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The role of laparoscopic surgery in patients presenting with acute cholecystitis remains controversial. From September 1989 through August 1992, a total of 720 patients underwent cholecystectomy. Ninety-six were unplanned admissions with a clinical diagnosis of acute cholecystitis. Laparoscopic surgery was attempted in 83 patients. Thirteen individuals were not offered laparoscopy because of the surgeon's inexperience. Twenty-two (27%) patients required the laparoscopic procedure converted to an open laparotomy. The mean postoperative hospital stay for patients undergoing laparoscopic cholecystectomy was 3.3 days versus 6.8 days for the laparotomy group. There was no mortality and no bile duct or major vascular injuries in either group. The overall operative morbidity rate was 16.9%. Laparoscopic cholecystectomy appears to be a safe and beneficial option in selected patients with acute cholecystitis. A low threshold for conversion to laparotomy appeared to be an important factor in maintaining a low incidence of operative complications. Several modifications to the technique of laparoscopic cholecystectomy have evolved over the 3-year study period and are described.

The litigator representing an injury victim must be aware of effective means of communicating a client's pain to the jury. Descriptions of pain are most powerful when given by medical personnel who have treated the plaintiff, although doctors can be difficult witnesses unless they have been properly prepared. Pain can be made real and empathy aroused in the jurors by using personalization techniques, and the jurors' understanding of the plaintiff's pain deepened by the skilled use of language, voice techniques, and demonstrative evidence.

Laparoscopic cholecystectomy, or removal of the gallbladder, is a minimally invasive procedure carried out through several small abdominal incisions. A laparoscope (illuminated optical instrument) and several surgical instruments, are inserted through these incisions. Under laparoscopic visualization, the gallbladder is manipulated and finally removed. Initial favorable responses to this procedure have been tempered by concern over the incidence of major complications. Previous reports evaluating the safety of this procedure have been based on studies of relatively small numbers of patients. A report is presented of 375 consecutive patients who underwent laparoscopic cholecystectomy from September 1989 to January 1991 at one medical center. Ninety-one percent of these patients were admitted for elective procedures. Twenty procedures were converted to open gallbladder surgery, performed through an upper abdominal incision; 95 percent of the laparoscopic procedures were successful. Most patients (90 percent) left the hospital within 24 hours of surgery. A total of 141 patients underwent cholangiography (a radiographic study that outlines the major bile ducts) during the laparoscopic cholecystectomy. Five of these patients were found to have stones in the common bile duct; in four patients they were removed endoscopically and in one by common duct exploration. Of the 214 patients who did not undergo cholangiography, two patients (0.9 percent) were found to have retained stones. Three patients (0.8 percent) required a second operation because of complications. The overall complication rate was 3.5 percent. The rate of major complications was 0.6 percent (common liver duct injury and delayed cystic duct leak). One patient died (0.3 percent) as the result of a heart attack three days after the procedure. It appears that laparoscopic cholecystectomy has significant advantages over traditional abdominal gallbladder surgery. The results of this study indicate that the laparoscopic procedure can be performed with complication and death rates similar to the more invasive operation. Detailed illustrations are presented. (Consumer Summary produced by Reliance Medical Information, Inc.)

The most effective treatment for gallbladder disease is cholecystectomy (removal of the gallbladder); 500,000 such operations are performed annually. Traditional open cholecystectomy is performed through a large abdominal incision, is associated with significant pain and discomfort after surgery, and requires three to seven days in the hospital and three to six weeks convalescence. Laparoscopic cholecystectomy is a recently developed, minimally invasive procedure that eliminates many of the disadvantages of open cholecystectomy. It is carried out through several small (1/2 inch or smaller) abdominal incisions. Under laparoscopic visualization (images from the illuminated optic instrument are displayed on a video monitor), the gallbladder is manipulated and removed. This laparoscopic procedure has generally been limited to elective surgery; acute cholecystitis (inflammation of the gallbladder) was considered a contraindication. A report is presented of 15 patients with the preoperative diagnosis of acute cholecystitis on whom emergency laparoscopic cholecystectomy was attempted. In each case, the procedure was performed within 72 hours of admission. Five patients required conversion of the laparoscopic procedure to open abdominal surgery, the traditional technique for cholecystectomy. One of these five patients had an abscess, and the other four had extensive edema (fluid retention) and inflammation that complicated safe removal of abdominal structures. Cholangiography (X-ray examination of the bile ducts), performed in 14 patients, was found to be helpful. Patients remained in the hospital an average of 2.7 days after the procedure. It is concluded that laparoscopic cholecystectomy may be performed safely on patients with acute cholecystitis. The procedure should be performed by surgeons experienced in the technique, and it should be converted to open abdominal surgery if the anatomy of the ducts and blood vessels cannot be clearly identified through the laparoscope. (Consumer Summary produced by Reliance Medical Information, Inc.)