Comparative study of conventional open versus laparoscopic cholecystectomy for symptomatic cholelithiasis
ABSTRACT Objective: To compare the results of conventional open with laparoscopic cholecystectomy regarding their operative time and postoperative parameters. Methodology: This is a comparative study of 400 patients of cholelithiasis operated for either open or Laparoscopic cholecystectomy during five years from January 2004 to December 2008. The cases were compared for operative time and various postoperative parameters in order to assess the advantages and disadvantages of each procedure. The patients were divided into two groups, group OC for open and group LC for laparoscopic cholecystectomy, each comprising of 200 cases. Results: The operative time was longer in OC than LC patients with mean operative time of 54.16± 11.94 minutes in OC and 46.89±14.83 minutes in LC group (P<0.001). The overall frequency of postoperative complications was relatively high in OC group 50.5% as compared to LC (37%) including all minor and major problems with combined morbidity of 43.75% (P<0.001). The mean hospital stay was shorter in LC group as compared to OC group i.e. 3.02±1.75 (range 1-5) days versus 5.56±9.8 (range 4-10) days respectively. Return to normal work was also significantly shorter in LC group i.e. 18.06±5.16 days (range 1-4 weeks) as compared to 31.61±7.6 days (range 3-6 weeks) in OC group with p value <0.001. Conclusions: The laparoscopic cholecystectomy is superior to open cholecystectomy due to short operative time, early mobilization and fast recovery, less postoperative pain and complications, short hospital stay and early return to work. Comparative study of conventional open versus laparoscopic cholecystectomy for symptomatic cholelithiasis. Pak J Med Sci 2011;27(1):33-37 1.
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ABSTRACT: Cholecystectomy is one of the most frequently performed operations. Open cholecystectomy has been the gold standard for over 100 years. Small-incision cholecystectomy is a less frequently used alternative. Laparoscopic cholecystectomy was introduced in the 1980s. To compare the beneficial and harmful effects of laparoscopic versus small-incision cholecystectomy for patients with symptomatic cholecystolithiasis. We searched TheCochrane Hepato-Biliary Group Controlled Trials Register (6 April 2004), The Cochrane Library (Issue 1, 2004), MEDLINE (1966 to January 2004), EMBASE (1980 to January 2004), Web of Science (1988 to January 2004), and CINAHL (1982 to January 2004) for randomised trials. All published and unpublished randomised trials in patients with symptomatic cholecystolithiasis comparing any kind of laparoscopic cholecystectomy versus small-incision or other kind of minimal incision open cholecystectomy. No language limitations were applied. Two authors independently performed selection of trials and data extraction. The methodological quality of the generation of the allocation sequence, allocation concealment, blinding, and follow-up was evaluated to assess bias risk. Analyses were based on the intention-to-treat principle. Authors were requested additional information in case of missing data. Sensitivity and subgroup analyses were performed if appropriate. Thirteen trials randomised 2337 patients. Methodological quality was relatively high considering the four quality criteria. Total complications of laparoscopic and small-incision cholecystectomy are high: 26.6% versus 22.9%. Total complications (risk difference, random-effects -0.01, 95% confidence interval (CI) -0.07 to 0.05), hospital stay (weighted mean difference (WMD), random-effects -0.72 days, 95% CI -1.48 to 0.04), and convalescence were not significantly different. High-quality trials show a quicker operative time for small-incision cholecystectomy (WMD, high-quality trials 'blinding', random-effects 16.4 minutes, 95% CI 8.9 to 23.8) while low-quality trials show no significant difference. Laparoscopic and small-incision cholecystectomy seem to be equivalent. No differences could be observed in mortality, complications, and postoperative recovery. Small-incision cholecystectomy has a significantly shorter operative time. Complications in elective cholecystectomy are prevalent.Cochrane database of systematic reviews (Online) 02/2006; · 5.70 Impact Factor
