Laparoscopic Cholecystectomy

Updated: Aug 09, 2016
  • Author: Danny A Sherwinter, MD; Chief Editor: Kurt E Roberts, MD  more...
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Overview

Background

Whereas it is true that no operation has been more profoundly affected by the advent of laparoscopy than cholecystectomy has, it is equally true that no procedure has been more instrumental in ushering in the laparoscopic age than laparoscopic cholecystectomy has. Laparoscopic cholecystectomy has rapidly become the procedure of choice for routine gallbladder removal and is currently the most commonly performed major abdominal procedure in Western countries. [1]

A National Institutes of Health consensus statement in 1992 stated that laparoscopic cholecystectomy provides a safe and effective treatment for most patients with symptomatic gallstones and has become the treatment of choice for many patients. [2] This procedure has more or less ended attempts at noninvasive management of gallstones.

The initial driving force behind the rapid development of laparoscopic cholecystectomy was patient demand. Prospective randomized trials were late and largely irrelevant because advantages were clear. Hence, laparoscopic cholecystectomy was introduced and gained acceptance not through organized and carefully conceived clinical trials but through acclamation.

Laparoscopic cholecystectomy decreases postoperative pain, decreases the need for postoperative analgesia, shortens the hospital stay from 1 week to less than 24 hours, and returns the patient to full activity within 1 week (compared with 1 month after open cholecystectomy). [3, 4] Laparoscopic cholecystectomy also provides improved cosmesis and improved patient satisfaction as compared with open cholecystectomy.

Although direct operating room and recovery room costs are higher for laparoscopic cholecystectomy, the shortened length of hospital stay leads to a net savings. More rapid return to normal activity may lead to indirect cost savings. [5] Not all such studies have demonstrated a cost savings, however. In fact, with the higher rate of cholecystectomy in the laparoscopic era, the costs in the United States of treating gallstone disease may actually have increased.

Trials have shown that laparoscopic cholecystectomy patients in outpatient settings and those in inpatient settings recover equally well, indicating that a greater proportion of patients should be offered the outpatient modality. [6]

Laparoscopic cholecystectomy has received nearly universal acceptance and is currently considered the criterion standard for the treatment of symptomatic cholelithiasis. [7, 6] Many centers have special “short-stay” units or “23-hour admissions” for postoperative observation following this procedure. [6]

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Indications

The general indications for laparoscopic cholecystectomy are the same as those for the corresponding open procedure. Although laparoscopic cholecystectomy was originally reserved for young and thin patients, it now is also offered to elderly and obese patients; in fact, these latter patients may benefit even more from surgery through small incisions.

Asymptomatic (silent) gallstones

Cholecystectomy is not indicated in most patients with asymptomatic (silent) gallstones, because only 2-3% of these patients go on to become symptomatic each year. For an accurate determination of the indications for elective cholecystectomy, the risk posed by the operation (with individual patient age comorbid factors taken into account) must be weighed against the risk of complications and death if the operation is not done. [8]

The widespread use of diagnostic abdominal ultrasonography has led to the increasing detection of clinically unsuspected gallstones. This development, in turn, has given rise to a great deal of controversy regarding the optimal management of asymptomatic gallstones. [9]

Patients who are immunocompromised, are awaiting organ allotransplantation, or have sickle cell disease are at higher risk for the development of complications and should be treated irrespective of the presence or absence of symptoms.

Additional reasons to consider prophylactic laparoscopic cholecystectomy include the following:

  • Calculi greater than 3 cm in diameter, particularly in individuals in geographic regions with a high prevalence of gallbladder cancer
  • Chronically obliterated cystic duct
  • Nonfunctioning gallbladder
  • Calcified (porcelain) gallbladder [9]
  • Gallbladder polyp larger than 10 mm or showing a rapid increase in size [10]
  • Gallbladder trauma [8]
  • Anomalous junction of the pancreatic and biliary ducts

Morbid obesity is associated with a high prevalence of cholecystopathy, and the risk of developing cholelithiasis is increased during rapid weight loss. Routine prophylactic laparoscopic cholecystectomy before Roux-en-Y gastric bypass (RYGB) is controversial, but laparoscopic cholecystectomy should clearly precede or be performed concurrently with RYGB in patients with a history of gallbladder pathology. [11]

Symptomatic gallstone disease

Biliary colic with sonographically identifiable stones is the most common indication for elective laparoscopic cholecystectomy. [8, 12]

