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Invited Critique
April 2008

Randomized Clinical Trial of Small-Incision and Laparoscopic Cholecystectomy in Patients With Symptomatic Cholecystolithiasis: Primary and Clinical Outcomes—Invited Critique

Arch Surg. 2008;143(4):377-378. doi:10.1001/archsurg.143.4.377

All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident.—Arthur Schopenhauer (1788-1860)

The authors have chosen to question and then to carefully examine whether laparoscopy is a better method to remove a diseased gallbladder than by means of a minilaparotomy (defined as < 8-cm incision). In these halcyon days of laparoscopy and natural-orifice surgery, they were bold enough to question which minimal operation is best for cholecystectomy—and the answers, while not surprising, are important for the larger debate now under way in America regarding methods of approach and incision. The authors have done so by carefully constructing a study to analyze both initial outcome measures (complications, length of procedure, etc) and secondary outcomes (cost, time to return to work, etc). Their study is both unique among publications as well as interesting, in that they have strived to reduce outside factors that inadvertently creep into studies, thus contaminating results. Keus et al specifically designed the study to reduce the 4 key domains of bias: generation of the allocation sequence, allocation concealment, blinding for type of surgery, and follow-up.