 costs: cost of hospitalization for LC with CBDE, cost of hospitalization for LC without CBDE, and cost of LC with IOC., Conclusions: The most cost-effective treatment strategy for the majority of patients with symptomatic cholelithiasis is LC with routine IOC. If stones are detected, CBDE should be forgone and the patient referred for ERCP., (Copyright © 2011 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Routine intraoperative cholangiography (IOC) has been advocated as a viable strategy to reduce common bile duct injury (CDI) during cholecystectomy. This is predicated, in part, on the low cost of IOC, making it a cost-effective preventive strategy. Using billed hospital charges as a proxy for costs, we sought to estimate costs associated with the performance of IOC., Methods: The 2001 National Inpatient Survey (NIS) database was assessed for IOC utilization and associated charges. Average charges for hospital admission where the primary procedure was laparoscopic cholecystectomy were compared for those associated with and without the performance of IOC., Results: Eighteen percent of cholecystectomies were performed in facilities that never perform IOC. Routine IOC (defined as >75% of cholecystectomies performed in any one hospital having a concomitant IOC) was performed in only 11% of hospitals. In the remaining 71% of hospitals, selective IOC was performed. IOCs were associated with US $706-739 in additional hospital charges when performed in conjunction with laparoscopic cholecystectomy. We project a cost of US $371,356 to prevent a single bile duct injury by using routine cholangiography., Conclusion: We conclude that only a minority of hospitals performs cholecystectomies with routine IOC. Because of the significant amount of hospital charges attributable to IOC, routine IOC is not cost-effective as a preventative measure against bile duct injury during cholecystectomy.

Between 10% to 15% of the adult population develop gallstones. Therefore, cholecystectomy is among the most common operations in general surgery. The diagnosis of cholelithiasis depends on the patient's history, clinical findings, laboratory tests and ultrasound examination. Once diagnosis of symptomatic gallbladder disease has been confirmed, laparoscopic cholecystectomy is the treatment of choice. Its advantages in comparison with open surgery are decreased morbidity, costs and hospital stay. Open cholecystectomy is still the treatment of choice for complicated gallstone disease (i.e. cancer, Mirizzi's syndrome, severe inflammation) and in high-risk patients. In case of acute cholecystitis, early laparoscopic cholecystectomy is a safe procedure and is associated with the same benefits as for symptomatic disease.

Background: The aim of this study was to show that laparoscopic cholecystectomy can be performed safely without routine intraoperative cholangiography., Methods: We performed a retrospective analysis of 1139 consecutive patients (376 men and 763 women with an average age of 51.4 years) who underwent laparoscopic cholecystectomy between 1991 and 1999. In all, 227 patients (20%) were selected to undergo preoperative endoscopic retrograde cholangiopancreatography (ERCP) on the basis of four criteria for risk of stones., Results: ERCP allowed us to make a diagnosis of biliary stones in 53.3% of the selected patients. Extraction of the stones was successful in 97% of the cases. In 14% of cases, ERCP was normal; in 32.7%, some useful diagnostic information was obtained. There were three complications (pancreatitis) following endoscopy (complication rate, 1.3%). Laparoscopic cholecystectomy was successful in 92% of patients. The postoperative morbidity rate was 3.2% (major complications, 0.5%). There were no deaths. During a follow-up period ranging from 3 to 97 months, six patients (0.6%) were found to have residual biliary stones., Conclusion: This study confirms the hypothesis that laparoscopic cholecystectomy can be performed safely without routine intraoperative cholangiography.

The time has come to subject surgery to the same rigours of economic assessment that other health-care sectors are already receiving--namely, the comparative assessment of costs and benefits. The surgical management of gallstones provides a good example of the role of economics in surgery. Gallstone disease is common and patients are usually referred to a surgeon, but the threshold for intervention is not agreed and varies widely, with considerable implications for resources. Gallstone removal has been subject to much innovation over the past 10 years, yet economic assessment of laparoscopic and "mini" cholecystectomy and of gallstone lithotripsy is rare, despite the fact that operation rates have increased by up to 50% in some countries. For surgery to compete with other interventions, economic assessment of new surgical techniques will be increasingly important. This assessment should be based on well-conducted clinical trials in which interventions are provided in a routine service setting, and in which benefits are assessed among other things on the basis of the patient's perceived quality of life. Economic assessment often needs data beyond those collected in a clinical trial, however pragmatic the trial design, so modelling will often be required, incorporating a range of sources of evidence. Finally, evidence alone will not be enough to promote cost-effective practices. The take-up of surgical techniques will always be affected by the way hospitals and surgeons are remunerated. Affecting practice requires a realistic system of reimbursement that reflects evidence on cost effectiveness.