Acute cholecystitis, if diagnosed within 72 hours after symptom onset, can and usually should be treated laparoscopically. Beyond this 72-hour period, inflammatory changes in 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-hour cutoff and have shown no difference in morbidity. Other options include interval laparoscopic cholecystectomy after 4-6 weeks and percutaneous cholecystostomy. [13, 14, 15]

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) scan should be obtained. The finding of a gallbladder ejection fraction lower than 35% at 20 minutes is considered abnormal and constitutes another indication for laparoscopic cholecystectomy. [16]

Complex gallbladder disease

Gallstone pancreatitis

Once the clinical signs of mild-to-moderate biliary pancreatitis have resolved, laparoscopic cholecystectomy can be safely performed during the same hospitalization. Patients diagnosed with gallstone pancreatitis should first undergo imaging to rule out the presence of choledocholithiasis. This can be achieved by means of preoperative magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasonography (EUS), or intraoperative cholangiography (IOC). [17]

In cases of acute moderate-to-severe biliary pancreatitis (5 Ranson criteria), laparoscopic cholecystectomy should be delayed. [18]

Choledocholithiasis

The following treatment options are available for patients found to have choledocholithiasis:

  • Preoperative ERCP with sphincterotomy
  • Postoperative ERCP with sphincterotomy
  • Laparoscopic IOC with laparoscopic common bile duct (CBD) exploration
  • Open CBD exploration and T-tube placement

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 to be associated with a shorter hospital stay than a two-stage procedure (eg, preoperative ERCP with sphincterotomy followed by laparoscopic cholecystectomy) would be. In experienced hands, laparoscopic CBD exploration appears to have high success rates (75-91%). The exact algorithm followed depends on local expertise.

Mirizzi syndrome

In 1948, Mirizzi described an unusual presentation of gallstones that, when lodged in either the cystic duct or the Hartmann pouch of the gallbladder, externally compressed the common hepatic duct, causing symptoms of obstructive jaundice. [19]

Although an initial trial of dissection may be performed by an experienced laparoscopic biliary surgeon, one must be prepared for conversion and for biliary reconstruction. Endoscopic stone fragmentation at ERCP, with papillotomy and stenting, is a viable alternative to operative surgery for treatment of Mirizzi syndrome in the acute setting. [20] Subsequent cholecystectomy may be performed. [21]

Cholecystoduodenal fistula

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 weeks later, after inflammation has subsided. [21]

Cholecystenteric fistula does not represent an absolute contraindication to laparoscopic surgery, though it does necessitate careful visualization of the anatomy and good laparoscopic suturing skills. [22]

Acalculous cholecystitis

A substantial proportion of patients with acalculous cholecystitis are too ill to undergo surgery. In these situations, percutaneous cholecystostomy guided by computed tomography (CT) or ultrasonography is advised. Ninety percent of these patients demonstrate clinical improvement. Once the patient has recovered, the cholecystostomy tube can be removed without sequelae; this usually takes place at about 6 weeks. Interval cholecystectomy is not necessary. [23]

Incidentalgallbladder cancer

Gallbladder cancer may be an incidental finding at laparoscopic cholecystectomy, with an incidence ranging from 0.3% to 5.0%. [24, 25, 26] Uncertainty about the diagnosis, lack of clarity regarding of the degree of tumor spread, or postoperative identification of cancer on pathologic examination of a routine cholecystectomy specimen should warrant early reoperation.

National Comprehensive Cancer Network (NCCN) guidelines advocate simple cholecystectomy as definitive treatment for patients with mucosal (T1a) disease and a negative cystic duct margin; all other patients (ie, those with involvement of muscle or beyond, a positive cystic duct margin, or a positive cystic lymph node) should undergo repeat operation for extended cholecystectomy (which includes hepatic resection, lymphadenectomy and, possibly, bile duct excision). [2]

Before reoperation, distant metastases should be excluded by means of a detailed clinical examination that includes examination both per rectum and per vaginam, examination for supraclavicular lymph nodes, and CT or magnetic resonance imaging (MRI) of the chest and abdomen.

