Cholecystectomy

Cholecystectomy is the surgical removal of the gallbladder. Cholecystectomy is a common treatment of symptomatic gallstones and other gallbladder conditions. Cholecystectomy can be performed either laparoscopically or through a laparotomy.

The surgery is usually successful in relieving symptoms, but up to 10 percent of people may continue to experience similar symptoms after cholecystectomy, a condition called postcholecystectomy syndrome. The gallbladder can also be removed in order to treat biliary dyskinesia or gallbladder cancer. The traditional risk factors for gallstones are the four "F's: female, fat, forty, and fertile. Of the more than 20 million people in the US with gallstones, only about 30% will eventually require cholecystectomy to relieve symptoms (pain) or treat complications.

Biliary colic

Biliary colic, or pain caused by gallstones, occurs when a gallstone temporarily blocks the bile duct that drains the gallbladder. Typically, pain from biliary colic is felt in the right upper part of the abdomen, is moderate to severe, and goes away on its own after a few hours when the stone is either passed or dislodges. Biliary colic usually occurs after meals when the gallbladder contracts to push bile out into the digestive tract. After a first attack of biliary colic, more than 90% of people will have a repeat attack in the next 10 years. Repeated attacks of biliary colic are the most common reason for removing the gallbladder, and lead to about 300,000 cholecystectomies in the US each year.

Acute cholecystitis

Cholecystitis, or inflammation of the gallbladder caused by interruption in the normal flow of bile, is another reason for cholecystectomy. It is the most common complication of gallstones; 90–95% of acute cholecystitis is caused by gallstones blocking drainage of the gallbladder. If the blockage is incomplete and the stone passes quickly, the person experiences biliary colic. If the gallbladder is completely blocked and remains so for a prolonged period, the person develops acute cholecystitis.

Pain in cholecystitis is similar to that of biliary colic, but lasts longer than six hours and occurs together with signs of infection such as fever, chills, or an elevated white blood cell count.

Cholangitis and gallstone pancreatitis

Cholangitis and gallstone pancreatitis are rarer and more serious complications from gallstone disease. Both can occur if gallstones leave the gallbladder, pass through the cystic duct, and get stuck in the common bile duct. The common bile duct drains the liver and pancreas, and a blockage there can lead to inflammation and infection in both the pancreas and biliary system. While cholecystectomy is not usually the immediate treatment choice for either of these conditions, it is often recommended to prevent repeat episodes from additional gallstones getting stuck. The gallbladder is not removed in pediatric transplantations as the left lobe of the liver is used instead.

Contraindications

There are no specific contraindications for cholecystectomy, and in general it is considered a low-risk surgery. However, anyone who cannot tolerate surgery under general anesthesia should not undergo cholecystectomy. People can be split into high and low risk groups using a tool such as the ASA physical status classification system. In this system, people who are ASA categories III, IV, and V are considered high risk for cholecystectomy. Typically this includes very elderly people and people with co-existing illness, such as end-stage liver disease with portal hypertension and whose blood does not clot properly. Alternatives to surgery are briefly mentioned below.

Risks

All surgery carries risk of serious complications including damage to nearby structures, bleeding, infection, or even death. The operative death rate in cholecystectomy is about 0.1% in people under age 50 and about 0.5% in people over age 50.

Biliary injury

A serious complication of cholecystectomy is biliary injury, or damage to the bile ducts. Laparoscopic cholecystectomy has a higher risk of bile duct injury than the open approach, with injury to bile ducts occurring in 0.3% to 0.5% of laparoscopic cases and 0.1% to 0.2% of open cases. In laparoscopic cholecystectomy, approximately 25–30% of biliary injuries are identified during the operation; the rest become apparent in the early post-operative period. This method was assessed by the Swedish SBU and routine use deemed to decrease risk of injury and morbidity following unaddressed injury while only increasing cancer rates due to radiation exposure by a lesser fraction.

!Complication

!Prevalence

|Wound infection

|1.25%

|Urinary retention

|0.90%

|Bleeding

|0.79%

|Retained stone in the common bile duct

|0.50%

|Respiratory

|0.48%

|Cardiac

|0.36%

|Intra-abdominal abscess

|0.34%

|Hernia

|0.21%

The same study found the prevalence of bowel injury, sepsis, pancreatitis, and deep vein thrombosis/pulmonary embolism to be around 0.15% each.

Another complication singular to the laparoscopic procedure is the phenomenon of the "spilled gallstone" which complicates 0.08–0.3% of cases. Here a stone escapes the resected gallbladder into the abdomen where it can become a focus for infection if it is not identified and removed. Some reports exist of spilled stones lying unnoticed for up to 20 years before eventually causing an abscess to form.

Conversion to open cholecystectomy

Experts agree that many biliary injuries in laparoscopic cases are caused by difficulties seeing and identifying the anatomy clearly. If the surgeon has problems identifying anatomical structures, they might need to convert from laparoscopic to open cholecystectomy.

<big>Peroperative Endoscopic Retrograde Cholangio-Pancreaticography (ERCP)/ Laparo-endoscopic rendezvous (LERV) technique</big>

CBDS are found in 10–15% of patients during cholecystectomy when intraoperative cholangiography (IOC) is routinely performed.

There are several strategies to manage choledocholithiasis but the optimal method as well as the timing of treatment is still under debate.

In recent years the LERV technique, in which access to the common bile duct by ERCP is facilitated by an antegrade guidewire, which is intraoperatively introduced during fluoroscopy and is advanced through the cystic duct to the duodenum, has been established as an alternative to treat common bile duct stones discovered during laparoscopic cholecystectomy. This technique was first described in 1993 by Deslandres et al.

and has, in several studies, been shown to have a high rate of CBD stones clearance and a reduced number of complications, particularly post-ERCP pancreatitis, in comparison with conventional ERCP.