Background: Local anesthesia at the trocar site in laparoscopic cholecystectomy is expected to decrease postoperative pain and hence expedite recovery. The aims of this prospective randomized study were to investigate the effect of local anesthesia and to discover whether it is cost effective., Methods: For this study, 100 patients undergoing laparoscopic cholecystectomy were randomized into two groups. The 43 study patients were injected with 0.5% bupivacaine hydrochloride at the trocar site before the trocars were inserted. They then were compared with 41 control patients who received no local anesthesia. The remaining 16 patients were excluded from the study. The postoperative pain was evaluated at the standard four trocar sites at 4 h and 24 h after surgery on a scale 1 (the mildest pain the patient had ever experienced) to 10 (the most severe pain the patient had ever experienced). Postoperative pain medications and their cost were evaluated., Results: There was no difference between the two groups with regard to gender, age, weight, operative time, estimated operative blood loss, and bile culture. The patients who received bupivacaine at the trocar site clinically had less pain (p < 0.001 for all four sites) both at 4 and 24 h after surgery. The treatment group patients used less mepiridine and promethzine than the control group (p = 0.001 and 0.002, respectively) postoperatively. Overall, the patients who had local anesthesia used less postoperative pain and antiemetic medication than the control patients (p = 0.02). This afforded a significant decrease in the costs and charges of these medications (p = 0.004 and 0.005, respectively). Three patients in the study group were discharged from the hospital the day of surgery., Conclusion: Preinsertion of local anesthesia at the trocar site in laparoscopic cholecystectomy significantly reduces postoperative pain and decreases medication usage costs.

Since 1997, laparoscopic cholecystectomy has been performed as one-day surgery (LC/DS) at our institution. Among the 122 patients enrolled in this program, 97 (80%) were successfully discharged within 24 hours after admission. Discharge was delayed for the other 25 patients, although 12 (48%) of them were discharged on postoperative day (POD) 2 or 3. This study not only verified the efficacy of LC/DS in shortening convalescence and allowing an early resumption of work but also confirmed the safety of LC/DS except in one patient with hemophilia A who required laparotomy for intraabdominal bleeding on POD 13. LC/DS is now the first choice of treatment for cholelithiasis regardless of symptoms. Discharge can be expected within 24 hours after admission in most cases, although the preference of patients should be considered when determining the timing of discharge.

A total of 140 patients underwent outpatient laparoscopic cholecystectomy in an outpatient clinic. Evaluation and follow-up of the patients were done prospectively. Population and preoperative data were comparable to published studies of patients operated on in hospitals. There were no serious intra- or postoperative complications. Postoperatively, patients needed less pain medication, were less tired and returned to work earlier than patients after clinical laparoscopic cholecystectomies. Outpatient laparoscopic cholecystectomy offers a good alternative to patients with moderate operative risks (ASA 1-3). It could reduce costs in the German health system and would be therefore highly cost effective.

Background: There has been a debate about the cost-effectiveness of laparoscopic cholecystectomy (LC), as well as a concern regarding its possible overutilization and changes in the indication for surgery., Methods: A retrospective analysis of all cholecystectomies performed at UCDMC from 1988 to 1994 was done. The annual rate of cholecystectomy increased by 50% in 1990 when LC was introduced but has since stabilized at a rate 11% higher than the rate before LC. The disease status and severity did not change., Results: The incidence of nonelective surgery remained stable at 31.2% to 37.5%. Elective cholecystectomy had lower mortality (0.16% vs 1.8%, P = 0. 029), morbidity (2.6% vs 11.2%, P = 0.0001), and conversion rate (2. 6% vs 16%, P = 0.0001) and a shorter length of stay (2.1 days vs 5.4 days), compared with nonelective procedure., Conclusions: The indication for surgery in cholelithiasis has not changed since the introduction of LC. In patients with symptomatic gallstones, early elective surgery is recommended and may be more cost-effective.

Background: Laparoscopic cholecystectomy (LC) has had a major impact on the treatment of patients with biliary tract disease, but the magnitude and the details of its effects on biliary surgery remain incompletely described. The purpose of this study was to perform a statewide, population-based, time-series analysis of the effects of LC on biliary surgery., Study Design: Patient data were obtained from the statewide hospital discharge database that collects data from all 157 hospitals in the state of North Carolina. All patients with hospital admissions for biliary tract disease from 1988 through 1993 were selected for analysis., Results: The use of open cholecystectomy (OC) dropped from 100 percent of all cholecystectomies in 1988 to 32.3 percent in 1993, while LC increased from eight cases in 1988 to over 7,800 per year in 1993. The increase in the rate of LC was not associated with an increase in the overall rate of cholecystectomy. Bile duct (BD) repairs increased from 13 in 1988 to a high of 36 in 1992. There was a strong, statistically significant correlation between the rate of LCs and the rate of BD repairs (R = 0.89, p = 0.0001). Hospital charges and component charges were lower for patients having elective LC compared to those having elective OC (p = 0.001). This remained true after stratification by age and type of gallbladder disease. Hospital stays were shorter for patients having LC than for those having OC (p = 0.001 for all). Surgeons in smaller hospitals were slower at adopting LC. Younger and board certified surgeons adopted LC more rapidly than older and non-board certified surgeons., Conclusions: In North Carolina, LCs progressed from nonexistent to the dominant approach for managing patients with cholelithiasis in a matter of a few years. Associated with this change were shorter hospitalizations and lower charges. Contrary to other published reports, North Carolina did not experience an increase in the overall rate of cholecystectomy with the adoption of LC. There was a highly correlated increase in the rate of bile duct repairs in the first years of the study.

