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A discussion paper.
Laparoscopic cholecystectomy is a new procedure for removal of the gallbladder that does not involve open surgery. It is diffusing rapidly in Australia. Indications for the procedure are still evolving, but it could potentially replace at least 80 per cent of open cholecystectomies.
Laparoscopic cholecystectomy promises low morbidity and mortality, short hospital stays, and reduced convalescence periods and patient discomfort. The decreased hospital stay and convalescence could result in large savings to the health care system and to the community as a whole.
Specialised equipment is needed, costing between $55,000 and $70,000. Specialised surgical instruments are also needed. Some are available as disposable or re-usable instruments; the total cost of disposable instruments per patient is about $510. Cost per patient for re-usable instruments is less. The relative merits of disposable versus re-usable instruments need to be resolved.
A preliminary estimate of the total cost per patient of a laparoscopic cholecystectomy is $3,650.
The safety of laparoscopic cholecystectomy is not yet well documented. There are little or no published data available on complications, morbidity and long-term effects, but the potential for serious complications exists. There is an urgent need for studies to establish its success rate, complications, morbidity, mortality, long-term effects, and its cost-effectiveness, in comparison with those for open cholecystectomy and gallstone lithotripsy. It would be desirable to include laparoscopic cholecystectomy in the trial comparing gallstone lithotripsy and surgery, currently in progress at St. Vincent's Hospital, Melbourne.
The procedure is being performed largely by biliary surgeons specially trained in the procedure. There is a learning curve and early in the surgeon's experience complications and conversions to open cholecystectomy are likely to be more frequent. If the procedure diffuses too rapidly there is a danger that training of surgeons and assistants will be inadequate and complication rates will be high. Steps will need to be taken to ensure that the procedure is performed only by fully trained teams and that case load is sufficiently high for expertise to be maintained.
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