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ABSTRACT: Laparoscopic cholecystectomy has rapidly become established as the treatment of choice for cholecystolithiasis. There is very little evidence, however, to support the claimed benefit to patients. In the present study 30 consecutive patients below the age of 65 years without acute cholecystitis and with no signs of common bile duct stones were randomized to laparoscopic or conventional open cholecystectomy. Median (interquartile range) intravenous consumption of pethidine with a patient-controlled injection device between 13 and 24 h after surgery was 125 (62-175) mg in patients who underwent the laparoscopic procedure and 200 (150-250) mg in those who had open operation. Urinary adrenaline and cortisol levels as well as those of plasma glucose, C-reactive protein and interleukin 6 were increased after surgery in both groups of patients, but without any significant difference between them. The mean(s.d.) duration of postoperative hospital stay (2.8(0.8) versus 1.8(0.6) days) and sick leave (24.0(4.4) versus 11.7(4.1) days) was significantly longer with open than laparoscopic cholecystectomy. The findings demonstrate obvious advantages of laparoscopic surgery as regards postoperative pain and convalescence, although factors reflecting the magnitude of trauma did not differ.British Journal of Surgery 10/1994; 81(9):1362-5. · 4.84 Impact Factor
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ABSTRACT: Since the introduction of laparoscopic cholecystectomy into general practice in 1990, it has rapidly become the dominant procedure for gallbladder surgery. The aim of this study was to compare the results of the laparoscopic, open and mini-laparotomy approaches to cholecystectomy. Our study covers a period of 6 years. A total of 1,276 patients underwent cholecystectomy for calculous biliary disease. The laparoscopic procedure was applied to 952 (74.6%) patients, while 210 (16.5%) underwent the traditional open cholecystectomy and the remaining 114 (8.9%) patients underwent mini-laparotomy cholecystectomy. Thirty-seven patients (3.9%) from the laparoscopic group required conversion to open cholecystectomy. Morbidity was similar in the open and laparoscopic groups (3.8%), while it was significantly lower in the mini-laparotomy group (0.8%). No major bile duct injuries occurred after the open or mini-laparotomy approaches. The median operation time was significantly shorter in the mini-laparotomy group than in the laparoscopic group (46 min vs 61 min). Hospital stay was significantly longer for the open cholecystectomy group (mean value 5.1 days) compared with the laparoscopic and mini-laparotomy groups (mean values 2.5 days and 2.7 days, respectively). Hospital expenses showed a saving of 786 Euro for each patient who underwent the open procedure and 980 Euro for each patient who underwent the mini-laparotomy approach compared with the laparoscopic one. We believe that commissioners of healthcare should question whether the benefits of laparoscopic cholecystectomy justify the additional cost after the introduction of the mini-laparotomy approach.Langenbeck s Archives of Surgery 07/2004; 389(3):172-7. · 1.89 Impact Factor
Pak J Med Sci 2011 Vol. 27 No. 1 www.pjms.com.pk 33
Comparative study of conventional open versus
laparoscopic cholecystectomy for symptomatic cholelithiasis
K. Altaf Hussain Talpur1, Arshad Mahmood Malik2, Ahmed Khan Sangrasi3,
Amir Iqbal Memon4, Abdul Aziz Leghari5, J awed Naeem Qureshi6
Objective: To compare the results of conventional open with laparoscopic cholecystectomy
regarding their operative time and postoperative parameters.
Methodology: This is a comparative study of 400 patients of cholelithiasis operated for either
open or Laparoscopic cholecystectomy during five years from J anuary 2004 to December 2008.
The cases were compared for operative time and various postoperative parameters in order to
assess the advantages and disadvantages of each procedure. The patients were divided into
two groups, group OC for open and group LC for laparoscopic cholecystectomy, each comprising
of 200 cases.
Results: The operative time was longer in OC than LC patients with mean operative time of
54.16± 11.94 minutes in OC and 46.89±14.83 minutes in LC group (P<0.001). The overall
frequency of postoperative complications was relatively high in OC group 50.5% as compared to
LC (37% ) including all minor and major problems with combined morbidity of 43.75% (P<0.001).
