Cholecystectomy is the surgical removal of the gallbladder. It is a common treatment
of symptomatic gallstones and other gallbladder conditions. Surgical options include the standard
procedure, called laparoscopic cholecystectomy, and an older more invasive procedure, called
open cholecystectomy.
Indications Indications for cholecystectomy include inflammation
of the gall bladder, biliary colic, risk factors for gall bladder cancer, and pancreatitis
caused by gall stones. Cholecystectomy is the recommended treatment
the first time a person is admitted to hospital for cholecystitis. Cholecystitis may be acute
or chronic, and may or may not involve the presence of gall stones. Risk factors for
gall bladder cancer include a "porcelain gallbladder," or calcium deposits in the wall of the gall
bladder, and an abnormal pancreatic duct. Cholecystectomy can prevent the relapse of
pancreatitis that is caused by gall stones that block the common bile duct.
Laparoscopic surgery Laparoscopic cholecystectomy has now replaced
open cholecystectomy as the first-choice of treatment for gallstones and inflammation
of the gallbladder unless there are contraindications to the laparoscopic approach. This is because
open surgery leaves the patient more prone to infection. Sometimes, a laparoscopic cholecystectomy
will be converted to an open cholecystectomy for technical reasons or safety.
Laparoscopic cholecystectomy requires several small incisions in the abdomen to allow the
insertion of operating ports, small cylindrical tubes approximately 5 to 10 mm in diameter,
through which surgical instruments and a video camera are placed into the abdominal cavity.
The camera illuminates the surgical field and sends a magnified image from inside the
body to a video monitor, giving the surgeon a close-up view of the organs and tissues.
The surgeon watches the monitor and performs the operation by manipulating the surgical
instruments through the operating ports. To begin the operation, the patient is placed
in the supine position on the operating table and anesthetized. A scalpel is used to make
a small incision at the umbilicus. Using either a Veress needle or Hasson technique, the abdominal
cavity is entered. The surgeon inflates the abdominal cavity with carbon dioxide to create
a working space. The camera is placed through the umbilical port and the abdominal cavity
is inspected. Additional ports are opened inferior to the ribs at the epigastric, midclavicular,
and anterior axillary positions. The gallbladder fundus is identified, grasped, and retracted
superiorly. With a second grasper, the gallbladder infundibulum is retracted laterally to expose
and open Calot's Triangle. The triangle is gently dissected to clear the peritoneal covering
and obtain a view of the underlying structures. The cystic duct and the cystic artery are
identified, clipped with tiny titanium clips and cut. Then the gallbladder is dissected
away from the liver bed and removed through one of the ports. This type of surgery requires
meticulous surgical skill, but in straightforward cases, it can be done in about an hour.
Recently, this procedure is performed through a single incision in the patient's umbilicus.
This advanced technique is called Laparoendoscopic Single Site Surgery or "LESS" or Single Incision
Laparoscopic Surgery or "SILS". In this procedure, instead of making 3-4 four small different
cuts, a single cut is made through the navel. Through this cut, specialized rotaculating
instruments are inserted to do the operation. The advantage of LESS / SILS operation is
that the number of cuts are further reduced to one and this cut is also not visible after
the operation is done as it is hidden inside the navel. A meta-analysis published by Pankaj
Garg et al. comparing conventional laparoscopic cholecystecomy to SILS Cholecystectomy demonstrated
that SILS does have a cosmetic benefit over convention four-hole laparoscopic cholecystectomy
while having no advantage in postoperative pain and hospital stay.
Procedural risks and complications
Laparoscopic cholecystectomy does not require the abdominal muscles to be cut, resulting
in less pain, quicker healing, improved cosmetic results, and fewer complications such as infection
and adhesions. Most patients can be discharged on the same or following day as the surgery,
and can return to any type of occupation in about a week. Furthermore, flexible instruments
are being used in laparoscopic surgery by some surgeons. Using the SPIDER surgical system,
they can perform the cholecystectomy through a single incision through the navel. These
patients often recover faster than traditional methods, and have an almost invisible scar.