Intraoperative identification of cancer is an indication for conversion to an open procedure. [27] 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. [28, 2]

Special populations

Children

Laparoscopic cholecystectomy is a safe and effective treatment for most children diagnosed with biliary disease. Although it takes longer to perform than open cholecystectomy does, it results in less postoperative narcotic use and a shorter hospital stay, as has been the case in the adult literature. [29]

Patients with cirrhosis

Laparoscopic cholecystectomy in safe in many patients with 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. Patients with Child class C cirrhosis who present with symptomatic cholelithiasis or cholecystitis should be considered for medical management if they are transplant candidates. Some consider repeated episodes of cholecystitis in a patient with Child class C cirrhosis an indication for transplant. [30, 31]

Diabetics

The presence of diabetes mellitus, in and of itself, does not confer sufficient risk to warrant prophylactic cholecystectomy in asymptomatic individuals. It should be kept in mind, however, that acute cholecystitis in a patient with diabetes is associated with a significantly higher frequency of infectious complications, such as sepsis.

Pregnant women

Biliary colic or uncomplicated cholecystitis in a pregnant patient is treated with conservative management followed by elective laparoscopic cholecystectomy. The use of antibiotics, analgesics, and antiemetics helps most pregnant women avoid surgical intervention. Surgery is generally indicated for patients with recurrent acute cholecystitis that does not respond to maximal medical therapy.

Classically, the second trimester is considered the safest time for surgical treatment. This is because of the increased risk of spontaneous abortion and teratogenesis during the first trimester and the increased risk of premature labor and difficulties with visualization in the third trimester.

At one time, pregnancy was considered to be an absolute contraindication to the laparoscopic approach, out of concern for the potential trocar injury to the uterus and the unknown effects of pneumoperitoneum to the fetal circulation. However, this concern has not been borne out in the literature, and laparoscopic cholecystectomy is now considered safe in pregnant patients.

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. [32]

Recommendations for pregnant patients who must undergo laparoscopic cholecystectomy include the following:

  • Placement in the left lateral recumbent position to shift the weight of the gravid uterus off the vena cava
  • Maintenance of insufflation pressures between 10 and 12 mm Hg
  • Monitoring of maternal arterial carbon dioxide tension (PaCO 2) - This may be done by measuring either arterial blood gases or end-tidal CO 2; the former may be more accurate

Other recommendations are as follows [33] :

  • Avoidance of rapid changes in intraperitoneal pressures
  • Avoidance of rapid changes in patient position
  • Use of open technique for umbilical port placement
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Contraindications

Absolute contraindications for laparoscopic cholecystectomy include an inability to tolerate general anesthesia and uncontrolled coagulopathy. Patients with severe obstructive pulmonary disease or congestive heart failure (eg, cardiac ejection fraction <20%) may not tolerate carbon dioxide pneumoperitoneum and may be better served with open cholecystectomy if cholecystectomy is absolutely necessary.

Gallbladder cancer must be considered a contraindication for laparoscopic cholecystectomy. 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. [34]

Many conditions once felt to be contraindications for laparoscopic cholecystectomy (eg, gangrenous gallbladder, empyema of the gallbladder, bilioenteric fistulae, obesity, pregnancy, ventriculoperitoneal shunt, previous upper abdominal procedures, cirrhosis, and coagulopathy) are no longer considered contraindications but are acknowledged to require special care and preparation of the patient by the surgeon and careful weighing of risk against benefit.

As surgeons have accumulated extensive experience with the laparoscopic technique, these contraindications have been discounted, and reports abound of successfully performed cases. [35, 36]

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Technical Considerations

Anatomic considerations

The extrahepatic biliary tree consists of the bifurcation of the left and right hepatic ducts, the common hepatic duct, the CBD, the cystic duct, and the gallbladder (see the image below).

Anatomy of biliary tree. Anatomy of biliary tree.

The gallbladder is a pear-shaped reservoir of bile, 7-10 cm in length and 2.5-5 cm in diameter, that is situated on the inferior surface of the liver, partially covered by peritoneum. It lies at the junction of the right and left hemilivers, between segments 4 and 5. The gallbladder is divided into four parts: fundus, body, infundibulum, and neck. Normally, it contains up to 60 mL of fluid, but it may be distended to a capacity as high as 300 mL in certain pathologic conditions. [37]

As the neck of the gallbladder joins the cystic duct, it makes an S-shaped bend. The Hartmann pouch is an outpouching of the wall in the region of the neck. This pouch varies in size, largely as a result of dilatation or the presence of stones. [16] 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 may also originate from the left hepatic, common hepatic, gastroduodenal, or superior mesenteric artery. The cystic artery typically courses superior to the cystic duct and posterior to the common hepatic artery. Its length varies, depending on which artery it originates from and whether it inserts into the neck or the body of the gallbladder. A double cystic artery may exist in 15% of the population. [38]

The cystic duct connects the gallbladder to the common hepatic duct to form the CBD. It is arguably the most important structure to be identified in a cholecystectomy. The cystic duct ranges from 1 to 5 cm in length and from 3 to 7 mm in width; an extremely short (<2 cm) cystic duct may pose a substantial challenge in the dissection and placement of clips during cholecystectomy.

