Is concomitant cholecystectomy necessary in obese patients undergoing laparoscopic gastric bypass surgery?

Background  Morbid obesity is associated with a high prevalence of cholecystopathy, and there is an increased risk of cholelithiasis during rapid weight loss following gastric bypass. In the era of open gastric bypass prophylactic cholecystectomy was advocated. However, routine cholecystectomy at laparoscopic gastric bypass is controversial. Methods  We performed a retrospective review of a prospectively maintained database of morbidly obese patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) from February 2000 to August 2006. All had routine preoperative biliary ultrasonography. Concomitant cholecystectomy at LRYGB was planned in patients with proven cholelithiasis and/or gallbladder polyp ≥1 cm diameter. Results  1711 LRYGBs were performed. Forty-two patients (2.5%) had a previous cholecystectomy and were excluded from further analysis. Two hundred and five patients (12%) had gallbladder pathology: cholelithiasis in 190 (93%), sludge in 14 (6.8%), and a 2 cm polyp in 1 (0.5%). One hundred and twenty-three patients with cholelithiasis (65%) had a concomitant cholecystectomy at LRYGB, while 68 (35.7%) did not. Of these, 123 (99%) were completed laparoscopically. Concomitant cholecystectomy added a mean operative time of 18 min (range 15–23 min). One patient developed an accessory biliary radicle leak requiring diagnostic laparoscopic transgastric endoscopic retrograde cholangiopancreatography (LTG-ERCP). Of the 68 patients with cholelithiasis who did not undergo cholecystectomy 12 (17.6%) required subsequent cholecystectomy. A further 4 patients with preoperative gallbladder sludge required cholecystectomy. All procedures were completed laparoscopically. One patient required laparoscopic choledochotomy and common bile duct exploration (CBDE) with stone retrieval. Eighty-eight patients (6%) with absence of preoperative gallbladder pathology developed symptomatic cholelithiasis after LRYGB; 69 (78.4%) underwent laparoscopic cholecystectomy; 3 presented with gallstone pancreatitis and 2 with obstructive jaundice, requiring laparoscopic transcystic CBDE in 4 and LTG-ERCP in one. Conclusion  In our experience, concomitant cholecystectomy at LRYGB for ultrasonography-confirmed gallbladder pathology is feasible and safe. It reduces the potential for future gallbladder-related morbidity, and the need for further surgery. Competing Interests Declared: None     

Comparison of cholecystectomy cases after Roux-en-Y gastric bypass,sleeve gastrectomy,and gastric banding

BackgroundRapid weight loss after bariatric surgery has been a factor of inducing gallstones postoperatively. Many studies have reported increased gallstone formation after laparoscopic Roux-en-Y gastric bypass (LRYGB). However, not many studies have compared symptomatic gallstone frequencies between LRYGB, laparoscopic sleeve gastrectomy (LSG), and laparoscopic adjustable gastric banding (LAGB). The aim of our study is to evaluate symptomatic cholelithiasis cases requiring cholecystectomy after each bariatric procedure.MethodsBetween January 2009 and August 2011, a total of 937 patients underwent bariatric surgery at our institution. Of these patients, 598 had primary LRYGB, 197 had LSG, and 142 had LAGB. We excluded patients with previous cholecystectomy or concomitant cholecystectomy at the time of bariatric procedure. A retrospective review of a prospectively collected database was performed for all patients.ResultsOf 367 LRYGB patients, 5.7% (n = 21) had symptomatic gallstones. Of 115 LSG patients, 6.1% (n = 7) required cholecystectomy, and of 104 LAGB patients, .0% (n = 0) developed symptomatic gallstones. The differences in the occurrences of symptomatic gallstones between LRYGB and LSG were not statistically significant (P>.88). However, statistical significance was present between LRYGB and LAGB (P<.02), as well as between LSG and LAGB (P<.02). Mean percentage of excess weight loss (%EWL) at 24 months was 85.7%, 58.8%, and 38.3% in LRYGB, LSG, and LAGB patients, respectively. There was no complication related to the cholecystectomy procedure.ConclusionsFrequency of symptomatic gallstones after LRYGB and LSG was not significantly different and after LAGB was significantly lower. Slow and less amount of weight loss would have contributed to the low rate of symptomatic gallstone formation in the LAGB patients. (Surg Obes Relat Dis 2013;0:000–00.) © 2013 American Society for Metabolic and Bariatric Surgery. All rights reserved.     