An uncommon but potentially serious complication is injury to the common bile duct, which connects
the cystic and common hepatic ducts to the duodenum. An injured bile duct can leak bile
and cause a painful and potentially dangerous infection. Many cases of minor injury to the
common bile duct can be managed non-surgically. Major injury to the bile duct, however, is
a very serious problem and may require corrective surgery. This surgery should be performed
by an experienced biliary surgeon. Abdominal peritoneal adhesions, gangrenous
gallbladders, and other problems that obscure vision are discovered during about 5% of laparoscopic
surgeries, forcing surgeons to switch to the standard cholecystectomy for safe removal
of the gallbladder. Adhesions and gangrene can be serious, but converting to open surgery
does not equate to a complication. A Consensus Development Conference panel,
convened by the National Institutes of Health in September 1992, endorsed laparoscopic cholecystectomy
as a safe and effective surgical treatment for gallbladder removal, equal in efficacy
to the traditional open surgery. The panel noted, however, that laparoscopic cholecystectomy
should be performed only by experienced surgeons and only on patients who have symptoms of
gallstones. In addition, the panel noted that the outcome
of laparoscopic cholecystectomy is greatly influenced by the training, experience, skill,
and judgment of the surgeon performing the procedure. Therefore, the panel recommended
that strict guidelines be developed for training and granting credentials in laparoscopic surgery,
determining competence, and monitoring quality. According to the panel, efforts should continue
toward developing a noninvasive approach to gallstone treatment that will not only eliminate
existing stones, but also prevent their formation or recurrence.
One common complication of cholecystectomy is inadvertent injury to analogous bile ducts
known as Ducts of Luschka, occurring in 33% of the population. It is non-problematic until
the gall bladder is removed, and the tiny supravesicular ducts may be incompletely cauterized
or remain unobserved, leading to biliary leak post-operatively. The patient will develop
biliary peritonitis within 5 to 7 days following surgery, and will require a temporary biliary
stent. It is important that the clinician recognize the possibility of bile peritonitis
early and confirm diagnosis via HIDA scan to lower morbidity rate. Aggressive pain management
and antibiotic therapy should be initiated as soon as diagnosed.
During laparoscopic cholecystectomy, gallbladder perforation can occur due to excessive traction
during retraction or during dissection from the liver bed. It can also occur during extraction
from the abdomen. Infected bile, pigment gallstones, male gender, advanced age, perihepatic location
of spilled gallstones, more than 15 gallstones and an average size greater than 1.5 cm have
been identified as risk factors for complications. Spilled gallstones can be a diagnostic challenge
and can cause significant morbidity to the patient. Clear documentation of spillage and
explanation to the patient is of utmost importance, as this will enable prompt recognition and
treatment of any complications. Prevention of spillage is the best policy.
Biopsy After removal, the gallbladder should be sent
for pathological examination to confirm the diagnosis and look for an incidental cancer.
If cancer is present, a reoperation to remove part of the liver and lymph nodes will be
required in most cases. Long-term prognosis
A minority of the population, from 5% to 40%, develop a condition called postcholecystectomy
syndrome, or PCS. Symptoms can include gastrointestinal distress and persistent pain in the upper
right abdomen. As many as 20% of patients develop chronic
diarrhea. The cause is unclear, but is presumed to involve the disturbance to the bile system.
Most cases clear up within weeks or a few months, though in rare cases the condition
may last for many years. It can be controlled with medication such as cholestyramine.
Complications The most serious complication of cholecystectomy
is damage to the common bile duct. This occurs in about 0.25% of cases. Damage to the duct
that causes leakage typically manifests as fever, jaundice, and abdominal pain several
days following cholecystectomy. A lacerated, leaky bile duct may be repaired through a
procedure called ERCP, or endoscopic retrograde cholangiopancreatography.
Epidemiology About 600,000 people receive a cholecystectomy
in the United States each year. References
External links Video of Laparoscopic Cholecystectomy
Laparoscopic Cholecystectomy "Gallbladder Removal". New York Times. 2007-08-01.
Information and Photographs of conventional and SILS Single Incision Laparoscopic Cholecystectomy