The mean hospital stay was shorter in LC group as compared to OC group i.e. 3.02±1.75 (range
1-5) days versus 5.56±9.8 (range 4-10) days respectively. Return to normal work was also
significantly shorter in LC group i.e. 18.06±5.16 days (range 1-4 weeks) as compared to 31.61±7.6
days (range 3-6 weeks) in OC group with p value <0.001.
Conclusions: The laparoscopic cholecystectomy is superior to open cholecystectomy due to
short operative time, early mobilization and fast recovery, less postoperative pain and
complications, short hospital stay and early return to work.
KEY WORDS: Cholelithiasis, Cholecystectomy, Laparoscopic, Conventional, Comparison.
Pak J Med Sci J anuary - March 2011 Vol. 27 No. 1 33-37
How to cite this article:
Talpur KAH, Malik AM, Sangrasi AK, Memon AI, Leghari AZ, Qureshi J N. Comparative study of
conventional open versus laparoscopic cholecystectomy for symptomatic cholelithiasis. Pak J
Med Sci 2011;27(1):33-37
K. Altaf Hussain Talpur, FCPS,
Arshad Mahmood Malik, FCPS,
Ahmed Khan Sangrasi, FCPS,
Amir Iqbal Memon, FCPS,
Abdul Aziz Leghari, FRCS,
J awed Naeem Qureshi, FRCS,
Liaquat University of Medical & Health Sciences,
J amshoro Sindh, Pakistan.
Ahmed Khan Sangrasi,
H. No: 212, Block-G,
Citizen Co-operative Housing Society,
Hyderabad, Sindh, Pakistan.
Received for Publication:August 23, 2010
Revision Received: October 6, 2010
Revision Accepted: October 8, 2010
Gall stones disease is the commonest biliary
pathology1 affecting females predominantly all over
the world. The prevalence of disease varies from
15-25 % in U.K, U.S.A. and Australia whereas it is
rare in Africa involving less than 1% of population.2
Cholecystectomy, open or laparoscopic is one of the
common operations performed in surgery.
Open cholecystectomy was the gold standard for
past 100 years3 and now the laparoscopic cholecys-
tectomy is considered as first option for cholelithi-
asis.4,5 Traditional biliary surgery has undergone
some changes from conventional open to
minilaparotomy cholecystectomy6 but since the
34 Pak J Med Sci 2011 Vol. 27 No. 1 www.pjms.com.pk
K. Altaf Hussain Talpur et al.
introduction of laparoscopy into general practice in
19907 the surgical treatment of gallstones is changed
and therefore elective laparoscopic cholecystectomy
has almost replaced the open procedure.8
About 70-80% of cholecystectomies are done
laparoscopically9 where as 20-30% are still completed
by open cholecystectomy4 often performed in eld-
erly patients, cardiopulmonary compromised pa-
tients and patients with complicated gallstones where
laparoscopic procedure is not feasible.10 However it
can safely be performed in cirrhotic patients11 and in
cases of acute cholecystitis12 by experienced surgeon.
Also clinically and financially laparoscopic cholecys-
tectomy has advantages over open cholecystectomy13
and has become popular alternative to open proce-
dure14 due to many advantages including shorter
operative time, early recovery, short hospital stay,
low morbidity, and low cost.15 This study will em-
phasize various operative and postoperative param-
eters of the two procedures in order to assess the
better surgical option for patients with cholelithiasis.
The criteria to be assessed was operative time,
mobilization, recovery time, postoperative pain and
complications, hospital stay and duration of return
to normal work.
This is an observational comparative study
conducted at the department of surgery Liaquat
University of Medical and Health Sciences, Jamshoro
for period of five years from Jan. 2004 to Dec. 2008.
All diagnosed cases of cholelithiasis admitted from
outpatient department were included in the study.
The criteria for selection of procedure either open
conventional or laparoscopic cholecystectomy were
decided on choice of patient, presentation of gallstone
disease (simple or complicated), obesity and associ-
ated comorbid conditions of patients. Usually the
cases above the age of 65 years, having compromised
cardio-respiratory status and patients with compli-
cated gallstone disease were preferred for open chole-
cystectomy. The cases with medical or surgical jaun-
dice, pancreatitis, and suspected or proven gallblad-
der malignancy were excluded from study.
