Muscle-splitting mini-incision cholecystectomy under spinal anesthesia: cost-effective equitable minimally invasive surgery in laparoscopy era

  • Jay Shah Patan hospital, Patan Academy of Health Sciences, Lalitpur, Kathmandu, Nepal
  • Ram Dayal Mandal
  • Jesifei Shah Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
  • Jenifei Shah


Conventional open cholecystectomy has been increasingly replaced by laparoscopy which requires resources for expensive equipment, training, and maintenance. Muscle-splitting mini-incision cholecystectomy under spinal anesthesia has comparable outcomes to laparoscopy and requires fewer resources. This study analyzes the feasibility and outcome of muscle-splitting mini-incision cholecystectomy under the spinal.
Consecutive cases of muscle-splitting mini-incision cholecystectomy ‘MC’ during 3- years ending in Dec 2019, at a periphery hospital in Janakpur, province-2, Nepal, were included. Complicated cholelithiasis (pancreatitis, jaundice, cholangitis, dilated common bile duct) was excluded. Written informed consents were obtained. The need for general anesthesia, complications during and after surgery, and patient satisfaction were analyzed descriptively. Ethical approval was obtained.
Out 148 MC completed under spinal. Six (4.1%) required fentanyl for shoulder discomfort. Mild post-operative pain was reported by 124 (83.8%) at 6 h and 146 (98.6%) at 12 h. The intravenous drip was stopped after surgery and oral liquid with analgesics started in 2 h in 143 (96.6%). Post-operative antibiotic was given in nine, 2 (1.4%) fistulas, 4 (2.7%) diabetic, and 3 (2%) mucocele. Mean hospital stay was 1-night. Wound complications occurred in 6 (2.8%). Overall, 144 (97.3%) were satisfied and would recommend to others. Selective histopathology was sent for three revealed adenocarcinomas in one. There was no bile-duct injury, re-surgery, or mortality.
Muscle-splitting mini-incision open cholecystectomy-MC under spinal anesthesia is safe and effective with less postoperative pain, early feeding, short hospital stays, less demand for resources, and good patient satisfaction.


1.Keus F, Gooszen HG, Van Laarhoven CJHM. Systematic review: open, small-incision or laparoscopic cholecystectomy for symptomatic cholecystolithiasis. Aliment Pharmacol Ther. 2009 Feb 15;29(4):359–78.
2.Oyogoa SO, Komenaka IK, Ilkhani R, Wise L. Mini-laparotomy cholecystectomy in the era of laparoscopic cholecystectomy: a community-based hospital perspective. Am Surg. 2003 Jul;69(7):604–7.
3.Ros A, Gustafsson L, Krook H, Nordgren C-E, Thorell A, Wallin G, et al. Laparoscopic Cholecystectomy Versus Mini-Laparotomy Cholecystectomy. Ann Surg. 2001 Dec;234(6):741–9.
4.Watanapa P. Mini-cholecystectomy: a personal series in acute and chronic cholecystitis. HPB. 2003;5(4):231–4.
5.Chalkoo M, Ahangar S, Durrani AM, Chalkoo S, Shah MJ, Bashir MI. Mini-lap cholecystectomy: Modifications and innovations in technique. Int J Surg. 2010 Jan 1;8(2):112–7.
6.Syrakos T, Antonitsis P, Zacharakis E, Takis A, Manousari A, Bakogiannis K, et al. Small-incision (mini-laparotomy) versus laparoscopic cholecystectomy: a retrospective study in a university hospital. Langenbecks Arch Surg. 2004 Jun;389(3):172–7.
7.Mabood W, Naeem M, Khattak IA, Mabood J, Urooj H. Mini laparotomy cholecystectomy; muscle splitting vs muscle dividing incision; a randomized study. J Med Sci. 2020 Aug 7;28(2):181–4.
8.Singh C, Nigam A, Bihari R, Khan A, Kumar D. Spinal Anesthesia versus General Anesthesia for open cholcystectomy: Comparison of Peri-operative and post-operative events. J Med Sci Clin Res. 2018 Jul 30;6(7):1090-5.