Objective: The aim of this study was to compare the cost of laparoscopic cholecystectomy with that of open cholecystectomy., Design: We analyzed the cost of both procedures regarding hospital stay, days of work lost and the cost derived from the morbidity of the complications of each technique in two groups of patients. With these data we were able to calculate direct and indirect costs of both procedures and compare them., Results: Morbidity was similar in both groups and had no influence in the cost; cost of the material used for laparoscopic cholecystectomy was higher; hospital stay and days of lost work were significantly lower for the laparoscopic procedure than for the open one. The total cost of laparoscopic cholecystectomy was 23% cheaper than that of open cholecystectomy., Conclusions: Laparoscopic cholecystectomy appears to be cheaper than open cholecystectomy. As the laparoscopic technique becomes more widespread its cost might decrease even further.

In order to strike the most favorable balance between health benefits and costs, three treatment modalities for symptomatic cholelithiasis were compared in a cost-effectiveness study: extracorporeal shock-wave lithotripsy (ESWL), conventional cholecystectomy (CC), and laparoscopic cholecystectomy (LC). Data were analyzed from 55 patients who were treated by ESWL, 45 patients who had CC, and 47 patients who had LC. The study was performed by analysis of patients charts and a written questionnaire. After ESWL 35% of the patients were free of stones, 23% had fragments < or = 5 mm, and 42% had fragments > 5 mm at 1-year follow-up. Persistent complaints were reported by 59% after ESWL, 11% after CC, and 14% after LC (P < 0.001). New complaints arose in 12% after ESWL, 11% after CC, and in 5% after LC (P = NS). Patient appreciation score was highest for LC and lowest for ESWL. Mean hospital stay was 2.4 days for ESWL, 10 days for CC, and 3.5 days for LC. Overall costs of treatment were: $5,066 for ESWL; $5,893 for CC; and $3,117 for LC. This study reveals that laparoscopic cholecystectomy is the most effective treatment of the large majority of patients with symptomatic cholelithiasis. ESWL should only be considered in the case of a solitary, relatively small, completely radiolucent stone.

The techniques of cost utility analysis (CUA) were used to evaluate the treatment of gallstone disease by open and laparoscopic cholecystectomy and by extracorporeal shockwave lithotripsy (ESWL). The application of the techniques in this context raised three methodological questions which are not satisfactorily resolved in the literature. The first is whether an ex ante or ex post perspective is best adopted for the measurement of quality of life (QoL). The second is the method for converting a short term deterioration in QoL followed by full health into QALYs and the reliability of the methods available. The third is the issue of indirect costs which, in the context of a temporary disease state, cannot be easily avoided. The economic evaluation found laparoscopic cholecystectomy to be generally superior than the competitor technologies (entailing lower costs and better outcomes). However, the results were sensitive to assumptions about the perspective for measuring benefits and the inclusion of indirect costs.

The costs and effects of open versus laparoscopic cholecystectomies are compared, from the point of view of hospitals and patients, for a consecutive series of 47 patients undergoing a cholecystectomy in the University Hospital Gasthuisberg, in Belgium. For the patients the laparoscopic technique is superior, since effects are better and direct costs are lower than for the open technique. From a financial viewpoint, hospitals have to weigh the higher costs of the laparoscopic equipment against the lower variable costs due to the shorter postoperative length of stay. Total hospital costs would be lower in case all cholecystectomies were performed with the laparoscopic rather than with the open technique if at least 140 cholecystectomies are done annually with the electrocautery technique, or 300 procedures with laser. However, more recent data reveal that the operating time reduces with the number of laparoscopic procedures (learning effects), implying that the laparoscopic electrocautery procedure would already be the cheaper alternative if more than 70 cholecystectomies are done annually, if disposables are used (or if 50 procedures are done with re-usables). It can be concluded that, once sufficient experience with laparoscopy has been achieved, most hospitals could realise cost savings by switching, as much as is medically justified, to laparoscopic procedures. This will also hold for hospitals performing few cholecystectomies, as long as re-usables and electrocautery are used.

After laparoscopic cholecystectomy (LC) has replaced open cholecystectomy (OC) to a large extent as standard method in the operative treatment of cholecystolithiasis the question of costs and economics raises. To evaluate this question the data of 50 patients who underwent elective LC were analysed in a retrospective study and compared with the data of 50 patients who were cholecystectomized using the open technique. The median of in-hospital stay was 6 (3-15) days for LC and 10 (3-33) days for OC. The median of time of working-disability was 14 (2-35) days for LC and 21 (2-56) days for OC. Total cost (median) of 3788 (2637-8101) DM for LC compared to 4509 (2041-15218) DM for OC. The median of hospital income was 2790 (1395-6975) DM for the LC-group and 4650 (1395-15346) DM for the OC-group. Due to the shorter in-hospital stay of LC-patients this method causes a microeconomical loss for the hospital compared to OC. Macroeconomically LC represents a benefit because of shorter working-disability.