The patients were given verbal and written infor-
mation concerning the type of operation along with
details of their intra and postoperative complications,
expected hospital stay and convalescence.
The patients were divided into two groups one for
open cholecystectomy (OC) and other for
laparoscopic cholecystectomy (LC) comprising equal
number of cases. The results of each procedure were
recorded on a special proforma designed according
to the objectives of study.
The open cholecystectomy was performed with
Kochers subcostal incision or transverse
minilaparotomy incision whereas laparoscopic pro-
cedure was done with standard four ports technique.
Every patient was encouraged for early mobilization
and necessary analgesia was given in form of non
steroidal anti inflammatory drugs and opioid deriva-
tives whatever required according to severity of pain.
The data was evaluated in statistical programme
SPSS version 16.0. The recode option was used for
numerical parameters and was categorized Pearson’s
chi square test was applied for categorical variables
on 95% confidence interval. P value <0.05 was
considered as level of significance.
All 400 patients of cholelithiasis included in the
study were divided into two groups (OC & LC) each
comprising of 200 cases. More cases preferred open
cholecystectomy in early years of study when
patients were reluctant for laparoscopic procedure,
however later on majority of cases preferred
Female to male ratio observed was 6.4:1 in OC and
8:1 in LC group. Age ranged from 10-80 years in both
groups with mean age of 45.56 ± 12.18 years in OC
and 37.64 ± 9.08 years in LC group. There was no
major difference in clinical presentation of both
groups and majority presented with upper abdomi-
nal pain (pain in right hypochondrium), dyspepsia
and nausea and vomiting. Ultrasound revealed
multiple stones in 77.5% of cases in OC and 76% in
Table-I: Operative time & Postoperative pain.
n = 200 (%)
30 Minutes17 (8.5%)
45 Minutes 53 (26.5%)
60 Minutes 78 (39.0%)
75 Minutes 32 (16.0%)
90 Minutes 20 (10.0%)
Severity of Pain:
Mild 29 (14.5%)
Moderate 98 (49.0%)
Sever 73 (36.5%)
Mean Operative Time:
OC = 54.16 ± 11.94 minutes,
LC = 46.8.9 ± 14.83 minutes.
Median Operative Time:
OC = 50.02 minutes,
LC = 43.15 minutes.
n = 200 (%)
Pak J Med Sci 2011 Vol. 27 No. 1 www.pjms.com.pk 35
Conventional open vs. laparoscopic cholecystectomy
Operative time was significantly longer in OC
group. 45 to 95 minutes in 91.5% as compared to LC
group where it ranged from 30-60 minutes in 86.5%
of cases with mean operative time of 54.16 ± 11.94
minutes in OC and 46.89 ± 14.83 in LC group
(Table-I). Similarly postoperative pain was of mod-
erate to severe nature in OC group (85.5%) in
comparison to LC group where it was of mild to
moderate nature in 88.5% of cases (Table-II).
Frequency of postoperative complications assessed
was also higher in OC group as compared to LC
group (Table-II). The general complications like nau-
sea and vomiting, chest infections, bleeding and bil-
iary leak was seen in both groups with relatively
higher incidence in OC patients. However wound
sepsis (13.5%) was particular problem of OC group
and port-site sepsis (6.5%) and shoulder pain (5.5%)
were specific complications related to LC group. Two
cases (1%) of LC group required conversion to open
cholecystectomy due to uncontrollable bleeding from
cystic artery where as re-exploration was required
in (1%) of cases in OC and 1.5% of LC group. The
postoperative bleeding observed from drain was
minor and stopped within 24-48 hours. Overall
morbidity assessed in both groups including minor
and major complications was 43.75% (OC=50.5% VS
The hospital stay (Table-III) was significantly
longer for OC patients ranging from 4-10 days (91%)
as compared to laparoscopic group where it was One
to five days (94.5%). The mean hospital stay was 5.56
± 2.98 days in OC and 3.02 ± 1.75 days in LC group.