Laparoscopic cholecystectomy after bariatric surgery

Background: This prospective study determines the value of laparoscopic cholecystectomy (LC) in patients with cholelithiasis after bariatric surgery. Methods: Eighty-four consecutive patients who underwent bariatric surgery without concomitant cholecystectomy were studied. Patients were divided in two groups; group A including 50 patients (59.5%) without gallbladder disease, and group B included 34 patients (40.5%) with symptomatic cholelithiasis within 2 years postoperatively. Characteristics of both groups were compared and analyzed by the use of chi-square tests. Results: In all 34 patients in group B LC was attempted, and the procedure was successful in 28 (82.4%). LC was converted to open procedure in 6 patients (17.6%). Two patients with choledocholithiasic obstructive jaundice underwent endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy prior to laparoscopic management. The mean operative time was 75 ± 12 min, and the mean hospitalization was 2.8 ± 1.1 days. Conclusion: Morbidly obese patients undergoing bariatric surgery are at high risk for developing symptomatic cholelithiasis postoperatively, which usually takes the form of acute cholecystitis. LC is feasible, effective, and seems to be the procedure of choice despite the technical difficulties.     

Treatment of massive super-obesity with laparoscopic adjustable gastric banding

BACKGROUND: Controversy exists concerning the optimal treatment of patients with massive super-obesity (body mass index >60 kg/m(2)). The ideal surgical operation must balance optimal weight loss with minimal morbidity and mortality. We report our results for this patient population undergoing laparoscopic adjustable gastric banding (LAGB). METHODS: We performed a retrospective review of all consecutive patients undergoing LAGB at our institution. Patients with a preoperative body mass index >60 kg/m(2) were identified and their charts were reviewed. Weight loss data were collected when the patients returned for band adjustments. All band adjustments were patient driven and performed under fluoroscopic guidance. RESULTS: Between November 2001 and October 2004, 352 patients underwent LAGB. Of these, 53 had a preoperative body mass index >60 kg/m(2) (15%). The mean absolute weight and body mass index was 186.6 kg (range 139.6-250.6) and 66 kg/m(2) (range 60.0-79.8), respectively. The average follow-up was 12.5 months (range 1.3-31). The most prevalent co-morbidities were obstructive sleep apnea (64%), hypertension (42%), and diabetes mellitus (42%). Postoperative complications included one band removal for chronic obstruction, one band revision for slippage, and one nonfatal pulmonary embolism. The mean percentage of excess weight loss was 15% (-1.1 to 27.4) with <6 months of follow-up, 28.1% (range 1.9-44.5) with 6-12 months of follow-up, 35.1% (range 8.8-84.9) with 12-18 months of follow-up, and 42.9% (range 15.7-80.1) with >18 months of follow-up. Compared with our cohort of nonmassive super-obese patients, massive super-obese patients required a longer period of follow-up to accomplish a similar percentage of excess weight loss. CONCLUSION: LAGB is an appropriate surgical option for the treatment of massive super-obesity. The procedure can be performed with minimal morbidity and mortality and leads to promising medium-term weight loss. Longer term follow-up of massive super-obese patients is necessary and may demonstrate even more successful results.     

Is Routine Cholecystectomy Indicated for Asymptomatic Cholelithiasis in Patients Undergoing Gastric Bypass?

