No other operation has been so profoundly affected by the advent of laparoscopy as Cholecystectomy. In fact, the reverse may be more accurate; laparoscopic Cholecystectomy (LC) has been instrumental in ushering in the laparoscopic era. Laparoscopic cholecystectomy has rapidly become the procedure of choice for routine gallbladder removal and has become the most common major abdominal procedure performed in Western countries.
Patient demand was the initial driving force behind the rapid development of LC. Because of the clear advantages Prospective randomized trials were late and largely irrelevant. Hence, LC was introduced and gained acceptance not through organized and carefully conceived clinical trials but by acclamation.
Postoperative pain has been decreased by LC, decreases need for postoperative analgesia, shortens hospital stay from 1 week to less than 24 hours, and returns the patient to full activity within 1 week compared to 1 month after open cholecystectomy (OC). As compared to OC, LC provides improved cosmesis and improved patient satisfaction.
Although the direct operating room and recovery room costs are higher for LC, the shortened length of hospital stay leads to a net savings. More rapid return to normal activity may lead to indirect cost savings. However, not all such studies have demonstrated a cost savings. In fact, with the higher rate of cholecystectomy in the laparoscopic era, the costs in the United States for treating gallstone disease may actually have increased. Recent trials show that LC patients in both outpatient and inpatient groups recover equally well, indicating that a greater proportion of patients should be offered the outpatient modality. No differences were seen between the groups.
Pairing cholecystectomy with other intra-abdominal surgery should only be considered when surgical exposure is adequate, the patient's condition is satisfactory, and operating time is not unduly prolonged. Following are the Procedures that can be combined with LC:
- Hernia repair (ventral, inguinal, umbilical, diaphragmatic)
- Diagnostic laparoscopy
- Breast lump excision
- Common bile duct (CBD) exploration
- Modified highly selective vagotomy
- Gynecological procedures such as hysterectomy
- Ovarian cystectomy
- Tubal ligation
- Hydatid cyst excision
- Lymph node biopsy
- Right adrenalectomy
- Transurethral resection of the prostate (TURP)
The duration of hospital stay for a patient who undergoes a combined procedure is similar to the duration of stay of a patient who undergoes a single procedure. Thus, the patient has the benefit of having undergone surgeries for 2 coexisting pathologies with the least perioperative morbidity. Combined procedures also appear to be cost-effective both to the patient and to the hospital services.
The extra-hepatic biliary tree consists of the bifurcation of the left and right hepatic ducts, the common hepatic duct, the common bile duct, the cystic duct, and the gallbladder. The gallbladder is situated on the inferior surface of the liver and is a pear-shaped reservoir of bile, partially covered by peritoneum. The gallbladder lies at the junction of the right and left lobes of the liver, between segments 4 and 5. The gallbladder is divided into 4 parts: fundus, body, infundibulum, and neck. The gallbladder varies from 7-10 cm in length and 2.5-5 cm in diameter. Normally, the gallbladder has a capacity of up to 60 mL of fluid, but it may be distended up to 300 mL in certain pathologies. The neck of the gallbladder makes an S-shaped bend as it joins the cystic duct. The Hartmann pouch is an out-pouching of the wall in the region of the neck. This varies in size, largely due to dilatation or presence of stones. A large Hartman pouch may easily obscure the cystic duct within the triangle of Calot.
The gallbladder is supplied by a single cystic artery, which is most commonly a branch of the right hepatic artery, but it may also originate from the left hepatic, common hepatic, gastro-duodenal, or superior mesenteric arteries. The cystic artery most commonly courses superior to the cystic duct and posterior to the common hepatic artery. Its length varies, depending on its origin and its insertion into either the gallbladder neck or body. In 15% of the population a double cystic artery may exist. The cystic duct connects the gallbladder to the common hepatic duct to form the common bile duct (CBD). It is arguably the most important structure to be identified in a cholecystectomy. The length of the cystic duct averages from 1-5 cm but may be extremely short (<2 cm), which may be a significant challenge in the dissection and placement of clips during cholecystectomy. A normal cystic duct ranges from 3-7 mm in width.
The CBD is 5-9 cm long and is divided into 3 segments: supra-duodenal, retro-duodenal, and intra-pancreatic. The CBD lies anterior to the portal vein and to the right of the common hepatic artery, at the free border of the lesser omentum. It courses behind the first part of the duodenum on top of the inferior vena cava and lies in a groove on the posterior surface of the head of the pancreas. It then continues down on the left side of the second part of the duodenum and unites with the main pancreatic duct into the ampulla of Vater, which opens into the second portion of the duodenum.
The triangle of Calot is an important landmark whose boundaries include the common hepatic duct medially, the cystic duct laterally, and the inferior edge of the liver superiorly. The cystic lymph node of Lund (also known as the Calot node) is within this triangle; also here, the cystic artery branches off the right hepatic artery. This triangular space is dissected in order to identify, divide, and ligate the cystic duct and artery. The Calot node is the main route of lymphatic drainage of the gallbladder.
