Full text of DOI:10.1080/110241500447236

ORIGINAL ARTICLE
Laparoscopic or Open Cholecystectomy in Patients with
Sickle Cell Disease: which Approach is Superior?
E. Leandros, G. D. Kymionis, M. M. Konstadoulakis, K. Albanopoulos, K. Dimitrakakis, I. Gomatos and
G. Androulakis
From the 1st Department of Propedeutic Surgery, Laboratory of Surgical Research, University of Athens, Athens, Greece
Eur J Surg 2000; 166: 859–861
ABSTRACT
Objective: To compare laparoscopic with open cholecystectomy in patients with sickle cell disease.
Design: Retrospective clinical study.
Setting: University hospital, Greece.
Subjects: 41 patients (22 men and 19 women) with sickle cell disease had laparoscopic cholecystectomy between September
1991 and June 1998. Each patient was matched for age, sex, year of operation, and number of preoperative transfusions with
control patients with sickle cell disease who had open cholecystectomy.
Main outcome measures: Duration of operation, postoperative stay in hospital, incidence of complications, and conversion to
open operation.
Results: The mean operation time was 81.4 min (range 55–125) for open cholecystectomy and 64.2 min (range 45–90) for
laparoscopic cholecystectomy (p < 0.01). Complications occurred in 5% (2/41) of the patients in the laparoscopic group and in
20% (8/41) of the patients in the open group (p = 0.04). The mean length of stay in hospital was 5.6 days (range 3–9) in the open
group and 2.7 days (range 2–5) in the laparoscopic group (p < 0.01). Conversion to open operation was necessary in 2 (5%)
patients.
Conclusions: Laparoscopic cholecystectomy resulted in a shorter hospital stay with fewer postoperative complications than
open operation in patients with sickle cell disease and may be the procedure of choice in the treatment of cholelithiasis in such
patients.
Key words: cholelithiasis, laparoscopic cholecystectomy, sickle cell disease, complications.
INTRODUCTION
patients with sickle cell disease might benefit from
laparoscopic cholecystectomy, we compared the re-
sults of laparoscopic with those of open operation.
Conventional cholecystectomy in patients with sickle
cell anaemia is associated with an increased morbidity
and mortality (9). These patients need meticulous
attention to the details of fluid balance, control of the
ambient temperature, prophylaxis against infection,
and anaesthesia. Reduced respiratory effort as a result
of incisional pain often leads to poor pulmonary toilet
and relative hypoxia. In addition, patients with sickle
cell disease remain at particular risk for development of
postoperative complications such as pneumonia or
acute respiratory distress syndrome, while transient
hypoxia, hypothermia, dehydration, and acidosis may
result from vaso-occlusive complications.
Laparoscopic surgery has generally been greeted
enthusiastically, primarily because it reduces post-
operative pain, hospital stay, and postoperative ileus
(7). However, the role of laparoscopic cholecystectomy
in patients with sickle cell disease is still debated
because many surgeons claim that the dissection may
be more difficult (cholecystitis, adhesions, or emer-
gency cholecystectomy), which can therefore increase
the rate of complications. Because we thought that
PATIENTS AND METHODS
During a 7-year period, 41 patients with sickle cell
disease had laparoscopic cholecystectomy. Age at
operation, sex, year of operation, diagnostic methods,
blood transfusions, duration of operation, postoperative
complications, hospital stay, and conversion rate from
laparoscopic to open cholecystectomy were recorded
for each patient.
Each patient was matched for age, sex, year of
operation, and number of preoperative transfusions
with a patient with sickle cell disease who had an open
cholecystectomy during the same seven years.
The surgical technique used for the open operation
was through a subcostal incision. Preoperative assess-
ment included a complete blood count and a sonogram
of the gallbladder to evaluate the biliary system and
document the existence of stones. Before cholecys-
tectomy all except three patients in each group were
 2000 Taylor & Francis. ISSN 1102–4151
Eur J Surg 166