Nine cases (4.5%) in OC group remained for 15-30
days where as 10 cases (5%) in LC group for 6-15
days due to either major complications or re-explo-
ration. The return to normal work was early in LC
group where majority of patients (98.5%) resumed
their job in one to four weeks however in OC 96.5%
joined there job in three to six weeks with mean
resumption time of 31.61 ± 7.6 days in OC and
18.06±5.16 days in LC group.
The principle variables of present study which will
help to analyze the efficacy of each procedure are
operative time and postoperative parameters like
pain, early mobilization, complications, hospital stay
and duration of resumption to work. The prevalence
of gallstones in females of western countries is about
twice to that of males2 which is lower than present
study. The sex ratio found in this study was 6.4:1
(86.5%: 13.5%) in OC and 8:1 (89%: 11%) in LC group
however sex ratio observed by Iqbal J. et al16 in their
Table-II: Mobilization Time and
4-8 hours 13 (6.5%)
9-12 hours30 (15.0%)
13-16 hours47 (23.5%)
17-20 hours76 (38.0%)
21-24 hour34 (17.0%)
Nausea & vomiting27 (13.5%)
Chest infection19 (9.5%)
Bleeding 17 (8.5%)
Wound Sepsis27 (13.5%)
Conversion to open0
Biliary leak9 (4.5%)
* Post operative morbidity in OC 50.5% and in LC 37%.
* Over all morbidity in both groups 43.75%
* CBD common bile duct
32 (16.0%) <0.001
Table-III: Showing Hospital Stay & Return to Work.
3 day9 (4.5%)
4 day 85 (42.5%)
5 day 53 (26.5%)
6 day19 (9.5%)
7 day16 (8.0%)
10 day9 (4.5%)
15 day5 (2.5%)
20 day3 (1.5%)
30 day1 (0.5%)
Return to work:
2 weeks7 (3.5%)
3 weeks35 (17.5%)
4 weeks 83 (41.5%)
5 weeks47 (23.5%)
6 weeks28 (14.0%)
Mean Hospital Stay:
OC= 5.56 ± 2.98 days,
LC = 3.02 ± 1.75 days.
Mean Resumption time:
OC = 31.61 ± 7.6 days,
LC = 18.06 ± 5.16 days.
36 Pak J Med Sci 2011 Vol. 27 No. 1 www.pjms.com.pk
K. Altaf Hussain Talpur et al.
study was 13.5:1 (93.10%:6.9%) for OC and 10.19:1
(91.06%:8.94%) for LC patients. The frequency of gall
stone formation increases with age so that between
50 and 60 years of age about 20% of women and 5%
of men are affected.17 In our study high incidence
was seen in 3rd to 6th decade in OC group with mean
age of 45.56 ± 12.18 years where as 3rd to 5th decade
with mean age of 37.64 ± 9.08 years in LC group
which shows higher mean age in OC group. Same
high incidence has been shown by Rosen muller M
et al18 59 years for OC and 49 years for LC group and
Meyer C et al10 60 years for OC and 54 years for LC
Mean operating time was 54.16 ± 11.94 minutes
for OC and 46.89 ± 14.83 minutes for LC with range
of 30-90 minutes in both groups (P< 0.001). How-
ever in OC group operative time utilized was longer
than LC groups (45-90 minutes in 91.5% for OC V/S
30-60 minutes in 86.5% for LC). This is contrary to
other studies which shows longer operative time in
LC group patients.8,10,19-22 The median operative time
utilized was 50.02 minutes for OC and 43.15 min-
utes for LC group which is shorter as compared to
study of Johansson M et al8 (OC = 80 V/s LC = 90
Patients with open cholecystectomy looks more
ill17, feel more pain and have delayed recovery as
compared to laparoscopic cholecystectomy where
they have minimum surgical stress, less postopera-
tive pain, fast recovery15,22 and early gastrointestinal
motility and feeding.24 In this study majority of cases
(85.5%) of OC group felt moderate to severe pain and
have late recovery as compared to LC group where
88.5% felt mild to moderate pain (P<0.001) with fast
recovery and early mobilization and therefore need
of postoperative analgesia was less in LC group.