Background The purpose of this study was to evaluate the natural history of patients undergoing Rouxen-Y gastric bypass (RYGBP) with known asymptomatic cholelithiasis in whom prophylactic cholecystectomy was not performed at the time of surgery. Methods The records of 144 consecutive patients from a single year experience in RYGBP surgery at the University of California, Davis Medical Center were reviewed. Patients undergoing RYGBP were routinely screened for cholelithiasis by ultrasound. Patients who did not have cholecystectomy were managed with ursodiol for 6 months postoperatively. Results 13 males (9.0%) and 131 females (91%) underwent RYGBP. The mean age was 43 years (SD 8.55), and mean BMI was 46 kg/m2 (SD 6.5). The comorbidities of our patient population included diabetes (14%), hypertension (48%), gastroesophageal reflux disease (50%), dyslipidemia (35%), obstructive sleep apnea (31%), and musculoskeletal complaints (69%). 22 patients were diagnosed with cholelithiasis by ultrasonography preoperatively. 9 of these patients (41%) were symptomatic and underwent concurrent cholecystectomy and RYGBP. The remaining 13 patients (59%) had asymptomatic cholelithiasis preoperatively but did not undergo cholecystectomy at the time of surgery. Only one of these asymptomatic patients eventually developed symptoms necessitating cholecystectomy at up to 1 year follow-up. Conclusions Our data suggest that it may not be absolutely indicated to perform prophylactic cholecystectomy at the time of RYGBP surgery for asymptomatic cholelithiasis. We believe that this phenomenon needs to be further studied in a randomized trial.     

Laparoscopic cholecystectomy and incidental carcinoma of the extrahepatic bilary tree.

BACKGROUND AND OBJECTIVES: Gallbladder carcinoma is found in 0.2% to 5% of patients undergoing cholecystectomy, and gallstones are found in 70% to 98% of patients with gallbladder carcinoma. Early diagnosis of carcinoma is difficult because of the absence of specific symptoms and the frequent association with chronic cholecystitis and gallstones. At present, laparoscopic cholecystectomy is the gold standard for the surgical treatment of symptomatic cholelithiasis and other benign gallbladder diseases. The aims of this study were to evaluate retrospectively the incidence of occasional and occult gallbladder carcinomas to ascertain the effect of laparoscopy on diagnosis and treatment of unexpected extrahepatic biliary tree carcinomas and to assess possible guidelines that can be taken into consideration when the problem is encountered. METHODS: Clinical records of 3900 patients undergoing laparoscopic cholecystectomy were reviewed. Patients with occasional (intraoperative = Group A) or occult (postoperative = Group B) diagnosis of gallbladder or common bile duct carcinoma entered the study group. Follow-up data were obtained in June 2000. RESULTS: A total of 14 patients (0.35%), 3 men and 11 women, mean age 60.8 years (range 37 to 73) with extrahepatic biliary tree carcinoma were found. Occasional carcinomas occurred in 8 patients, occult carcinomas in 6. No deaths occurred in either group. The overall survival at mean follow-up of 30.5 months is 50%. Five patients are disease free, and 2 are alive with evidence of recurrence. DISCUSSION: In 2 large series of unselected consecutive laparoscopic cholecystectomy, only 14 unsuspected malignant tumors of the extrahepatic biliary tree were found (0.35%). The limits of the preoperative workup and the difficult diagnosis of biliary tract carcinoma during laparoscopic cholecystectomy, has led to the present retrospective study and several significant recommendations.     

Gallbladder Findings after Cholecystectomy in Morbidly Obese Patients

Morbidly obese patients constitute a high risk group for the development of gallbladder disease. In our series 70 consecutive patients underwent vertical gastroplasty in an effort to manage morbid obesity. The mean age was 37 years (range 20-60), and the mean excess body weight was 92 kg (range 52-265). Six patients (8.5%) had undergone cholecystectomy before bariatric surgery because of symptomatic cholelithiasis. The remaining 64 patients underwent cholecystectomy at the time of vertical gastroplasty. Ninety-seven percent of the removed gallbladders had gross or histologic abnormalities, including cholelithiasis 18.5% (13 patients), and cholesterolosis 31% (22 patients). Histologically, chronic cholecystitis was present in all patients with cholelithiasis and cholesterolosis. Chronic cholecystitis alone was found in 27 patients (38.5%) and only two patients (3%) had normal findings. The mean excess body weight of the patients with cholesterolosis (96 kg) was not significantly greater than that of patients with cholelithiasis (89 kg) or chronic cholecystitis (88 kg). Our findings suggest that cholecystectomy should be performed in all morbidly obese patients concomitant with vertical gastroplasty.     

Does gallbladder ejection fraction predict pathology after elective cholecystectomy for symptomatic cholelithiasis?

