Laparoscopic Cholecystectomy

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 (NIH) 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]

Data from all over the world have, however, shown that the risk of a bile duct injury (BDI) during laparoscopic cholecystectomy is about 0.5%—that is, about two the three times the risk previously reported for open cholecystectomy.[8]

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 is now offered to elderly and obese patients as well; in fact, these latter patients may benefit even more from surgery through small incisions.

Asymptomatic (silent) gallstones

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

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 and comorbid factors taken into account) must be weighed against the risk of complications and death if the operation is not done.[10]

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 ^[11]
• Gallbladder trauma ^[10]
• Anomalous junction of the pancreatic and biliary ducts without cystic dilatation of the common bile duct (CBD), because of a very high risk of gallbladder cancer

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.[12]

A normal gallbladder is often removed as a part of another surgical procedure (eg, liver resection, excision of a choledochal cyst, or pancreatoduodenectomy.

Symptomatic gallstone disease

Biliary colic with sonographically identifiable stones is the most common indication for elective laparoscopic cholecystectomy.[10, 13]

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 when the procedure is performed by expert and experienced surgeons. Other options include interval laparoscopic cholecystectomy after 4-6 weeks and percutaneous cholecystostomy.[14, 15, 16]

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.[17]

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 US, magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), endoscopic US (EUS), or intraoperative cholangiography (IOC).[18]

In cases of acute moderate-to-severe biliary pancreatitis (according to the Ranson criteria), laparoscopic cholecystectomy should be delayed.[19]

Choledocholithiasis

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

• Preoperative endoscopic sphincterotomy and stone extraction
• Laparoscopic CBD exploration with or without T-tube placement
• Open CBD exploration with or without T-tube placement
• Postoperative endoscopic sphincterotomy

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 endoscopic stone extraction 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 (CHD), causing symptoms of obstructive jaundice.[20]

Although an initial trial of dissection may be performed by an experienced laparoscopic biliary surgeon, one must be prepared for subtotal (partial) cholecystectomy or for conversion to open operation 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.[21] Subsequent cholecystectomy may be performed.[22]

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 (GI) 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.[22]

Cholecystoduodenal fistula does not represent an absolute contraindication for laparoscopic surgery, though it does necessitate careful visualization of the anatomy and good laparoscopic suturing and stapling skills.[23]

Acalculous cholecystitis

A substantial proportion of patients with acalculous cholecystitis are too ill to undergo surgery. In these situations, percutaneous cholecystostomy guided by US or computed tomography (CT)  is advised. As many as 90% 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.[24]

Incidentalgallbladder cancer

Gallbladder cancer may be an incidental finding at laparoscopic cholecystectomy, with an incidence ranging from 0.3% to 5.0%.[25, 26, 27] Uncertainty about the diagnosis, lack of clarity regarding 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 have advocated simple cholecystectomy (which has already been done) 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 (radical) cholecystectomy (which includes hepatic resection, lymphadenectomy and, sometimes, bile duct excision). (See Gallbladder Cancer.)

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 (and, possibly, positron emission tomography [PET]).

Intraoperative identification of cancer during laparoscopic cholecystectomy is an indication for conversion to an open procedure.[28] 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.[29, 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.[30]

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.[31, 32]

Diabetics

The presence of diabetes mellitus, in and of itself, does not confer sufficient risk to warrant prophylactic cholecystectomy in asymptomatic individuals with gallstones. 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 of the gallbladder in the third trimester.

At one time, pregnancy was considered to be an absolute contraindication for 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.[33]

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[34] :

• Avoidance of rapid changes in patient position
• Avoidance of rapid changes in intraperitoneal pressures
• Use of open technique for the first (umbilical) port placement

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.