Same has been found in other studies conducted by
Jan YY and Chen MF25 and Buanes T and Mjaland
O26 and Gondal SH et al.27 The mobilization time
ranged from 9-24 hours in 93.5% cases of OC and 4-
16 hours in 87% cases (P<0.001) of LC group. Similar
results has been found by Porte RJ and De Varies BC
in their study.28
The Postoperative morbidity due to various major
and minor complications was found higher in OC as
compared to LC group (OC=50.5% V/s LC=37%).
Overall morbidity in both groups was 43.75%
(P<0.001) which is quite high as compared to Leo
Jonas et al29 (6%). The rate of postoperative compli-
cations given by Jan YY and Chen MF25 (LC=4.4%
V/s OC=2.2%) and by Buanes T and Mjaland O26
[(LC=9% V/s OC=16% (P<0.01)] is also less than
present study. The wound sepsis assessed in OC was
13.5% as compared to LC group (6.5%) which is two
times higher than LC group. However frequency of
wound infection given by Siddiqui K and Khan AF30
in their study for cases of acute cholecystitis and
empyma is three times higher in OC as compared to
LC patients. The bleeding (OC=8.5% Vs LC=5.5%)
and biliary leak (OC=4.5% Vs LC=3.5%) were the
complications responsible for re-exploration [OC=2
cases (1%) V/s LC=3 cases (1.5%)] and conversion [2
cases (1%) from LC to OC] of the patients. The con-
version rate from LC to OC varies from 3.9% to 12%
as given in different studies.7,28,16,31 In cases of biliary
leak two patients of OC and three of LC group had
common bile duct injury. The bile duct injury given
by Ros A et al22 was one case in each group in his
Laparoscopic cholecystectomy is associated with
a shorter hospital stay and quicker convalescence as
compared to classical open cholecystectomy.3 The
hospital stay in this study ranged from 3-30 days in
OC and 1-20 days in LC with mean length of hospi-
talization as 5.56 ± 2.98 days in OC and 3.02 ± 1.75
days in LC group (P 0.001). It is comparable to other
studies given by different authors like 5.1 days in
OC Vs 2.5 days in LC7, 7.9 days in OC Vs 2.6 days
(P<0.001) in LC10, 6.5 ± 3 days for OC and 2.0 ± 2
days for LC.31
Return to normal work extended from three to six
weeks in OC and 1-4 weeks in LC group in majority
of cases [OC=96.5% Vs LC 98.5% (P<0.001)]. Mean
resumption time to work was 31.61 ± 7.6 days for
OC and 18.06 ± 5.16 days for LC patients. This shows
early return to job in LC as compared to OC group.
Return to normal work given by Supe ANN et al21 in
their study was 19.5 ± 5.4 days for
minicholecystectomy and 91.1 ± 3.2 days for LC
group. The sick leave time given by Buanes T and
Mjaland O26 is 28 days (18 to 48 days) for OC and 10
days (2-21 days) for LC patients. This duration is
shorter as compared to our study which may be due
to reluctancy of our patients to join their duty after
any operation. Over all time of return to normal
activity and work is shorter in LC as compared to
OC patients which is also supported by other
studies19,21,31,32 published in literature.
This study concludes that LC is superior than OC
in many respects like short operating time, early
mobilization, less postoperative pain, less postopera-
tive complications, short hospital stay and early
return to job.
Disclosure statement and conflict of interest:
Authors have no financial interest in any commer-
cial device, equipment, instrument or drug that is a
subject of the article.
KAH Talpur conceived, designed and did statistical
analysis & editing of manuscript. AM Malik, AK
Sangrasi, AI Memon & AA Leghari did data collec-
tion and manuscript writing. JN Qureshi reviewed
and approved the final manuscript.
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