INCIDENCE OF DEEP-VEIN THROMBOSIS AFTER LAPAROSCOPIC VS MINILAPAROTOMY CHOLECYSTECTOMY

Objectives: To determine the frequency of deep vein thrombosis (DVT) a ssociated with minimally invasive cholecystectomy and to determine, us ing minilaparotomy cholecystectomy as a control operation, the influen ce of the laparoscopic pneumoperitoneum on DVT formation. Design: Pros pective nonrandomized control trial. Setting: Tertiary care university hospital. Patients: One hundred consecutive patients intended to unde rgo either laparoscopic cholecystectomy (59 patients) or minilaparotom y cholecystectomy (41 patients) with either of 2 surgeons were prospec tively enrolled between April 1996 and April 1997. The minilaparotomy cholecystectomy group served as controls to isolate the effect of the pneumoperitoneum. Patient details, operative details, and any thromboe mbolic or bleeding complications were recorded. The same thromboprophy laxis regimen was prescribed for each group; namely, preoperative and postoperative subcutaneous low-molecular-weight heparin (LMWH), gradua ted compression stockings, and intraoperative intermittent calf compre ssion. intervention: Minimally invasive cholecystectomy. Main Outcome Measure: Frequency of DVT. Bilateral lower limb venous color duplex sc anning was used to detect DVT. Scans were performed on 3 occasions: (1 ) preoperatively on admission to hospital, (2) on the first postoperat ive day, and (3) between 2 and 4 weeks postoperatively. Results: Three patients in the laparoscopic group and 2 patients in the minilaparoto my group underwent conversion to conventional open cholecystectomy. Th ere were no significant differences between patients in the 2 groups f or age, sex, body mass index, preoperative white blood cell count, pla telet count, prothrombin time, or activated partial thromboplastin tim e. There were no significant differences between the 2 groups for elec tive vs emergency operations, public hospital vs private hospital admi ssions, or consultant vs resident surgeon. Macroscopic gallbladder pat hology grades for both. groups were not significantly different, and t here was no significant difference in the duration of postoperative ho spital stay. Operative cholangiography was performed in a significantl y larger proportion of laparoscopic cases (86% vs 66% in the minilapar otomy group; chi(2) test, P=.002), and the duration of anesthesia was significantly longer for the laparoscopic operation (118 minutes vs 98 minutes; t test, P=.05). Ninety-seven patients received preoperative LMWH and all patients received graduated compression stockings, intrao perative intermittent calf compression, and postoperative LMWH. Two of the 100 patients had postoperative DVT, 1 after laparoscopic cholecys tectomy and 1 after minilaparotomy cholecystectomy. Both DVTs were det ected by duplex examination on the first postoperative day. The DVT fo und after laparoscopic cholecystectomy was in 1 of the 3 patients who did not receive preoperative LMWH. There were no DVTs in any of the 40 patients who had an additional duplex scan between 2 and 4 weeks afte r operation. Conclusions: Despite the theoretical risk of thromboembol ic disease due to use of the laparoscopic pneumoperitoneum, the freque ncy of DVT after either laparoscopic cholecystectomy or minilaparotomy cholecystectomy is low if adequate thromboprophylaxis is provided.