This is probably due to the facilitated access to the common bile duct with a lesser degree of manipulation and trauma to the papilla Vateri. In a study by Swahn et al. the rendezvous method was shown to reduce the risk of PEP from 3.6 to 2.2% compared with conventional biliary cannulation.

The success rate of passing the transcystic guidewire into the duodenum has been reported to be over 80%.

Procedure

thumb|Abdomen of a 45-year-old male approximately one month after a laparoscopic cholecystectomy. Surgical incision points are highlighted; the point at top right is barely visible. The gall bladder was removed via the incision at the navel. There is a fourth incision (not shown) on the person's right lower flank, used for draining. All incisions have healed well and the most visible remaining effect of surgery is from the pre-operative [[hair removal.]]

thumb|Steps of a cholecystectomy, as seen through a laparoscope

thumb|The 1-week-old incisions of a post-operative laparoscopic cholecystectomy as indicated by red arrows. The 3 abdominal incisions are approximately 6mm, while the fourth incision near the umbilicus is 18mm, each closed with dissolvable sutures. Minor inflammation can be seen surrounding each site due to skin irritation caused by removal of [[Tegaderm dressings.]]

Pre-operative preparation

Before surgery, a complete blood count and liver function tests are usually obtained. Prophylactic treatment is given to prevent deep vein thrombosis. Gas may be removed from the stomach with an OG or NG tube. Laparoscopic surgery is thought to have fewer complications, shorter hospital stay, and quicker recovery than open cholecystectomy.

Single incision

Single incision laparoscopic surgery (SILS) or laparoendoscopic single site surgery (LESS) is a technique in which a single incision is made through the navel, instead of the 3-4 four small different incisions used in standard laparoscopy. There appears to be a cosmetic benefit over conventional four-hole laparoscopic cholecystectomy, and no advantage in postoperative pain and hospital stay compared with standard laparoscopic procedures.

Natural orifice transluminal

Natural orifice transluminal endoscopic surgery (NOTES) is an experimental technique where the laparoscope is inserted through natural orifices and internal incisions, rather than skin incisions, to access to the abdominal cavity. This offers the potential to eliminate visible scars.

Open cholecystectomy

In open cholecystectomy, a surgical incision of around 8 to 12 cm is made below the edge of the right rib cage and the gallbladder is removed through this large opening, typically using electrocautery.

Post-operative management

After surgery, most patients are admitted to the hospital for routine monitoring. For uncomplicated laparoscopic cholecystectomies, people may be discharged on the day of surgery after adequate control of pain and nausea. Essentially, only part of the gall bladder is removed and a drain is left in place for several days. Complications include continued output from the drain, which may result in the need for an ERCP stent placement to stop drainage.

Long-term prognosis

In 95% of people undergoing cholecystectomy as treatment for simple biliary colic, removing the gallbladder completely resolves their symptoms. Symptoms are typically similar to the pain and discomfort of biliary colic with persistent pain in the upper right abdomen and commonly include gastrointestinal distress (dyspepsia). A nationwide cohort study in Korea reported a significantly increased total cancer risk, including increased risk of several different specific types of cancer, after cholecystectomy.

Considerations

Pregnancy

It is generally safe for pregnant women to undergo laparoscopic cholecystectomy during any trimester of pregnancy. ERCP does not require general anaesthesia and can be done outside of the operating room. While ERCP can be used to remove a specific stone that is causing a blockage to allow drainage, it cannot remove all stones in the gallbladder. Thus, it is not considered a definitive treatment and people with recurrent complications from stones will still likely need a cholecystectomy.

Cholecystostomy

Cholecystostomy is the drainage of the gallbladder via insertion of a small tube through the abdominal wall. This is usually done using guidance from imaging scans to find the right place to insert the tube. Cholecystostomy can be used for people who need immediate drainage of the gallbladder but have a high risk of complications from surgery under general anaesthesia, such as elderly people and those with co-existing illnesses. Draining pus and infected material through the tube reduces inflammation in and around the gallbladder. It can be a lifesaving procedure, without requiring that the person undergo emergency surgery.

The procedure does come with significant risks and complications—in one retrospective study of patients who received percutaneous cholecystostomy for acute cholecystitis, 44% developed choledocholithiasis (one or more stones stuck in the common bile duct), 27% had tube dislodgment, and 23% developed postoperative abscess.

Gallstones affect approximately 10-15% of the global adult population, with the incidence rising with age and more commonly affecting women. As a result, cholecystectomy is one of the most common abdominal surgeries performed worldwide.

History

right|thumb|Carl Langenbuch performed the first successful cholecystectomy in 1882.

Carl Langenbuch performed the first successful cholecystectomy at the Lazarus hospital in Berlin on July 15, 1882. Langenbuch's rationale for developing the new technique stemmed from 17th century studies in dogs that demonstrated the gallbladder to be nonessential and medical opinion among his colleagues that gallstones formed in the gallbladder. Mühe was inspired to develop a technique for laparoscopic cholecystectomy by the first laparoscopic appendectomy, performed by gynecologist Kurt Semm in 1980. Mühe presented his technique to the Congress of the German Surgical Society in 1986, claiming reduced postoperative pain and shorter hospitalization. His work was met with strong resistance by the German surgical establishment and he had difficulty communicating it in English. It was consequently ignored. He was exonerated in 1990 after further investigation.

By 2014 laparoscopic cholecystectomy had become the gold standard for the treatment of symptomatic gallstones.

Laparoscopic cholecystectomy can be a challenging procedure and surgeons must be trained with advanced laparoscopic skills to complete the operation with safety and effectiveness.