Accessory hepatic ducts, also known as the Ducts of Luschka, connect directly from the hepatic bed to the gallbladder. The ducts drain a normal segment of the liver. When encountered during a laparoscopic cholecystectomy, they should be ligated to prevent a bile leak or a biliary fistula.
The general indications for laparoscopic cholecystectomy (LC) are the same as for the open procedure. Although LC was originally reserved for patients who are young and thin, LC is also offered today to patients who are elderly and obese; patients in the latter categories may, in fact, benefit even more from surgery through small incisions.
- Patients who are immune-compromised, are awaiting organ allotransplantation, or have sickle cell disease are at higher risk of developing complications and should be treated irrespective of the presence or absence of symptoms.
- Cholecystectomy is not indicated in most patients with asymptomatic stones because only 2-3% of these patients go on to become symptomatic per year. To properly determine the indications for elective cholecystectomy, the risk of the operation (taking into account the age and comorbid factors of the individual patient) must be weighed against the risk of complications and death without operation.
- The widespread use of diagnostic abdominal ultrasonography has led to the increasing detection of clinically unsuspected gallstones. This, in turn, has given rise to a great deal of controversy regarding the optimal management of asymptomatic (silent) gallstones.
- Morbid obesity is associated with a high prevalence of cholecystopathy, and the risk of developing cholelithiasis is increased during rapid weight loss. Routine prophylactic LC prior to gastric bypass (RYGB) is controversial, but LC should clearly precede or be performed at the time of RYGB in patients with a history of gallbladder pathology.
Additional reasons to consider prophylactic LC include the following:
- Calcified (porcelain) gallbladder
- Gallbladder trauma
- Calculi >3 cm in diameter, particularly in individuals in geographical regions with a high prevalence of gallbladder cancer
- Chronically obliterated cystic duct
- Gallbladder polyp >10 mm or showing rapid increase in size
- Nonfunctioning gallbladder
- Anomalous junction of the pancreatic and biliary ducts
Symptomatic gallstone disease
- Biliary dyskinesia should be considered in patients who present with biliary colic in the absence of gallstones, and a cholecystokinin–diisopropyl iminodiacetic acid (CCK-DISIDA) scanning should be obtained. The finding of a gallbladder ejection fraction <35% at 20 minutes is considered abnormal and constitutes another indication for LC.
- Biliary colic with sonographically identifiable stones is the most common indication for elective LC.
- Acute cholecystitis, when diagnosed within 72 hours from the onset of symptoms, can and usually should be treated laparoscopically. Once 72 hours pass after the onset of symptoms, inflammatory changes in the surrounding tissues are widely believed to render dissection planes more difficult. This may, in turn, increase the likelihood of conversion to an open procedure to 25%. Randomized control trials have not borne out this 72-h cutoff and have shown no difference in morbidity. Interval LC after 4-6 weeks or percutaneous cholecystostomy is other options.
Complex gallbladder disease
A. Gallstone pancreatitis
- LC should be delayed in cases of acute moderate to severe biliary pancreatitis (5 Ranson criteria).
- LC can be safely performed during the same hospitalization after the clinical signs of mild to moderate biliary pancreatitis have resolved. Patients diagnosed with gallstone pancreatitis should first undergo imaging to rule out the presence of choledocholithiasis. This can be achieved by preoperative magnetic resonance cholangiopancreatography (MRCP) +/-, endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound, or intra-operative cholangiography.
- The following treatment options are available for patients found to have choledocholithiasis:
- Preoperative ERCP with sphincterotomy
- Open CBD exploration and T-tube placement
- Postoperative ERCP with sphincterotomy
- Laparoscopic intraoperative cholangiogram with laparoscopic common bile duct (CBD) exploration
- In a patient with documented choledocholithiasis, a single laparoscopic procedure that treats both cholelithiasis and choledocholithiasis in a single setting is preferable. This approach appears to be cost-effective and associated with a shorter hospital stay than a 2-stage procedure (e.g., preoperative ERCP with sphincterotomy followed by LC). In experienced hands, laparoscopic bile duct exploration appears to have high success rates (75-91%). This exact algorithm used depends greatly on the local expertise.
C. Cholecystoduodenal fistula
- Cholecystenteric fistula does not represent an absolute contraindication to laparoscopic surgery, although it does require careful visualization of the anatomy and good laparoscopic suturing skills.
- Patients with cholecystoduodenal fistula leading to gallstone ileus should undergo exploratory laparotomy and removal of the stone, followed by exploration of the remainder of the gastrointestinal tract for additional stones. The fistula may be addressed at the time of the initial procedure but is probably better addressed at a second operation (3-4 wk postoperatively) after inflammation has subsided.
D. Acalculous cholecystitis
- A greater proportion of patients with acalculous cholecystitis are too ill to undergo surgery. In these situations, percutaneous cholecystostomy guided by CT or ultrasonography is advised. Ninety percent of these patients demonstrate clinical improvement. Once the patient has recovered, the cholecystostomy tube can be removed, usually at 6 weeks, without sequelae. Interval cholecystectomy is not necessary.