At one time, gallbladder cancer was considered a contraindication for laparoscopic cholecystectomy, but laparoscopic extended (radical) cholecystectomy for gallbladder cancer has since been reported to have results equivalent to those of the open operation.[35]  If there is any suspicion of gallbladder cancer, laparoscopic simple cholecystectomy should not be performed. 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; in addition, lymph nodes can be sampled intraoperatively to facilitate staging.[36]

Many conditions once felt to be contraindications for laparoscopic cholecystectomy (eg, gangrenous gallbladder, empyema of the gallbladder, cholecystoenteric 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 of successfully performed cases have become abundant.[37, 38]

Anatomy

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

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.[39]

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.[17] 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, proper hepatic, gastroduodenal, or superior mesenteric artery. The cystic artery typically courses superior to the cystic duct. Its length varies, depending on which artery it originates from and whether it enters into the neck or the body of the gallbladder. A double cystic artery may exist in 15% of the population.[40]

The cystic duct connects the gallbladder to the CHD 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 proper 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 (IVC) 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 at the papilla.[41]

The triangle of Calot is an important landmark whose boundaries include the CHD 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, clip and divide the cystic duct and the cystic 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 operative 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 ^{[42, 43]}
• 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 (0.2-0.3%%), can be devastating when they do occur (see Complications). Repairs for such injuries range from primary repair over a stent to hepaticojejunostomy.[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 ^[44]
• Before clipping and transection, carefully identifying the cystic duct and artery in the critical view of safety (CVS) (see Conventional Laparoscopic Cholecystectomy) as the only two structures entering the gallbladder ^[45]

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

Recommendations for the prevention of BDIs include the use of the critical view technique and bailout  procedures (eg, subtotal cholcystectomy and early conversion of laparoscopic cholecystectomy to open cholecystectomy) (see Conventional Laparoscopic Cholecystectomy).[46, 47, 48]

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

• Prevention of CBD injury - Although IOC may help prevent such injuries, ^{[49, 50]} 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 ^[51]
• 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 ^{[52, 53]}

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

Laparoscopic cholecystectomy remains an extremely safe procedure, with a mortality of 0.22-0.4%.[54, 55] Major morbidity occurs in approximately 5% of patients.[56] Complications include the following:

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

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 typically required for laparoscopic cholecystectomy includes the following:

• Light source, preferably with two video monitors (for the surgeon and the assistant)
• Laparoscope (telescope), 0° or 30° (preferred)
• Standard gas insufflation equipment
• Hasson trocar
• Trocars, 5 mm (2)
• Subxiphoid trocar, 11 mm (this can be replaced with another 5-mm trocar if a 5-mm laparoscopic clip applier is available)
• Blunt graspers
• Maryland dissector and L-hook cautery
• Electrocautery equipment
• Laparoscopic suction irrigator
• Laparoscopic clip applier
• Endoscopic ligature loop (eg, Endoloop; Ethicon Endo-Surgery, Blue Ash, OH)
• Cotton swab affixed to a 5-mm shaft (eg, Endo Peanut; Covidien, Mansfield, MA)
• Endoscopic retrieval pouch (eg, Endo Catch; Covidien, Mansfield, MA)

Many surgeons do not routinely use a Foley catheter for laparoscopic cholecystectomy.

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).

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.

An important issue for surgeons performing a laparoscopic cholecystectomy is whether and when the procedure should be converted to an open cholecystectomy. In the following situations, a low threshold for conversion to an open procedure should be maintained[67] :

• Excessive uncontrollable bleeding is encountered
• Patient anatomy is unclear
• Multiple tubular structures are seen entering the “gallbladder,” or a very large cystic duct is seen (especially if it appeared normal on ultrasonography [US]; these findings suggest that the surgeon may be in the wrong place—that is, what is perceived as the cystic duct may actually be the common bile duct [CBD])

Conversion to an open procedure should not be considered a complication, and the possibility that it will prove necessary or advisable should be discussed with the patient preoperatively. In most series, conversion rates are higher with emergency operations. Reported rates range from 1.5% to 15%, with most studies reporting rates around 5% in elective cases.[13]

A multivariate analysis identified male gender, elevated white blood cell count, low serum albumin, pericholecystic fluid noted on US, diabetes mellitus, and elevated total bilirubin as independent predictors of conversion. Another multivariate analysis identified male sex, positive Murphy sign, gallbladder-wall thickness exceeding 4 mm, and previous upper abdominal surgery as independent predictors of conversion to an open procedure.