860 E. Leandros et al.
Table I. Age, sex, preoperative haemoglobin concentration, duration of operation, and mean hospital stay in both
groups
Variable
Open cholecystectomy (n = 41)
Laparoscopic cholecystectomy (n = 41)
Mean age (years) (range)
Sex, ratio (M/F)
23 (18–44)
22/19
24 (17–47)
22/19
Preoperative haemoglobin (g/L)
Mean duration of operation (min) (range)
Postoperative analgesia (no. of patients)
Mean hospital stay (days) (range)
116 (95–139)
81 (55–125)
10 (24%)
118 (91–141)
64 (45–90)*
2 (5%)**
5.6 (3–9)
2.7 (2–5)*
* p < 0.01.
** p = 0.02.
given blood transfusions, hydrated intravenously at 1.5
times the maintenance rate on the night before
operation, and given a single dose of an antibiotic
prophylactically at induction of anaesthesia.
All patients were followed up in our clinic for a
minimum of six months.
Patients who had open operations were more likely
than patients treated laparoscopically to require post-
operative analgesia (10/41, 24% compared with 2/41,
5%) (p = 0.02).
Conversion to open cholecystectomy was necessary
in two patients (5%), one for inflammation and
adhesions that hampered dissection in Calot’s triangle
and the other because of bile duct injury, shown by an
operative cholangiogram. In the laparoscopic group
there were 2 (5%) postoperative complications while in
the open group there were 8 (20%) (Table II). The
intra-abdominal bleeding in one patient resulted in an
exploratory laparotomy to control the bleeding. Post-
operative ileus was defined by symptoms (constipation,
abdominal distension, vomiting, and hiccups), physical
signs (silent abdomen on auscultation), and radio-
graphic findings (air-fluid levels).
We found a higher rate of complications overall in
the open group than in the laparoscopic group
(p = 0.04). No patients experienced vaso-occlusive
crises and there were no deaths in either group.
No long-term biliary complications were seen in any
of the patients during a mean follow-up period of 11.7
months (range 6–15).
Statistical analysis
Complication rates in the two groups were compared
using Fisher’s exact tests for proportions. Probabilities
of 0.05 or less was considered significant. For com-
parison of means, Student’s t test or an analysis of
variance (ANOVA) were applied where appropriate.
RESULTS
The mean age of the laparoscopic group was 24.1 years
(range 17–47) and of the open group 22.8 years (range
18–44). There were 22 men and 19 women in each
group (Table I).
After completing the preoperative transfusion regi-
men the mean preoperative haemoglobin concentration
was 116 g/L and 118 g/L in open and laparoscopic
group, respectively (Table I).
The mean operation time was 81.4 minutes (range
55–125) in the open group and 64.2 minutes (range 50–
90) in the laparoscopic group; the difference was
significant (p < 0.01) (Table I). The mean hospital stay
was 2.7 days (range 2–5) in the laparoscopic group and
5.6 days (3–9) in the open group (p < 0.01) (Table I).
DISCUSSION
There are many potential benefits of laparoscopic
cholecystectomy compared with conventional surgery
(2, 5, 13). Firstly, the postoperative pain that results
Table II. Postoperative complications. Figures are number of patients
Laparoscopic
cholecystectomy
Complications
Open cholecystectomy
p value
Pulmonary (atelectasis/pneumonia)
Intra-abdominal bleeding
Bile duct injury
Postoperative ileus
Any complication
3/1
1
1
2
8
1/0
0
1
0
2
0.4
1
1
0.5
0.04
Eur J Surg 166

Laparoscopic or open cholecystectomy in patients with sickle cell disease 861
from the small abdominal incision is less than after a
ACKNOWLEDGEMENT
standard subcostal incision. Secondly, the absence of
postoperative ileus allows the patients to return quickly
to normal dietary habits and activity, thereby reducing
the duration of hospital stay. Thirdly the small
incisions give better looking scars. The advantages of
laparoscopic cholecystectomy may be even more
pronounced in patients with sickle cell disease, because
the reduced pain, avoidance of an upper abdominal
incision and the speedy return to normal activities
allows rapid recovery and minimises the chance of a
postoperative infection (6).
The prevalence of asymptomatic cholelithiasis in
patients with sickle cell disease ranges from 4% to 55%
(1). Surgeons have avoided operations on these patients
unless absolutely necessary, because of the high
morbidity. However, careful preoperative preparation
and precise management has produced an acceptably
low morbidity and mortality when operation is required
(12).
Dr G. D. Kymionis was supported by a grant from the
Bardinogiannio Foundation, Athens, Greece.
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Several recently published studies on laparoscopic
cholecystectomy in patients with sickle cell disease
(3, 4, 11) have shown a significant reduction in the rate
of complications and an improvement in the outcome.
These studies were in small series and without
controlling variables such as age, sex, time of opera-
tion, and number of preoperative transfusions, which
influence the outcome. In our study, after controlling
for these variables, we found that laparoscopic opera-
tions reduced postoperative time in hospital and
discomfort, and allowed the patients to return to
routine activities faster than open operations. Elective
conversion rate for laparoscopic to open cholecystec-
tomy in our study was 5% (2/41) (10). Postoperatively,
three patients in the open group required aggressive
chest physiotherapy and oxygen for atelectasis and
hypoxaemia, probably secondary to incisional pain.
One patient in the laparoscopy group also developed
atelectasis and hypoxaemia.
In conclusion, laparoscopy is superior to open
operation in patients with sickle cell disease. It has a
low rate of complications, results in a shorter hospital
stay, and offers the patient a more comfortable post-
operative time than open cholecystectomy. The re-
duced postoperative morbidity after laparoscopic cho-
lecystectomy may encourage surgeons to reduce the
number of erythrocyte transfusions before operation
and thereby to minimise the risk of infective agents and
allosensitisation against erythrocyte antigens (8). How-
ever, prospective comparative studies and larger series
of patient are necessary to confirm this hypothesis.
13. Way LW. Changing therapy for gallstone disease. N
Engl J Med 1990; 323: 1273–1274.
Submitted December 17, 1999; submitted after revision
February 29, 2000; accepted March 8, 2000
Address for correspondence:
G. D. Kymionis, M.D.
Ag. Sikelianou 4
GR-74100 Rethimno
Greece
Eur J Surg 166