The evolution and maturation of laparoscopic cholecystectomy in an academic practice - Reply

Background: The technique of laparoscopic cholecystectomy (LC) has evolved since its adoption in the late 1980s. We sought to document these changes and assess whether patient outcomes were influenced during this maturational process. Study Design: A prospective data base was used to record the outcomes of all LCs performed in an academic surgeons practice. Trends over time among 1,165 consecutive patients were assessed by comparing the first 100 LCs (group I), the middle 100 LCs (group II), and the most recent 100 LCs (group III). Results: During a 93-month period with 1,165 patients undergoing LC, 25 procedures (2.1%) were converted to open cholecystectomy. Perioperative complications occurred in 31 patients (3%): grade I in 9 (0.8%), grade II in 16 (1.4%), grade III in 5 (0.4%), and grade IV (death) in 1 (0.1%). Length of hospital stay and convalescence were 1.1 ± 0.1 and 9.5 ± 0.5 days, respectively. Nineteen patients (2%) were readmitted early after operation and 10 (1%) developed long-term complications (portsite hernia or retained stone). In group III, cholangiography was largely replaced by intraoperative ultrasonography for ductal evaluation. Operating room time decreased, while the rates of conversion, morbidity, and readmission remained the same. Patients had higher ASA classifications in the latter two groups, whereas operative charges were greater in Group III than in Groups I and II. These trends occurred even though most procedures are currently performed by residents, and fewer LCs are being done. Conclusions: Laparoscopic cholecystectomy has matured into a more efficient operation, yet remains safe with low morbidity when performed by residents at an academic institution.