The decision to convert to open cholecystectomy should be made when important anatomic structures cannot be clearly identified or when no progress is being made. As a general rule, if the junction of the gallbladder and the cystic duct has not been identified within 30 minutes of the start of the procedure, a laparoscopic cholecystectomy should be converted to an open cholecystectomy.

Several surgical societies have produced guidelines for safe cholecystectomy.[68] The Society of Endoscopic and Laparoscopic Surgeons of India (SELSI) has also published a Consensus Statement for Safe Cholecystectomy.[69, 70]

The skin is initially prepared with chlorhexidine from just below the nipple line to the inguinal ligaments and laterally to the anterior superior iliac spines.[45] The operative field is then draped with sterile drapes.

Placement of ports and instruments

A 1.5-cm longitudinal incision is made at the inferior aspect of the umbilicus, then deepened through the subcutaneous fat to the anterior rectus sheath. A Kocher clamp is used to grasp the reflection of the linea alba onto the umbilicus and elevate it cephalad.

A 1.2-cm longitudinal incision is made in the linea alba with a No. 15 blade. Two U stitches, one on either side of the fascial incision, are placed with 0 polyglactin suture on a curved needle (see the video below).

The peritoneum is elevated between two straight clamps and incised so as to afford safe entry into the abdominal cavity. An 11-mm blunt Hasson trocar is placed into the abdominal cavity, and insufflation of carbon dioxide is initiated to a maximum pressure of 15 mm Hg.

The author prefers a 30° laparoscope to a 0° laparoscope on the grounds that it gives better visualization of the cystic structures from multiple vantage points. A 30° scope, however, requires a more skilled scope operator.

The laparoscope is white-balanced and advanced slowly into the abdominal cavity. A 1.2-cm incision is made three fingerbreadths below the xiphoid process and deepened into the subcutaneous fat. An 11-mm trocar is advanced into the abdominal cavity under direct vision (see the image below) in the direction of the gallbladder through the abdominal wall, with care taken to enter just to the right of the falciform ligament.

The table is then adjusted to place the patient in a reverse Trendelenburg position with the right side up to allow the small bowel and the transverse colon to fall away from the operative field (see the image below).

A 5-mm grasper is placed through the 11-mm subxiphoid port and applied to the fundus of the gallbladder. The gallbladder is then elevated cephalad over the dome of the liver to facilitate the surgeon’s choice of the optimal positions for the lateral 5-mm ports.

After appropriate port sites are chosen, the lateral skin incisions are made, and two 5-mm trocars are advanced into the peritoneal cavity under direct vision (see the first image below). A 5-mm grasper with locking mechanism is placed through one of these lateral ports to hold and retract the gallbladder fundus (and thus the liver) (see the second image below).

Exposure and dissection

The lateral grasper is applied to the fundus and used to hold it cephalad over the dome of the liver (see the first image below); the medial grasper is used to retract the infundibulum caudolaterally (see the second and third images below). This maneuver straightens the cystic duct (ie, retracts it at 90° from the CBD) and helps protect the CBD from inadvertent injury.[71] In contrast, cephalad retraction of the infundibulum tends to bring the cystic duct in line with the CBD, making the CBD more prone to injury as a consequence of being misidentified as the cystic duct.

Occasionally, adhesions are encountered between the gallbladder and the omentum or duodenum. These may be carefully lysed with a hook cautery. The authors prefer to use an L-hook electrocautery, which allows a very clean and delicate dissection, but any electrosurgical device can be used for this purpose.

