Preprocedural Planning
Antibiotic prophylaxis
Numerous studies have found no significant differences in the rate of surgical-site infection (SSI) when perioperative antibiotics were compared with placebo in patients undergoing elective cholecystectomy. [57, 58, 59]
A systemic review by Sanabria et al assessed the use of antibiotic prophylaxis in laparoscopic cholecystectomy. [60] The review concluded that the available evidence was not sufficient either to support or to rule out the use of antibiotic prophylaxis to reduce SSIs. However, larger, randomized clinical trials are needed.
Although some surgeons use antibiotics followed by surgery for patients with acute cholecystitis, this approach has not been studied in a randomized, controlled fashion. Published studies comparing different lengths of antibiotic courses in patients with acute cholecystitis who undergo cholecystectomy have shown no benefit to a longer course of antibiotics. [61]
Combined cholecystectomy
Laparoscopic cholecystectomy is sometimes done in conjunction with other intra-abdominal surgery, but such pairing should be considered only when surgical exposure is adequate, the patient’s condition is satisfactory, and operating time is not unduly prolonged. Several other abdominal and pelvic surgical procedures can be combined with laparoscopic cholecystectomy
The duration of hospital stay for a patient who undergoes a combined procedure is similar to that for a patient who undergoes a single procedure. Thus, the patient has the benefit of receiving surgical therapy for two coexisting conditions concurrently while experiencing substantially less perioperative morbidity than would have been expected with two discrete procedures. Combined procedures also appear to be cost-effective both for patients and for hospital services. [62, 63]
Equipment
Equipment typically required for laparoscopic cholecystectomy includes the following:
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Light source, preferably with two video monitors (for the surgeon and the assistant)
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Laparoscope (telescope), 0° or 30° (preferred)
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Standard gas insufflation equipment
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Hasson trocar
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Trocars, 5 mm (2)
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Subxiphoid trocar, 11 mm (this can be replaced with another 5-mm trocar if a 5-mm laparoscopic clip applier is available)
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Blunt graspers
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Maryland dissector and L-hook cautery
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Electrocautery equipment
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Laparoscopic suction irrigator
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Laparoscopic clip applier
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Endoscopic ligature loop (eg, Endoloop; Ethicon Endo-Surgery, Blue Ash, OH)
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Cotton swab affixed to a 5-mm shaft (eg, Endo Peanut; Covidien, Mansfield, MA)
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Endoscopic retrieval pouch (eg, Endo Catch; Covidien, Mansfield, MA)
Many surgeons do not routinely use a Foley catheter for laparoscopic cholecystectomy.
Patient Preparation
Anesthesia
Because pneumoperitoneum is necessary for laparoscopic cholecystectomy, general anesthesia with intubation is routinely required. Case reports of epidural anesthesia [64] and a pilot study comparing spinal anesthesia with general anesthesia in young, thin, healthy patients showed no significant differences in outcome. [65] Further studies involving acute cholecystitis and an older patient population are needed.
Positioning
For this procedure, the patient should be in the supine position. Peripheral intravenous lines are inserted, and electrocardiography (ECG), pulse oximetry, and blood pressure monitors are placed. The patient is intubated and general anesthesia initiated.
The patient’s arms are abducted or tucked comfortably at the sides. The two laparoscopic towers are situated on either side of the patient’s trunk, toward the head. The surgeon stands on the patient’s left, and the assistant who holds the laparoscope stands on the left of the surgeon to the patient's left. An additional assistant stands on the patient's right to hold and retract the gallbladder fundus (and thus the liver).
Monitoring & Follow-up
The postoperative course is generally uncomplicated. If the cholecystectomy was done as an elective procedure, patients can be discharged the same day and usually should regain their normal level of physical activity within 1 week. Patients should expect some degree of postoperative discomfort around the port sites but should nonetheless be alert for any signs or symptoms (eg, fever, uncontrolled vomiting, extreme pain or jaundice) that could be manifestations of complications. [66]
All patients who have undergone laparoscopic cholecystectomy should have a follow-up visit within 1-2 weeks postoperatively. The histopathologic report should be checked to ensure that an incidental cancer is not missed. After that initial postoperative check, patients should be seen on an individual basis as needed.
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Laparoscopic cholecystectomy. Placement of fascial stay sutures.
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Laparoscopic cholecystectomy. Visualization of gallbladder after placement of table in reverse Trendelenburg position.
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Laparoscopic cholecystectomy. Advancement of 11-mm trocar under direct vision.
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Laparoscopic cholecystectomy. Placement of two lateral 5-mm ports under direct vision.
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Laparoscopic cholecystectomy. External view after port placement.
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Laparoscopic cholecystectomy. Lateral grasper is used to retract fundus cephalad and retract adhesions.
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Laparoscopic cholecystectomy. Medial grasper is applied to infundibulum.
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Laparoscopic cholecystectomy. Medial grasper is used to retract infundibulum in caudolateral direction.
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Laparoscopic cholecystectomy. Critical view, with only cystic duct and cystic artery seen entering gallbladder.
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Laparoscopic cholecystectomy. Use of L-hook electrocautery to score anterior peritoneum.
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Laparoscopic cholecystectomy. Division of peritoneum along medial aspect.
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Laparoscopic cholecystectomy. Use of Endo Peanut to identify cystic structures.
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Laparoscopic cholecystectomy. Use of Maryland dissector to dissect cystic duct.
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Laparoscopic cholecystectomy. Use of Maryland dissector to dissect cystic artery.
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Laparoscopic cholecystectomy. Continued dissection of critical structures.
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Laparoscopic cholecystectomy. Placement of clip at lower aspect of cystic artery.
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Laparoscopic cholecystectomy. Placement of superior clips on cystic artery.
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Laparoscopic cholecystectomy. Transection of cystic artery with Endo Shears.
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Laparoscopic cholecystectomy. Placement of clips on distal cystic duct.
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Laparoscopic cholecystectomy. Placement of proximal clip on cystic duct.
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Laparoscopic cholecystectomy. View of clipped cystic duct before transection.
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Laparoscopic cholecystectomy. Transection of cystic duct between clips with Endo Shears.
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Laparoscopic cholecystectomy. Use of hook to develop plane in areolar tissue between gallbladder and liver.
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Laparoscopic cholecystectomy. Use of traction and hook to remove gallbladder from gallbladder bed.
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Laparoscopic cholecystectomy. Side-to-side sweeping motion with electrocautery to remove gallbladder from gallbladder bed.
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Laparoscopic cholecystectomy. Cauterization of any bleeding in gallbladder bed before complete division of gallbladder.
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Laparoscopic cholecystectomy. Placement of gallbladder into endoscopic retrieval pouch.
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Laparoscopic cholecystectomy. Placement of gallbladder into endoscopic retrieval pouch and removal of instrument from pouch.
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Laparoscopic cholecystectomy. Irrigation and suction of gallbladder bed.
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Laparoscopic cholecystectomy. Removal of ports under direct vision.
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Laparoscopic cholecystectomy. Abdomen after skin closure.
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Laparoscopic cholecystectomy. CT scan illustrating biloma.
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Laparoscopic cholecystectomy. Postcholecystectomy ERCP showing leak of contrast.
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Laparoscopic cholecystectomy. Postcholecystectomy ERCP.
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Laparoscopic cholecystectomy. ERCP-guided stent placement.
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Laparoscopic cholecystectomy. HIDA scan showing postcholecystectomy leak.
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Anatomy of biliary tree.
