Gallstone disease is one of the most common gastrointestinal disorders worldwide, and its incidence is steadily rising due to lifestyle changes, obesity, and dietary habits. When gallstones become symptomatic, they can cause biliary colic, cholecystitis, pancreatitis, or cholangitis. For decades, the standard treatment was open cholecystectomy, requiring a large incision and prolonged recovery. However, since the late 1980s, laparoscopic cholecystectomy (LC) has emerged as the gold standard for gallbladder removal, offering minimal invasiveness, faster recovery, and improved patient satisfaction.

Indications

The primary indication for laparoscopic cholecystectomy is symptomatic gallstone disease, but it is also performed in several other conditions:

Symptomatic cholelithiasis (gallstones with abdominal pain or dyspepsia).

Acute or chronic cholecystitis.

Gallstone pancreatitis (after stabilization).

Gallbladder polyps larger than 1 cm.

Porcelain gallbladder (due to malignancy risk).

Gallbladder dyskinesia or functional disorders unresponsive to medical therapy.

Asymptomatic gallstones are usually not treated unless the patient is at high risk of complications.

Contraindications

While laparoscopic cholecystectomy is safe and widely performed, certain situations require caution:

Absolute contraindications: uncorrectable coagulopathy, gallbladder carcinoma requiring radical surgery, and inability to tolerate general anesthesia.

Relative contraindications: severe cardiopulmonary disease, advanced cirrhosis, pregnancy (especially third trimester), and previous upper abdominal surgery with dense adhesions.

With advances in technology and surgeon expertise, many relative contraindications are now manageable.

Preoperative Preparation

Clinical evaluation: History, physical examination, and confirmation of gallstones via ultrasound.

Laboratory tests: Liver function tests, complete blood count, and coagulation profile.

Imaging: In cases of suspected choledocholithiasis, MRCP or ERCP may be required.

Patient preparation: Informed consent, preoperative fasting, prophylactic antibiotics, and optimization of comorbid conditions.

Surgical Technique
Anesthesia and Positioning

The patient is placed under general anesthesia and positioned supine, often with slight reverse Trendelenburg and left tilt to move the intestines away from the operative field.

Port Placement

The standard four-port technique includes:

A 10-mm umbilical port for the laparoscope.

A 10-mm epigastric port for the working instrument.

Two 5-mm ports in the right subcostal and right flank areas for retraction and assistance.

Exposure of Gallbladder

The fundus of the gallbladder is grasped and retracted cephalad, while the infundibulum is retracted laterally, exposing Calot’s triangle.

Dissection of Calot’s Triangle

Careful dissection is performed to identify the cystic duct, cystic artery, and gallbladder wall. Achieving the “Critical View of Safety (CVS)” is essential before dividing structures to avoid bile duct injury.

Ligation of Cystic Structures

The cystic duct and cystic artery are secured with clips, ligatures, or energy devices, then divided. Some surgeons use extracorporeal knots such as Mishra’s Knot for cost-effectiveness and safety.

Gallbladder Removal

The gallbladder is dissected from the liver bed using electrocautery or ultrasonic devices. Hemostasis is ensured, and the specimen is retrieved via the umbilical port, often in an extraction bag.

Closure

Ports are removed under vision, and the fascia of larger ports is closed to prevent hernia formation. Skin incisions are sutured or stapled.

Advantages

Laparoscopic cholecystectomy offers several significant benefits over open surgery:

Smaller incisions – improved cosmetic outcome.

Reduced pain – minimal tissue trauma leads to less postoperative discomfort.

Shorter hospital stay – most patients are discharged within 24–48 hours.

Faster recovery – quicker return to normal activities and work.

Lower risk of wound complications – such as infection or incisional hernia.

Complications

Although generally safe, complications can occur:

Intraoperative complications: bile duct injury, bleeding, bowel injury, or bile leak.

Postoperative complications: infection, port-site hernia, retained stones, or post-cholecystectomy syndrome.

The incidence of major bile duct injury is approximately 0.3–0.6%, which is higher than in open cholecystectomy, highlighting the importance of proper training and adherence to the critical view of safety.

Recent Advances

Advancements have further refined laparoscopic cholecystectomy:

Single-incision laparoscopic cholecystectomy (SILC) – fewer scars, better cosmesis.

Mini-laparoscopic cholecystectomy – ports as small as 2–3 mm.

Robotic-assisted cholecystectomy – enhanced precision and ergonomics.

Fluorescent cholangiography using indocyanine green (ICG) – real-time visualization of biliary anatomy to reduce bile duct injuries.

Conclusion

Laparoscopic cholecystectomy has revolutionized the management of gallbladder disease, becoming the gold standard due to its safety, effectiveness, and patient-friendly outcomes. While complications are rare, careful dissection, achieving the critical view of safety, and proper training are crucial to success. Continuous innovations such as single-incision and robotic surgery promise to further enhance outcomes. For both patients and surgeons, laparoscopic cholecystectomy represents a remarkable advancement in modern surgical practice.