Laproscopic Cholecystectomy
Laparoscopic cholecystectomy is a minimally invasive surgical procedure for removal of a diseased gallbladder. The incidence of gallstones increases with an increase in age, with females more likely to form gallstones than males. Age 50 to 65 approximately 20% of women and 5% of men have gallstones. Overall, 75% of gallstones are composed of cholesterol, and the other 25% are pigmented. Despite the composition of gallstones, the clinical signs and symptoms are the same.
Indications
Cholecystitis (Acute/Chronic)
- Symptomatic cholelithiasis
- Biliary dyskinesia
- Acalculouscholecystitis
- Gallstone pancreatitis
- Gallbladder masses/polyps
Contraindications
- Inability to tolerate pneumoperitoneum or general anesthesia
- Uncorrectable coagulopathy
- Metastatic disease
Complications
Common complications include but are not limited to bleeding, infection, and damage to surrounding structure. Bleeding is a common complication as the liver is a very vascular organ. Experienced surgeons must be knowledgeable in regards to anatomical anomalies of arteries to prevent potential significant blood loss. The most serious complication is an iatrogenic injury of the common bile/hepatic duct. Injury to either of these structures may require a further surgical procedure to divert the flow of bile into the intestines. This procedure usually requires a specially trained hepatobiliary surgeon
Lastly, although not a complication, conversion to an open procedure has become a rare event as the experience of surgeons has increased over the years. Conversion to an open procedure creates a larger abdominal incision, causes significant pain control issues postoperatively, and leads to a cosmetically displeasing scar. Please note that conversion to an open procedure should not be viewed as a complication but seen as a well-educated decision made by an experienced surgeon to safely care for the patient
Clinical Significance
Arthroscopic surgery usually results in less joint pain and stiffness than open surgery. Recovery also generally takes less time.
You’ll have small puncture wounds where the arthroscopic tools went into your body. The day after surgery, you may be able to remove the surgical bandages and replace them with small strips to cover the incisions. Your doctor will remove non-dissolvable stitches after a week or 2.
While your wounds heal, you’ll have to keep the site as dry as possible. This means covering them with a plastic bag when you shower.
Your doctor will tell you what activities to avoid when you go home. You can often go back to work or school within a few days of surgery. Full joint recovery typically takes several weeks. It may take several months to be back to normal.
The etiology of gallbladder disease is associated with a poorly functioning gallbladder and superconcentrated bile. Normally, the gallbladder empties its contents in response to physiologic changes associated with digestion (cholecystokinin, vagal input from antral distension, migrating myoelectric complex). High concentrations of cholesterol within the gallbladder is a known cause for precipitation of cholesterol gallstones. Pigmented stones precipitate typically from hemolytic diseases (black stones) or from infection (brown stones) where bacterial enzymes break down bilirubin into an insoluble content. Stasis within the gallbladder or bile ducts increases the likelihood of stone formation. Gallbladder disease is exemplified by obstruction of the cystic duct. Patients may experience acute obstruction of the cystic duct by stones, or occasionally, in most critically ill patients, there is acute acalculouscholecystitis, where there is no mechanical obstruction but a functional obstruction. This obstruction, mechanical or not, in conjunction with attempted bile excretion for digestion will cause acute inflammation of the gallbladder.
A classic finding for gallbladder disease is right upper quadrant or epigastric abdominal pain. The pain typically has an onset 30 minutes to two hours after consumption of fatty foods. The pain can last from one to two hours, up to more than 24 hours. Pain lasting more than 24 hours is associated with a secondary infection known as acute cholecystitis. Pain radiates from the right upper quadrant to the right flank, and occasionally to the right shoulder due to sympathetic innervation. Associated symptoms include but are not limited to nausea, vomit (bilious), fever, chills, and diarrhea. Less specific symptoms may be experienced like indigestion, GERD-like symptoms, PUD symptoms, and dyspepsia. Earlier in the disease process pain will be intermittent and associated with oral intake of fatty foods. As the process progresses, pain may become more frequent and occur regardless of oral intake.
Complete a thorough history and physical examination, including abdominal examination, and specifically check for a “Murphy’s Sign.”
- Murphy’s sign: deep palpation in the right upper quadrant while the patient inspires deeply. A positive test is when the patient abruptly stops their inspiration secondary to pain[10].
- Labs: Complete Blood Count (CBC) with differential (leukocytosis), Liver function panel (Elevated total bilirubin, alkaline phosphatase, and possible transaminitis), Amylase/Lipase (Elevation can indicate gallstone pancreatitis).
- Imaging:
- Abdominal ultrasound of the right upper quadrant will identify the presence of gallstones/sludge/polyps/masses, thickness of the gallbladder wall (normal limits less than 3 mm), width of common bile duct (normal limits less than 6 mm, however, 1 mm may be added per decade of life after 50 years of age or in pregnant women), and the presence/absence of pericholecystic fluid
- Magnetic resonance cholangiopancreatography (MRCP): MRI imaging study for noninvasive visualization of biliary and pancreatic ducts
- Endoscopic Retrograde Cholangiopancreatography (ERCP): an invasive endoscopic procedure is utilizing x-rays and dye to visualize biliary and pancreatic ducts. The advantage of ERCP is that it is both diagnostic and therapeutic. However, this is an invasive procedure and comes with procedural risks
- Hepatobiliary Iminodiacetic Acid (HIDA) Scan: imaging study to visualize liver, gallbladder, and bile ducts. A radioactive tracer is injected into the vein, attaches with bile substrates, and is processed by the liver. A nuclear scanner then tracks the flow of the tracer through the liver, into the bile ducts, gallbladder, and into the duodenum. The addition of cholecystokinin, CCK, in the absence of gallstones is useful to diagnose acalculouscholecystitis. A measured ejection fraction of less than 35% is usually indicative of a poorly functioning gallbladder. Reproduction of symptoms with administration of cholecystokinin also has been shown to predict the resolution of symptoms after cholecystectomy. Cholecystokinin should not be administered in the presence of gallstones as this may provoke passage of the stones into the common bile duct.
