IMPACT OF LAPAROSCOPIC CHOLECYSTECTOMY IN A MAJOR TEACHING HOSPITAL -CLINICAL AND HOSPITAL OUTCOMES

Objective: To compare the clinical, training and cost implications of laparoscopic cholecystectomy with open cholecystectomy. Setting: A uni versity teaching hospital. Design: A retrospective review of all patie nts who underwent cholecystectomy in 1989, before the introduction of the laparoscopic technique, and in 1993, after the learning curve for laparoscopic cholecystectomy had been overcome. Main outcome measures: Surgical indications, feasibility of laparoscopic approach, type of s urgeon, operating time, hospital stay, postoperative complications, an d cost analysis. Results: 240 cholecystectomies were performed in 1989 and 293 in 1993. This is a 22% increase in overall workload and inclu des a significant increase (85%; P < 0.0001) in elective caseload. In 1993, 89% of patients underwent laparoscopic surgery, with conversion to open cholecystectomy in 6.8% of elective patients and 33% of emerge ncy patients. Surgical indications remained the same, as did the time from diagnosis to cholecystectomy. There were significant changes in m edian length of hospital stay (from 10 days in 1989 to 4 days in 1993; P < 0.0001), successful intraoperative cholangiography (93% versus 73 %; P < 0.0001), and exploration of the common bile duct (15% versus 5% of patients; P = 0.0005). The number of cholecystectomies performed b y surgeons-in-training decreased from 65% to 40%, individual treatment costs were reduced by 62% and overall hospital costs were reduced by 53%. Complications fell from 12% to 7% (P = 0.07), with the only major bile duct injury occurring in 1989. There were three deaths in 1989 a nd two deaths in 1993. All deaths followed open surgery. Conclusions: Laparoscopic cholecystectomy is associated with improved patient outco mes and, despite the increased workload, significant savings for hospi tals.