Abstract
Background
Most of the expense of laparoscopic cholecystectomy (LC) is incurred while the patient is in the operation room; however, heretofore there has been no critical analysis of the time required to perform the various steps of the operation. An understanding of how operative time is used is the first step toward improving the efficiency of the procedure and decreasing costs while maintaining an acceptable standard of care.
Methods
Of 194 patients undergoing LC at a university hospital between 1994 and 1997, operational videotapes of 48 randomly chosen patients were reviewed. Three groups of patients were identified: those undergoing LC for chronic cholecystitis (n=27), those undergoing LC for acute cholecystitis (n=11), and those with common bile duct stones (CBDS), (n=10) undergoing LC with transcystic common bile duct exploration. The procedure was divided into the following seven steps; trocar entry, laparoscopic ultrasound, dissection of the triangle of Calot, cholangiogram, dissection of the gallbladder, extraction of the gallbladder, and irrigation-aspiration with removal of ports. Time spent for camera cleaning, bleeding control, and insertion of the cholangiocatheter into the cystic duct was also calculated. The groups were compared in terms of time spent for each step using the Kruskal-Wallis and Mann-Whitney U tests.
Results
The mean±SD operating time was 66.5±20.5 min. The acute group had the longest operating time, followed by the CBDS and chronic groups. Dissection of the gallbladder, insertion of the cholangiocatheter, and irrigation-aspiration were longer steps in the acute group than in the other groups (p<0.05). Dissection of the triangle of Calot took longer in acute cholecystitis than in chronic cholecystitis (p<0.05). CBDS cases took longer (p<0.05) than chronic cases because stone extraction added an average of 17.5 min to the time required for the cholangiogram in chronic cholecystitis. Laparoscopic ultrasound took longer in the CBDS group than in the other groups (p<0.05). The mean ± SD time spent for the cholangiogram and laparoscopic ultrasound in chronic cholecystitis was 7.5±4.3 and 4.8±1.9 min, respectively.
Conclusions
This time analysis study demonstrates that acute cholecystitis requires a longer operating time because most of the individual steps in the procedure take longer. In patients with choledocholithiasis, stone extraction was responsible for longer operating times. This study should serve as a basis for future studies focusing on time utilization in laparoscopic surgery.
Similar content being viewed by others
References
Barkun JS, Fried GM, Barhun AN, Sigman HH, Hinchey EJ, Garzon J, Wexler MJ, Meakins JL (1993) Cholecystectomy without operative cholangiography. Ann Surg 218: 371–379
Bass EB, Pitt HA, Lillemoe KD (1993) Cost-effectiveness of laparoscopic cholecystectomy versus open cholecystectomy. Am J Surg 165: 466–471
Cisek PL, Greaney GC (1994) The role of endoscopic retrograde cholangiopancreatography with laparoscopic cholecystectomy in the management of choledocholithiasis. Am Surg 60: 772–776
Crolla RM, van Ramshorst B, Jansen A (1997) Complication rate in laparoscopic cholecystectomy not different for residnets in training and surgeons [in Dutch]. Ned Tijdschr voor Geneeskd 141: 681–685
Garcia-Caballero M, Martin-Palanca A, Vara-Thorbeck C (1994) Common bile duct stones after laparoscopic cholecystectomy and its treatment: the role of ultrasound and intravenous and intraoperative cholangiography. Surg Endosc 8: 1182–1185
Hashimoto D, Shouji M (1997) Development of a fogless scope and its analysis using infrared radiation pyrometer. Surg Endosc 11: 805–808 DOI: 10.1007/s004649900458
Hurd WW, Diamond MP (1997) There is a hole in my bucket: the cost of disposable instruments. Fertil Steril 67: 13–15
Jones DB, Soper NJ (1996) The current management of common bile duct stones. Adv Surg 29: 271–289
Kenyon TAG, Lenker MP, Swanstrom LL (1997) Cost and benefit of the trained laparoscopic team: a comparative study of the trained nursing team versus a nontrained team. Surg Endosc 11: 812–814 DOI: 10.1007/s004649900460
Kuster GG, Fischer B (1993) Pharmacologic hemostasis in laparoscopy: topical epinephrine facilitates cholecystectomy. Am Surg 59: 281–284
Liberman MA, Phillips EH, Carroll BJ, Fallas MJ, Rosenthal R, Hiatt J (1996) Cost-effective management of complicated choledocholithiasis: laparoscopic transcystic duct exploration or endoscopic sphincterotomy. J Am Coll Surg 182: 488–494
Lo C, Liu C, Lai ECS, Fan S, Wong J (1996) Early versus delayed laparoscopic cholecystectomy for treatment of acute cholecystitis. Ann Surg 223: 37–42
Machi J, Sigel B, Zaren HA, Schwartz J, Hosokawa T, Kitamura H, Kolecki RV (1993) Technique of ultrasound examination during laparoscopic cholecystectomy. Surg Endosc 7: 544–549
Melvin WS, Johnson JA, Ellison EC (1996) Laparoscopic skills enhancement. Am J Surg 172: 377–379
Philips EH, Liberman M, Carroll BJ, Fallas MJ, Rosenthal RJ, Hiatt JR (1995) Bile duct stones in the laparoscopic era: is preoperative sphincterotomy necessary? Arch Surg 130: 880–886
Rothlin MA, Schob O, Schlumpf R, Largiader F (1996) Laparoscopic ultrasonography during cholecystectomy. Br J Surg 83: 1512–1516
Schirmer BD, Edge BS, Dix J, Hyser MJ, Hanks JB, Jones RS (1991) Laparoscopic cholecystectomy: treatment of choice for symptomatic cholelithiasis. Ann Surg 213: 665–676
Siperstein A, Pearl J, Macho J, Hansen P, Gitomirsky A, Rogers S (1999) Comparison of laparoscopic ultrasonography and fluorocholangiography in 300 patients undergoing laparoscopic cholecystectomy. Surg Endosc 13: 113–117 DOI: 10.1007/s00464990917
Traverso LW, Koo KP, Hargrave K, Unger SW, Roush TS, Swanstrom LL, Woods MS, Donohue JH, Dezeil DJ, Simon IB, Froines E, Hunter J, Sopper NJ (1997) Standardizing laparoscopic procedure time and determining the effect of patient age/gender and presence or absence of surgical residents during operation: a prospective multicenter trial. Surg Endosc 11: 226–229 DOI: 10.1007/s004649900331
Wetter LA, Payne JH, Kirschenbaum G, Podoll EF, Bachinsky T, Way LW (1992) The ultrasonic dissector facilitates laparoscopic cholecystectomy. Arch Surg 127: 1195–1199
Wiesen SM, Unger SW, Barkin JS, Edelman DS, Scott JS, Unger HM (1993) Laparoscopic cholecystectomy: the procedure of choice for acute cholecystitis. Am J Gastroenterol 88: 334–337
Author information
Authors and Affiliations
Additional information
Online publication: 12 December 2000
Rights and permissions
About this article
Cite this article
Berber, E., Engle, K.L., Garland, A. et al. A critical analysis of intraoperative time utilization in laparoscopic cholecystectomy. Surg Endosc 15, 161–165 (2001). https://doi.org/10.1007/s004640000329
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s004640000329