Once the area of the hilum of the gallbladder has been reached, the importance of exposure and delicate dissection cannot be overemphasized. The cystic duct and artery must be carefully dissected and identified in the triangle of Calot to obtain the "critical view of safety" (CVS). This critical view is achieved when the surgeon can see only two structures (the cystic duct and artery) entering directly into the gallbladder (see the image below); it must be obtained before any structures are clipped or transected.[72]

The key to obtaining the CVS is complete clearance of the areolar tissue in the subhepatic space. With the infundibulum held caudolaterally, the hook is used to score the anterior (medial) peritoneum overlying the infundibulum−cystic duct junction (see the image below).

Next, the peritoneum is incised along the medial aspect all the way to within 1 cm of the liver (see the image below), and the incision is continued cephalad toward the fundus of the gallbladder.

The gallbladder is then retracted caudomedially, and a similar dissection is carried out on the lateral (posterior) surface. This technique is sometimes referred to as the flag technique.[1]

An Endo Peanut or a Maryland dissector can be of great help in better defining these structures (see the images below). At this point, the surgeon should be able to identify the cystic duct and cystic artery entering directly into the gallbladder; this is the CVS.

Clipping and division of cystic structures

Once the CVS has been achieved and the cystic structures clearly identified, the structures can be clipped and divided (see the images below). An endoscopic clip applier is used to place clips on the artery and duct (two proximally and one distally), which are then divided with endoscopic shears (eg, Endo Shears; Covidien, Mansfield, MA).

When the cystic duct is large, there are several options that may be considered, including an endoscopic stapler, Endoloops, and the overlapping clip technique.[73, 74, 75] If an Endoloop is used, it should be placed through the subxiphoid port. The grasper from the infundibulum is used to gently hold the cystic stump through the loop; the loop is then pulled taut.

Mobilization and removal of gallbladder

Once the cystic structures have been clipped and divided, the infundibulum is retracted cephalad. A hook or spatula is used to develop a plane in the areolar tissue between gallbladder and liver (cystic plate) with smooth sweeping movements from right to left and back again. As in any surgical procedure, the traction-countertraction rule is essential. As the dissection marches up the gallbladder bed, the assistant should reposition his or her graspers to ensure optimal tension on the areolar tissue between gallbladder and liver bed (see the images below).

It is important to be alert for any aberrant vessels and ducts that may arise from the liver bed and enter directly into the gallbladder. These should be clipped and not simply cauterized.

Before the last strands connecting the gallbladder to the liver are divided, a final inspection of the gallbladder fossa and the clipped cystic structures should be carried out. Any bleeding points in the gallbladder fossa should be controlled at this time, before the gallbladder is completely separated from the liver (see the image below). This is the surgeon’s last opportunity to visualize these areas well.

Both 5-mm graspers are applied to the gallbladder and used to hold it over the right upper quadrant. An endoscopic retrieval pouch is inserted into the peritoneal cavity through the subxiphoid trocar. The gallbladder is placed in the bag, which is then cinched closed and extracted thorugh the subxiphoid port. (See the images below.) Some surgeons transfer the laparoscope to the subxiphoid port and place and extract the bag through the umbilical port. A final inspection and washout is performed.

The table is returned to the neutral position. The gallbladder bed and the suprahepatic spaces are irrigated and suctioned to ensure adequate hemostasis and removal of any debris or bile that may have spilled (see the image below).

Port removal and closure

The subxiphoid port and the two 5-mm ports are removed under direct vision, followed by the Hasson trocar (see the image below).

Overall, the incidence of port-site hernias is very low. Tonouchi et al reported an incidence of 0.65-2.8%; their recommendation was to close all port sites larger than 10 mm.[76]  Some surgeons, however, do not close the subxiphoid port. The fascia is closed at the umbilical port by using the two U stitches placed at the beginning of the procedure. All of the skin incisions are closed with 4-0 absorbable monofilament suture, followed by cyanoacrylate tissue adhesive. (See the image below.)

Postoperative care

Finally, the patient is extubated, transferred to the postanesthesia care unit, and monitored for 4-6 hours. In cases of elective cholecystectomy, the patient can be discharged home with a combination oral pain medication containing acetaminophen and an opiate.[3]

Minilaparoscopic cholecystectomy

Since the introduction and widespread adoption of laparoscopic cholecystectomy, investigators have attempted to make further improvements to the established technique, aiming to reduce the invasiveness of the procedure by decreasing the number and, more commonly, the size of the operating ports, as well as the size of the instruments.