The CBD is 5-9 cm long and is divided into three segments: supraduodenal, retroduodenal, and intrapancreatic. It lies anterior to the portal vein and to the right of the common hepatic artery, at the free border of the lesser omentum. The CBD runs 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 pancreatic head. It continues down the left side of the second part of the duodenum, joining the pancreatic duct to form the ampulla of Vater, which opens into the second part of the duodenum. [39]

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. It contains the cystic lymph node of Lund (also known as the Calot node); it is also where the cystic artery branches off the right hepatic artery. This triangular space is dissected to allow the surgeon 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.

Best practices

The following measures may facilitate performance of laparoscopic cholecystectomy, reduce perioperative morbidity, or both:

  • All ports should be inserted under direct vision
  • Placing the patient in the reverse Trendelenburg position with the right side up permits gravity to assist in retraction and allows the structures to fall away from the field
  • The use of a 30° laparoscope is optional but significantly improves visualization
  • The subxiphoid incision should be made in an oblique manner so it can be extended in case conversion to open cholecystectomy becomes necessary
  • An additional 5-mm port placed in the left upper quadrant to retract a floppy liver or press down on a very fatty omentum or duodenum may be the key to success in a difficult case
  • The liver bed should always be rechecked for bleeding before the gallbladder is completely removed
  • A subtotal cholecystectomy, as described by Bornman et al, may be an excellent option in cases of severe fibrosis or inflammation [40, 41]
  • Drains are not routinely placed but may be necessary in the event of (1) severe acute cholecystitis with significant inflammation, (2) suspicion of inadequate control of a duct of Luschka, or (3) subtotal cholecystectomy
  • The drain may be placed laparoscopically and brought out through the most lateral of the 5-mm ports at the end of the procedure

Complication prevention

Major CBD injuries, though infrequent (0.24%), can be devastating when they do occur (see Complications). Repairs for such injuries range from primary repair over a stent to choledochoenterostomy. [3] Tricks that can help the surgeon avoiding this potentially serious complication include the following:

  • Avoiding excessive cephalad traction on the gallbladder so as to prevent tenting and misidentification of the CBD as the cystic duct [42]
  • Before clipping and transection, carefully identifying the cystic duct and artery in the critical view (see Conventional Laparoscopic Cholecystectomy) as the only two structures entering the gallbladder [43]

Litigation is much more common after laparoscopic cholecystectomy than after open cholecystectomy, for two apparent reasons. First, bile duct injuries are more common with laparoscopic cholecystectomy; second, missed intraoperative injuries may be more common in laparoscopic cholecystectomy cases.

Recommendations for the prevention of bile duct injuries include early conversion of laparoscopic cholecystectomy to open cholecystectomy and the use of the critical view technique (see Conventional Laparoscopic Cholecystectomy) [44, 45, 46]

IOC has the potential to benefit the surgeon in the following two ways:

  • Prevention of CBD injury - Although IOC may help prevent such injuries, [47, 48] the literature does not support using it on a routine basis; this modality is most likely to yield benefit if used selectively in cases of unclear anatomy [49]
  • Identification of choledocholithiasis - Even if IOC is performed only selectively, many cholangiograms would have to be obtained to find a small number of stones; thus, IOC is not cost-effective for this purpose [50, 51]

In randomized trials, formal residency training, like routine use of IOC, has not been shown to reduce the number of bile duct injuries.

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Outcomes

Laparoscopic cholecystectomy remains an extremely safe procedure, with a mortality of 0.22-0.4%. [52, 53] Major morbidity occurs in approximately 5% of patients. [54] Complications include the following:

  • Trocar/Veress needle injury
  • Hemorrhage
  • Postcholecystectomy syndrome
  • CBD injury or stricture
  • Wound infection or abscess
  • Ileus
  • Gallstone spillage
  • Deep vein thrombosis
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