Patients with symptomatic cholelithiasis are selected for elective cholecystectomy with the expectation that their symptoms will improve after operation. However, some patients fail to improve because their preoperative symptoms were not related to gallbladder disease. A test that would indicate the severity of gallbladder disease in patients with gallstones would therefore have great potential benefit. Twenty-five patients who presented as outpatients with episodic abdominal pain and gallstones were scheduled for elective cholecystectomy. On the day before operation patients underwent nuclear medicine cholescintigraphy with measurement of ejection fraction. All patients then underwent laparoscopic cholecystectomy. Pathologic specimens were reviewed by a pathologist who was blinded to the ejection fraction results and scored for degree of inflammation on a scale of zero to three. There was a wide range of ejection fractions measured (0-84%). There was, however, no correlation between ejection fractions and degree of gallbladder inflammation. We conclude that gallbladder ejection fraction does not predict the degree of gallbladder inflammation at the time of elective cholecystectomy. This test is therefore unlikely to predict which patients with cholelithiasis will have symptomatic relief after cholecystectomy.     

Taste change after laparoscopic Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding

BACKGROUND: Many patients have described changes in taste perception after weight loss surgery. Our hypothesis was that patients develop postoperative changes in taste that vary by bariatric procedure. METHODS: Patients who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic adjustable gastric banding (LAGB) completed a 23-question institutional review board-approved survey postoperatively regarding their degree and type of taste changes and food aversion and how these influenced their eating habits. RESULTS: A total of 127 patients participated. After removing the inadequately completed surveys, 82 LRYGB and 28 LAGB patients were included. Of these, 87% of LRYGB and 69% of LAGB patients believed taste is important to the enjoyment of food. More LRYGB patients (82%) than LAGB patients (46%) reported a change in the taste of food or beverages after surgery (P <.001). In addition, 92% of LAGB versus 59% of LRYGB patients characterized the change as a decrease in the intensity of taste (P <.05). Additionally, 68% of LRYGB and 67% of LAGB patients found certain foods repulsive and had developed aversions. Also, 66% of LRYGB and 70% of LAGB patients believed the taste changes were greater than expected preoperatively. Most patients (83% of LRYGB and 69% of LAGB patients) agreed that the loss of taste led to better weight loss. CONCLUSION: Although most LRYGB and many LAGB patients experienced taste changes and food repulsion postoperatively, procedural differences were found in these taste changes. Taste changes need to be investigated further as a possible mechanism of weight loss after bariatric surgery.     

Acalculous gallbladder disease: the outcomes of treatment by laparoscopic cholecystectomy

INTRODUCTION

The treatment of symptomatic patients with the presence of gallstones is well established, with laparoscopic cholecystectomy being the treatment of choice for symptomatic cholelithiasis. The results of surgery in symptomatic patients without gallstones are highly variable. These patients are often referred to as having acalculous gallbladder disease and represent between 5% and 30% of laparoscopic cholecystectomies performed annually. We retrospectively reviewed the outcomes of patients who underwent laparoscopic cholecystectomy for acalculous gallbladder disease in our institution.

PATIENTS AND METHODS

We retrospectively analysed the period from February 2005 to January 2006 where 20 laparoscopic cholecystectomies had been performed specifically for a preoperative diagnosis of acalculous gallbladder disease. The histology of all laparoscopic cholecystectomies performed during this year was analysed and it was found that a further 46 patients had histological specimens that demonstrated the absence of gallstones in the presence of an intact gallbladder specimen. These patients were therefore included in the study group for acalculous gallbladder disease. All patients were sent a questionnaire comparing their state of health before and after surgery.

RESULTS

After laparoscopic cholecystectomy, 66% of patients were completely pain free. The remainder, however, experienced infrequent, moderate pain with occasional pain on eating. Following surgery, all patients were able to conduct their activities of daily living without any limitation.

CONCLUSIONS

We therefore conclude that laparoscopic surgery for patients with acalculous gallbladder disease is effective in symptom control and allowing patients to return to their normal lifestyle.     