9.Rodgers A, Walker N, Schug S, McKee A, Kehlet A, van Zundert A, et al. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ. 2000;321:1-12.
10.Kuju RB, Dongol Y, Verma R. Effectiveness of Spinal Anaesthesia versus General Anaesthesia for Open Cholecystectomy. J Nepal Health Res Counc. 2016 May;14(33):93–8.
11.Ariyo P, Trelles M, Helmand R, Amir Y, Hassani GH, Mftavyanka J, et al. Providing Anesthesia Care in Resource-limited Settings: A 6-year Analysis of Anesthesia Services Provided at Médecins Sans Frontières Facilities. Anesthesiology. 2016 Mar;124(3):561–9.
12.Rosenbaum AJ, Maine RG. Improving Access to Laparoscopy in Low-Resource Settings. Ann Glob Health. 2019;85(1):114.
13.Jha AK, World Health Organization, World Alliance for Patient Safety, Research Priority Setting Working Group. Summary of the evidence on patient safety: implications for research. Geneva, Switzerland: World Health Organization; 2008. 118p.
14.Scheiner A, Rickard JL, Nwomeh B, Jawa RS, Ginzburg E, Fitzgerald TN, et al. Global Surgery Pro–Con Debate: A Pathway to Bilateral Academic Success or the Bold New Face of Colonialism? J Surg Res. 2020 Aug 1;252:272–80. |
15.Shah JN, Maharjan SB. Clipless laparoscopic cholecystectomy-a prospective observational study. Nepal Med Coll J. 2010 Jun;12(2):69–71.
16.Zimmerman M, Lee M, Retnaraj S. Non-doctor anaesthesia in Nepal: developing an essential cadre. Trop Doct. 2008 Jul;38(3):148–50.
17.Shah JN, Maharjan S, Gurung R. Shortened Preoperative Fasting Time to Allow Oral Rehydration Solution Clear Liquid up to Two Hours before Elective Major Surgery in Adults. J Coll Physicians Surg Pak. 2018 May;28(5):348–51.
18.Shah JN, Maharjan SB, Paudyal S. Routine use of antibiotic prophylaxis in low-risk laparoscopic cholecystectomy is unnecessary: a randomized clinical trial. Asian J Surg. 2012 Oct;35(4):136-9.
19.Shah JN, Maharjan SB, Shah S, Manadhar K, Shrestha S, Shrestha A, et al. Feasibility, safety and benefit of no drip after cholecystectomy: a prespective observational study. Health Renaiss. 2012 Dec 4;10(3):187–91.
20.Shah JN, Maharjan SB, Manandhar K, Paudyal S, Shrestha S, Shah S, et al. Early feeding and discontinuation of intravenous fluid after laparoscopic cholecystectomy. J Nepal Health Res Counc. 2012 Jan;10(1):28–31.
21.Bastiaenen VP, Tuijp JE, van Dieren S, Besselink MG, van Gulik TM, Koens L, et al. Safe, selective histopathological examination of gallbladder specimens: a systematic review. Br J Surg. 2020 Oct;107(11):1414-28.
22.Shaikh HR, Abbas A, Aleem S, Lakhani MR. Is mini-laparoscopic cholecystectomy any better than the gold standard?: A comparative study. J Minimal Access Surg. 2017;13(1):42–6.
23.Rosenmüller MH, Örnberg MT, Myrnäs T, Lundberg O, Nilsson E, Haapamäki MM. Expertise-based randomized clinical trial of laparoscopic versus small-incision open cholecystectomy. Br J Surg. 2013;100(7):886–94.
24.Srivastava A, Srinivas G, Misra MC, Pandav CS, Seenu V, Goyal A. Cost-effectiveness analysis of laparoscopic versus minilaparotomy cholecystectomy for gallstone disease. A randomized trial. Int J Technol Assess Health Care. 2001;17(4):497–502.
