Ashley Davidoff MD
Definition
Cholecystectomy is the most commonly performed major surgery in western countries. It was first performed 1882 and has been the treatment of choice for symptomatic gallbladder disease. In 1987 laparoscopic cholecystectomy was developed in France by Phillippe Mouret. It provided a less-invasive way to definitively cure gallstone disease, while minimizing mortality, morbidity, and cost.
Indications
Laparascopic cholecystectomy is now the treatment of choice for symptomatic gallstone disease. It is generally preferred after a course of antibiotics and IV resuscitation allow for a period of “cool down” of the inflamed gallbladder which renders it friable and susceptible to rupture and associated complications. This appropriate interval is generally thought to be between 48-72 hours of the attack or acute cholecystitis, although there are increasing arguments against expectant management in favor of operating to reduce duration of illness, as well as risk complications. If perforation of empyema is suspected, emergency surgery must be performed, and is usually done in an open fashion.
Contraindications
Absolute contraindications to this procedure are peritonitis, septic shock, acute pancreatitis, advanced cirrhosis, gallbladder carcinoma, and coagulopathy. Prior abdominal surgery is not considered a contraindication. In addition, relative contraindications, such as morbid obesity and mild liver cirrhosis are decreasing with increased prevalence and development of laparoscopic technique. If a patient is severely ill or suffering from concomitant disease, the operation may be delayed till the patient can be stabilized.
Advantages
One major advantage of laparoscopic technique over open technique is the decreased scarring. Trocar incisions are typically 10-15 millimeters and usually number less than 6 in total. In addition, as there is no large midline incision, the incidence of abdominal hernias and adhesions is less. There is evidence suggesting that hospitalization and sick leave are shortened with laparoscopic technique, as well as the amount of post-operative pain experienced by patients.
Disadvantages
Some argue that laparoscopic technique is more costly. Time required for the procedure is only marginally higher. These disadvantages are slowly decreasing with time.
Aim
The aim of this procedure is to remove the gallbladder, and prevent the formation of gallstones. As the gallbladder is the primary site of bile concentration, removing this structure is believe to prevent the hyper-concentration that is believe to contribute to the formation of stones.
Patient preparation
Patients are usually prevented from taking anything by mouth for 8-12 hours before the procedure. This is not usually an issue, as patients suffering from acute cholecystitis are often nauseous and unable to tolerate oral intake anyway. Copious IV fluids are given for resuscitation and correcting electrolyte imbalances. IV antibiotics, usually a cephalosporin, though in severe disease more aggressive broad spectrum therapy may be given.
Equipment
Laparoscopic equipment used for this procedure allow visualization of the peritoneal cavity and intra-abdominal structures, through minimal incisions. A pump is used to pass CO2 into the cavity. This minimizes oxygen exposure to immune cells and is easily reabsorbed into the bloodstream post-operatively. Nearly all tools used in open surgical procedures have laparoscopic equivalents, and the implements used offer great control to a well-trained surgeon.
Technique
The patient is placed supine on the operating table and placed under general anesthesia. Typically the primary surgeon stands to the left of the patient, directly opposite the gallbladder. An incision is made at the umbilicus, though which a trocar is placed and pushed through the fascia into the peritoneal cavity. Carbon dioxide is insufflated into the abdomen. 3 or 4 more incisions are made, through which trocars for the various instruments and cameras are placed. The gallbladder is identified, and the cystic artery and cystic duct are slowly dissected and visualized. Clamps are placed on these structures, and they are ligated. The gallbladder is then dissected out of the fossa under the liver. The sourrounding structures are examined for evidence of trauma. The gallbladder is then captured in a plastic bag and retrieved through the incision site.
Results
It is estimated that as high as 32% of cases are converted to open procedures. Deat rate overall is 5% in all patients with acute cholecystitis and 0.1% in those undergoing cholecystectomy. Early diagnosis and early surgery are correlated with reduced chance mortality.
Conclusion
Laparoscopic cholecystectomy is the procedure of choice for the management of symptomatic gallbladder disease. It is both safe and effective, and earlier procedures are associated with improved outcomes. There are relatively few disadvantages or contraindications, and these factors appear to be decreasing with improved imaging, surgical technique and early intervention.
References
Holzheimer, R. & Mannick, J. (ed.) Surgical Treatment: Evidence-Based and Problem-Oriented W. Zuckschwerdt, 2001
Doherty, G. M. & Way, L. W. Current Surgical Diagnosis & Treatment Lange Medical Books/McGraw-Hill, 2006, 1453
Brunicardi, F. C. & Schwartz, S. I. Schwartz’s Principles of Surgery McGraw-Hill, Health Pub. Division, 2005, 1950