Predictors of gallstone formation after bariatric surgery: a multivariate analysis of risk factors comparing gastric bypass, gastric banding, and sleeve gastrectomy

Background  Risk factors for gallstone formation in the general population have been well studied while those after weight reduction surgery are unknown. The aim of this study was to identify the risk factors for the development of symptomatic gallstones after bariatric surgery. Method  Retrospective review was performed for patients who underwent laparoscopic Roux-en-Y gastric bypass (RYGBP), adjustable gastric banding (LAGB) or sleeve gastrectomy (LSG) between 2004 and 2006. Statistical evaluation was performed using a univariate and multivariate analysis. Risk factors, including age, gender, preoperative body mass index (BMI), BMI > 45 kg/m², diabetes mellitus, hyperlipidemia, types of operation, and weight loss >25% of original weight, were analyzed for their association with postoperative symptomatic gallstones formation. Results  670 laparoscopic RYGBP, 47 LAGB, and 79 LSG were performed in our institute. Preoperative gallbladder disease, as indicated by presence of gallstones or sludge on preoperative transabdominal ultrasound, or previous cholecystectomy, were found in 25.3, 14.9, and 30.4% of patients who subsequently had RYGBP, LAGB, and LSG, respectively. A total of 586 patients were included for analysis. Mean follow-up was 25.9 (range 12–42) months. Overall rate of symptomatic gallstone formation was 7.8% and mean time for its development was 10.2 (range 2–37) months. Incidence of symptomatic gallstones with complications as initial presentation was found in 1.9% of the patients. Logistic regression analysis showed that only postoperative weight loss of more than 25% of original weight was associated with symptomatic gallstones formation [B = 1.482, SE = 0.533, odds ratio 4.44, 95% confidence interval (CI) 1.549–12.498, p = 0.005]. Conclusions  Traditional risk factors for gallstone formation in the general population are not predictive of symptomatic gallstone formation after bariatric surgery. Weight loss of more than 25% of original weight was the only postoperative factor that can help selecting patients for postoperative ultrasound surveillance and subsequent cholecystectomy once gallstones were identified. Accepted as poster, SAGES 2008 and presented April, 10–12th. An erratum to this article can be found at     

Routine gallbladder screening not necessary in patients undergoing laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Management of the gallbladder in patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP) is controversial. We reviewed our experience in patients undergoing LRYGBP without routine gallbladder screening. METHODS: The data of 644 patients who underwent LRYGBP at our institution were analyzed. Preoperative ultrasonography was routinely obtained early in our series and selectively thereafter in patients with suspected symptomatic biliary disease. Cholecystectomy at LRYGBP was performed in symptomatic patients with positive ultrasound findings. Postoperatively, patients with intact gallbladders were prescribed ursodiol for 6 months. RESULTS: Of the 644 patients, 155 (24%) had history of cholecystectomy. A total of 104 patients underwent preoperative ultrasonography. Of the 104 patients, 20 had positive ultrasound findings and symptoms consistent with biliary disease and underwent concomitant cholecystectomy. Twelve patients had positive ultrasound findings and no biliary symptoms and did not undergo cholecystectomy. At a mean follow-up of 26.4 months, only 1 (8.3%) of the 12 patients had required cholecystectomy. Of the 104 patients, 72 had negative ultrasound findings. At a mean follow-up of 21.2 months, 5 of them (6.9%) had required cholecystectomy. The remaining 385 patients did not undergo any gallbladder screening. At a mean follow-up of 14 months, 32 (8.3%) of 385 patients had required cholecystectomy. Compliance with ursodiol for >4 months was only 39%. A time-to-event analysis did not reveal a significant difference in the cholecystectomy rate between asymptomatic patients with preoperative gallbladder screening and patients with no screening. CONCLUSION: Omission of gallbladder screening in asymptomatic patients undergoing LRYGBP is a reasonable approach that spares the patient a potentially unnecessary procedure with all its associated risks.     

Does Estrogen Cause Low Conversion Rates in Laparoscopic Cholecystectomies for Acute and Chronic Cholecystitis in Women?

Laparoscopic cholecystectomy is the preferred treatment for symptomatic cholelithiasis. Severe local inflammation and scar formation are commonly responsible for conversion to open surgery. Fibrosuppressive effects of estrogen on peritoneal inflammatory conditions could provide low, dense fibrosis or scar formation around the gallbladder and make laparoscopic cholecystectomy easier in women and we believe that male sex is a conversion factor in laparoscopic cholecystectomy.     