25.Why third world?: Third World Quarterly: Vol 1, No 1 [Internet]. [cited 2020 Oct 16].
26.Pauyo T, Debas HT, Kyamanywa P, Kushner AL, Jani PG, Lavy C, et al. Systematic Review of Surgical Literature from Resource-Limited Countries: Developing Strategies for Success. World J Surg. 2015 Sep 1;39(9):2173–81.
27.Teerawattananon Y, Mugford M. Is it worth offering a routine laparoscopic cholecystectomy in developing countries? A Thailand case study. Cost Eff Resour Alloc CE. 2005 Oct 31;3:10.
28.Keus F, de Jonge T, Gooszen HG, Buskens E, van Laarhoven CJ. Cost-minimization analysis in a blind randomized trial on small-incision versus laparoscopic cholecystectomy from a societal perspective: sick leave outweighs efforts in hospital savings. Trials. 2009 Sep 4;10(1):80.
29.Naraynsingh V, Singh Y, Dan D, Maharaj R. Expertise-based randomized clinical trial of laparoscopic versus small-incision open cholecystectomy (Br J Surg 2013; 100: 886-894). Br J Surg. 2014 Feb;101(3):288.
30.Balasubramanian A, Cheddie S, Naidoo NM, Singh B. An evaluation of mini-laparotomy cholecystectomy in the laparoscopic era: a rural experience. S Afr J Surg. 2018 Jan 1;56(2):36–40.
31.Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WR, et al. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet Lond Engl. 2008 Jul 12;372(9633):139–44.
32.Shah JN. Taking Specialist Surgical Services to the Rural District Hospitals at One Forth Cost: A Sustainable “Return on Investment” Public Health Initiative of Patan Hospital, Patan Academy of Health Sciences, Nepal. Kathmandu Univ Med J KUMJ. 2015 Jun;13(50):186–92.
33.Dubois F, Berthelot B. [Cholecystectomy through minimal incision (author’s transl)]. Nouv Presse Med. 1982 Apr 3;11(15):1139–41.
34.Sultan AI, Hussein KK. Comparative Study between Muscle-Split Versus the Classical Muscle-Cut Subcostal Incision for Open Cholecystectomy. Indian J Public Health Res Dev. 2019;10(7):938.
35.Tangjaroen S, Watanapa P. Mini-cholecystectomy under local anaesthesia. Asian J Surg. 2007 Oct;30(4):235–8.
36.Holmer H, Lantz A, Kunjumen T, Finlayson S, Hoyler M, Siyam A, et al. Global distribution of surgeons, anaesthesiologists, and obstetricians. Lancet Glob Health. 2015 Apr 27;3:S9–11.
37.Task shifting: Global recommendations and guidelines. World Health Organization - Geneva: World Health Organization, 2008. [Internet]. [cited 2020 Sep 26]. Maeseneer J, Bourek A, McKee M, Barry M, Brouwer W, Kringos DS, et al. Task Shifting and Health System Design: Report of the Expert Panel on effective ways of investing in Health (EXPH). European Union; 2019.
39.Wang X-X, Zhou Q, Pan D-B, Deng H-W, Zhou A-G, Guo H-J, et al. Comparison of Postoperative Events between Spinal Anesthesia and General Anesthesia in Laparoscopic Cholecystectomy: A Systemic Review and Meta-Analysis of Randomized Controlled Trials. BioMed Research International. 2016;2016:9480539.
40.Aliev IG, Kurbanov FS, Chinnikov MA, Popovich VK, Panteleeva IS, Sushko AN, et al. [Minilaparotomy cholecystectomy in patients with acute calculous cholecystitis]. Khirurgiia (Sofiia). 2014;(1):30–3.
How to Cite
SHAH, Jay et al. Muscle-splitting mini-incision cholecystectomy under spinal anesthesia: cost-effective equitable minimally invasive surgery in laparoscopy era. J Soc Surg Nep, [S.l.], v. 24, n. 1, p. 2-9, dec. 2021. ISSN 2392-4772. Available at: <>. Date accessed: 28 jan. 2022.