Novitsky et al concluded that laparoscopic cholecystectomy can be safely performed with the use of 10-mm umbilical, 5-mm epigastric, 2-mm subcostal, and 2-mm lateral ports. They suggest that minilaparoscopy can be routinely offered to properly selected patients undergoing elective laparoscopic cholecystectomy.[77]

Single-site cholecystectomy

Cholecystectomy can also be performed through single-port access (SPA) surgery, also known as single-incision laparoscopic surgery (SILS)—so-called single-port cholecystectomy.[78, 79] In these procedures, the surgeon operates almost exclusively through a single entry point, typically the patient’s umbilicus.

In a retrospective review that included 360 consecutive patients who underwent single-incision laparoscopic cholecystectomy (SILC), Sato et al concluded that SILC appeared to be relatively safe and to have an acceptable postoperative complication rate but noted that poor physical status and acute cholecystitis were significant risk factors for postoperative complications.[80]

An approach in which three discrete ports are placed through three mini-incisions at a single site has also been described.[81]

Robotic cholecystectomy

Robotic-assisted cholecystectomy is feasible and safe; however, its cost is high, and no clear benefit for patients has been established. At present, therefore, the use of this technology is not justified.[82, 83]

Hasson trocar/Veress needle injury

Intestinal injury may occur during establishment of abdominal access, adhesiolysis, or dissection of the gallbladder away from the duodenum or colon. An injury to the bowel should be repaired with careful one- or two-layer suture closure.

The rates of injury to viscera or vessels from a Hasson trocar or from a Veress needle are comparable (in the range of 0.2%).

Hemorrhage

When a large-vessel vascular injury occurs, it is usually at the time of initial abdominal access. Such injuries may be lethal complications. Development of a retroperitoneal hematoma or hypotension should be treated immediately by converting to laparotomy.

Excessive bleeding in the region of the triangle of Calot should not be treated laparoscopically. In this situation, attempts at blind clipping or cauterization usually lead to worsening hemorrhage or hepatic artery injury. If, and only if, a bleeding site can be definitely identified and the locations of both the hepatic artery and the CBD are known, bleeding may be controlled with cauterization or clipping.

Bleeding in the gallbladder bed can usually be controlled by fulgurating the bleeding site. The author prefers using a spatulated electrocautery wand for this purpose. If a larger intrahepatic sinus has been entered, hemostatic agents (eg, microfibrillar collagen) can be placed laparoscopically in the gallbladder bed, and pressure can be maintained with a clamp. The argon plasma coagulator (APC) can be an excellent tool for severe gallbladder fossa oozing that is not responsive to simple electrocauterization.

Postcholecystectomy syndrome

The term postcholecystectomy syndrome refers to a set of abdominal symptoms that occur in as many as 40% of patients after cholecystectomy. Symptoms are often vague and include dyspepsia, flatulence, bloating, right-upper-quadrant pain, and epigastric pain. The most common causes of this syndrome are dietary indiscretion, retained CBD stones, inflammation of the cystic duct remnant, and sphincter of Oddi dysfunction.[84]

Bile duct injury

The most dreaded complication of laparoscopic cholecystectomy is bile duct injury (BDI; ie, injury to the CBD or the common hepatic duct [CHD]). The estimated incidence of BDI in cholecystectomies performed laparoscopically ranges from 0.3% to 2.7%. By way of comparison, BDIs have been estimated to occur in 0.25-0.5% of open cholecystectomies.

A major risk factor for BDI is relative inexperience on the part of the surgeon.[85, 86, 87] Other risk factors are the presence of aberrant biliary tree anatomy and the presence of local acute or chronic inflammation.

BDI may manifest as bile leak (which is due to partial or complete bile duct transection leading to bile leakage into the peritoneum) or as biliary obstruction (which may be either partial or complete and is secondary to acute ductal ligation or chronic stricture formation).