E. Incidental gallbladder cancer
- Intra-operative identification of cancer is an indication for conversion to an open procedure.
- National Comprehensive Cancer Network (NCCN) guidelines advocate simple cholecystectomy as definitive treatment for patients with mucosal (T1a) disease and negative cystic duct margin; all other patients (involvement of muscle or beyond, positive cystic duct margin, or positive cystic lymph node) should be re-operated for extended cholecystectomy (which includes hepatic resection, lymphadenectomy and, possibly, bile duct excision).
- Gallbladder cancer may be an incidental finding at LC, with an incidence ranging from 0.3-5.0%.
- Before reoperation, distant metastases should be excluded by a detailed clinical examination including a per-rectal/per-vaginal examination, examination for supraclavicular lymph nodes, and CT/MRI of the chest and abdomen.
- Uncertainty of diagnosis, uncertainty of the degree of tumor spread, or postoperative identification of cancer on pathological examination of a routine cholecystectomy specimen should engender early reoperation.
- If a malignant gallbladder is removed laparoscopically, the risk of port site recurrence is high; the port of extraction should then be excised at the time of reoperation.
- LC is a safe and effective treatment for most children diagnosed with biliary disease (BD).
- Although LC takes longer than open cholecystectomy, it results in less postoperative narcotic use and a shorter hospital stay, similar to reports in the adult literature.
- LC in safe in patients with Child class cirrhosis.
- The laparoscopic approach should be considered the procedure of choice in the patients with Child class A and B cirrhosis and symptomatic gallstone disease.
- A patient with Child class C cirrhosis who presents with symptomatic cholelithiasis or cholecystitis should be considered for medical management if he or she is a transplant candidate. Some consider repeated episodes of cholecystitis in a patient with Child class C cirrhosis an indication for transplant.
C. Diabetes mellitus
- However, consider that acute cholecystitis in a patient with diabetes is associated with a significantly higher frequency of infectious complications such as sepsis.
- The presence of diabetes mellitus, in and of itself, does not confer sufficient risk to warrant prophylactic cholecystectomy in asymptomatic individuals.
- Pregnancy was formerly considered to be an absolute contraindication to the laparoscopic approach because of concern for potential trocar injury to the uterus and the unknown effects of pneumoperitoneum to the fetal circulation. However, this has not been borne out in the literature, and LC is now considered safe in pregnant patients.
- The treatment of biliary colic or uncomplicated cholecystitis in a pregnant patient is conservative management followed by elective laparoscopic cholecystectomy. Using antibiotics, analgesics, and antiemetics help most pregnant women avoid surgical intervention. Surgery is generally indicated for patients with recurrent acute cholecystitis who have failed maximal medical therapy.
- Classically, the second trimester is considered the safest time for surgery. This is because of the findings of increased risk for spontaneous abortion and teratogenesis during the first trimester, and the increased risk for premature labor and difficulties with visualization in the third trimester.
- Reported predictors of fetal complications are laparoscopy, diagnosis, admission urgency, year, hospital size, location, teaching status, and high-risk obstetric cases; predictors of maternal complications are an open procedure and greater patient comorbidity.
- Recommendations for pregnant patients who must undergo LC include placing them in the left lateral recumbent position to shift the weight of the gravid uterus off the vena cava and maintenance of insufflation pressures between 10 and 12 mm Hg. In addition, maternal PaCO2 monitoring must be performed by measuring either arterial blood gases or end-tidal CO 2, but arterial PaCO2 may be more accurate.
- Other recommendations include avoiding rapid changes in intraperitoneal pressures, avoiding rapid changes in patient position, and using open technique for the umbilical port placement.
- Gallbladder cancer must be considered a contraindication for laparoscopic cholecystectomy (LC). If gallbladder cancer is diagnosed intraoperatively, the operation must be converted to an open procedure. Theoretically, an open procedure allows a more controlled performance, with less chance of spillage; also, lymph nodes can be sampled intraoperatively to stage the disease.
- Absolute contraindications include an inability to tolerate general anesthesia and uncontrolled coagulopathy. Patients with severe obstructive pulmonary disease or congestive heart failure (e.g., cardiac ejection fraction <20%) may not tolerate carbon dioxide pneumoperitoneum and may be better served with open cholecystectomy (OC) if cholecystectomy is absolutely necessary.
- The conditions once felt to be contraindications to LC (e.g., gangrenous gallbladder, empyema of the gallbladder, bilio-enteric fistulae, obesity, pregnancy, ventriculoperitoneal shunt, previous upper abdominal procedures, cirrhosis, coagulopathy) are no longer contraindications to the laparoscopic approach but require special care and preparation of the patient by the surgeon and a careful evaluation of risk versus benefit. As surgeons have accumulated extensive experience with the laparoscopic technique, these contraindications have been discounted, and reports abound of successfully performed cases.