How successful is cholecystectomy by laser, via scope? Are there any side effects. J.S,Lichey.
A:Cholecystectomy, or removal of the gallbladder, is the operation of choice at the moment among the most common surgery performed in Britain for anyone with persistent gallstones.The medical profession is agog with the development of a new technique which replaces the old method of opening you up and cutting out the diseased organ. This is "laparoscopic cholecystectomy" in which a surgeon pumps your stomach full of carbon dioxide (as is done in gynaecological laparoscopy, when investigating whether, say, you have a blocked fallopian tube). Four tiny incisions are made, through which a high resolution TV camera monitor system and other instruments are inserted. The gallbladder is finally separated from the liver by laser or an electrosurgical device. The laparoscope helps to guide the removal of the organ through the incision made nearest the umbilical cord.
The great advantage of the procedure over the normal "open" surgery for cholecystectomy is that you only need to stay in the hospital two or three days, can rapidly return to full activity in a week or two and only have to have these small incisions, rather the one large one. This compares with a hospital stay of one to two weeks for normal "open" surgery and a convalescence of three weeks. Furthermore, as the Lancet says (28 September 1991), "It is becoming increasingly clear that the size of the abdominal incision has a profound effect on both immediate and medium term complications with respect to pain and general patient mobility."
The medical community is waxing lyrically about this procedure (one recent Lancet article was entitled "Elective Cholecystectomy for All Comers") after the results of several studies have shown a very low incidence of adverse effects. The combined results of two major studies in Europe and America show about a 5 per cent rate of complications, with two deaths among more than 3000 patients. This compares to a complications rate of 22 per cent with ordinary cholecystectomy.
It also compares favourably with dissolving of gallstones by shock wave, which has an overall rate of adverse effects, including inflammation of the pancreas of 39 per cent.
According to the Lancet, the electrosurgical device called "diathermy" is much preferred over the laser for actual removal of the organ. It is cheaper, less time consuming and less likely to cause complications.
But before you get in what will be undoubtedly a lengthening queue to get your gallbladder removed in this fashion, it's worth bearing a few facts in mind. Like many a new breakthrough procedures, this operation has never been subjected to the kind of scientific double blind comparison to open surgery that would prove its safety and effectiveness. Medicine always seems to forget about these scientific studies in its rush to embrace any promising new whizz bang procedure. As the above Lancet editorial warned, "Once again a surgical procedure is finding a niche in general practice after uncontrolled evaluation that would never pass muster for a new drug."
Secondly, it takes considerable expertise to adapt from three to two dimensional surgery. As enthusiasm for this technique grows it could be attempted by surgeons without the necessary training. The most serious injuries thus far are common duct injury. But presumably, as with gynaecological laparoscopy, an inexperienced surgeon with poor aim could puncture an organ.
If you are considering this kind of surgery, we'd suggest that you investigate non surgical management of your problem (food intolerances have been implicated in the formation of some gallstones). If you decide to have your gallbladder removed, search out a surgeon with a good deal of experience in performing this operation. When you do, "interview" him first. Ask him how many procedures he's done and how many complications have resulted. Only go ahead with someone with a long and excellent track record.