BDI may present at different points in the treatment of the patient, as follows:

• Intraoperative presentation - The injury is identified during the index procedure (ie, laparoscopic cholecystectomy)
• Delayed presentation - Patients may present 3-7 days after surgery with fever, abdominal pain, anorexia, ileus, ascites, nausea, or jaundice
• Late-onset stricture - Patients may present months later with abdominal pain and jaundice

Management of BDI depends on the timing of identification and the degree of injury and the expertise and experience of the surgon in reconstructive biliary surgery. If the injury is identified intraoperatively, the injured duct should be repaired immediately. Depending on degree, most partial CBD injuries can be primarily repaired over a T-tube,[88] though in some cases, repair may require transfer to a specialized center.

If the injury is identified postoperatively, imaging (US, computed tomography [CT], or both) is indicated to look for collections or ductal dilatation (see the first image below). Biliary scintigraphy with99m Tc-IDA or hepatobiliary iminodiacetic acid (HIDA) can be used to diagnose and sometimes localize the source of bile leakage (see the second image below). Endoscopic retrograde cholangiopancreatography (ERCP) can be used both diagnostically and therapeutically (see the third and fourth images below).

Treatment of BDI can be an involved subject but may be summarized as follows:

• CT-guided drainage of biloma followed by ERCP with endoscopic sphincterotomy and stent placement (see the image below) is the treatment of choice for less severe lesions, such as minor lacerations of the CBD, duct of Luschka leak, or displaced cystic duct clips
• Lesions in the proximal biliary tree may be more amenable to percutaneous transhepatic approaches
• Surgical biliary reconstruction may be necessary in cases of complete BDI

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Class Summary

Local anesthetic agents are used to increase patient comfort during the procedure.

Lidocaine and epinephrine (Lignospan Forte, Xylocaine with Epinephrine)

Lidocaine is an amide local anesthetic used in a 0.5-1% concentration in combination with bupivacaine (50:50 mixture). This agent inhibits depolarization of type C sensory neurons by blocking sodium channels. Epinephrine prolongs the duration of the anesthetic effects from lidocaine by causing vasoconstriction of the blood vessels surrounding the nerve axons.

Bupivacaine (Marcaine, Sensorcaine)

Bupivacaine 0.25% may be used in combination with lidocaine plus epinephrine (50:50 mixture). It decreases permeability to sodium ions in neuronal membranes. This results in the inhibition of depolarization, blocking the transmission of nerve impulses.

Class Summary

After standard monitoring equipment is attached and peripheral venous access achieved but before the arterial line is inserted, the midazolam or lorazepam dose is administered.

Propofol (Diprivan, Fresenius Propoven)

Propofol is a phenolic compound unrelated to other types of anticonvulsants. It has general anesthetic properties when administered intravenously. Intravenous propofol produces rapid hypnosis, usually within 40 seconds. The effects are reversed within 30 minutes, following the discontinuation of infusion. Propofol has also been shown to have anticonvulsant properties.

Class Summary

Typically, a single dose of a cephalosporin is administered by the anesthesiologist before the skin incision.

Cefazolin

Cefazolin is a first-generation semisynthetic cephalosporin that arrests bacterial cell wall synthesis, inhibiting bacterial growth. It is used for infections caused by gram-positive cocci (except enterococci)

Class Summary

Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients who experience moderate to severe pain.

Acetaminophen and codeine (Tylenol #3)

This combination is indicated for mild to moderate pain.

Acetaminophen (Tylenol, Aspirin-Free Anacin, Cetafen, Mapap Extra Strength)

Acetaminophen is the drug of choice for the treatment of pain in patients with documented hypersensitivity to aspirin or NSAIDs, as well as in those with upper GI disease or who are taking oral anticoagulants.

Hydrocodone bitartrate and acetaminophen (Vicodin ES, Lortab, Lorcet Plus, Norco, Maxidone)

This agent is indicated for the relief of moderately severe to severe pain.