Implantation metastasis of unsuspected gallbladder carcinoma after laparoscopy

In a 73-year-old woman elective laparoscopic cholecystectomy for symptomatic cholelithiasis had to be changed to open cholecystectomy because of technical problems. Unsuspected microscopic adenocarcinoma of the gallbladder was found after operation. Two months later abdominal-wall metastasis developed at the periumbilical and the right abdominal laparoscopic tract through which the laparoscope and instruments had been introduced and removed. The paramedian abdominal wall incision for the laparotomy was free of tumor.     

Laparoscopic cholecystectomy in adults with sickle cell disease

BACKGROUND: Chronic hemolysis predisposes adults with sickle cell disease (SCD) to the formation of bilirubinate cholelithiasis. METHODS: To study the impact of laparoscopic cholecystectomy (LC) on this groups, we reviewed our records of all patients with SCD and cholelithiasis treated electively from 1991 to 1999. During that period, 13 consecutive patients with SCD underwent elective LC for symptomatic cholelithiasis. Nine patients (69.2%) were managed with a preoperative transfusion regimen to achieve a hemoglobin value of >/=10 g/dl, independent of hemoglobin S percentage. Five patients who presented with jaundice were referred for preoperative endoscopic retrograde cholangiopancreatography (ERCP), which identified choledocholithiasis in two of them. Three other patients underwent intraoperative cholangiography, which revealed common bile duct stones in one patient. RESULTS: One patient developed pyrexia for 2 days. There were no vaso-occlusive crises or deaths. The mean hospital stay was 3.3 days. CONCLUSIONS: LC has proven to be a safe and efficacious method for the treatment of symptomatic cholelithiasis in this high-risk population. Hematologists are now more willing to refer early, well-prepared patients with SCD and uncomplicated gallbladder disease for elective LC.     

Incomplete excision of the gallbladder during laparoscopic cholecystectomy

Dissection and transection of the cystic duct close to the gallbladder has been advocated as a means of avoiding common bile injury during laparoscopic cholecystectomy (LC). We present three cases in which inadequate identification of the gallbladder—cystic duct junction resulted in incomplete cholecystectomy. In two patients an unsecured gallbladder infundibulum presented as cystic duct leaks and one patient developed recurrent symptomatic cholelithiasis. These cases emphasize the need for complete dissection and visualization of the cystic duct at the gallbladder prior its division and secure ligation during LC.     

Prophylactic cholecystectomy with gastric bypass operation: incidence of gallbladder disease

Background: Morbid obesity is one of the major risk factors for gallbladder disease, and this risk is even greater following rapid weight loss. Because of this, prophylactic cholecystectomy has been offered to our patients undergoing the transected silastic ring vertical Roux-en-Y gastric bypass (TSRVRYGBP). A study was undertaken to determine the incidence of pathologic gallbladders in patients undergoing this prophylactic cholecystectomy. Method: The records of all patients who underwent TSRVRYGBP from June 1999 through December 2000 were reviewed. Pathologic findings of the gallbladder were documented as cholelithiasis, cholecystitis, cholesterolosis, polyps or normal. Results: 761 patients underwent the operation. 178 patients (23%) had cholecystectomy before the surgery. 154 (20%) had gallstones documented by ultrasound and had cholecystectomy at the time of the surgery. 324 of the 429 patients with negative preoperative findings by ultrasound had pathologic evidence of gallbladder disease. Conclusion: Because of the high incidence of gallbladder disease even with negative preoperative findings in morbidly obese patients and the lack of significant morbidity with cholecystectomy in experienced hands, routine cholecystectomy at the time of the weight loss operation is justified.     

Low incidence of deep venous thrombosis after laparoscopic cholecystectomy

The effects of the increased intraabdominal pressure that occurs during laparoscopic cholecystectomy and the effects of the reverse Trendelenburg position adopted for the procedure on deep venous thrombosis (DVT) were investigated prospectively. Thirty patients who underwent laparoscopic and 13 who underwent open cholecystectomy for symptomatic cholelithiasis were investigated for postoperative DVT. Lower extremity venous blood flow was examined by color Doppler ultrasonography before and after operations. Thrombus formation was not found in the femoral, popliteal, or iliac veins of any of the patients who underwent either open or laparoscopic cholecystectomy. None of the patients in either group displayed signs of DVT or pulmonary embolus. We concluded that the incidence of DVT does not increase with laparoscopic cholecystectomy.