Cholecystectomy

Laparoscopic Cholecystectomy as seen through laparoscope

X-Ray during Laparoscopic Cholecystectomy

Cholecystectomy
Is the surgical removal of the gallbladder. It is the most common method for
treating symptomatic gallstones. Surgical options include the standard procedure,
called laparoscopic cholecystectomy, and an older more invasive procedure,
called open cholecystectomy.

Open surgery
A traditional open cholecystectomy is a major abdominal surgery in which the
surgeon removes the gallbladder through a 5-7 inch incision. Patients usually remain in
the hospital at least 2-3 days and may require several additional weeks to recover at
home.

Laparoscopic surgery
Laparoscopic cholecystectomy has now replaced open cholecystectomy as the
first-choice of treatment for gallstones and inflammation of the gallbladder unless there
are contraindications to the laparoscopic approach. This is because open surgery makes
you more prone to infection. Sometimes, a laparoscopic cholecystectomy will be
converted to an open cholecystectomy for technical reasons or safety.

A US Navy general surgeon and an operating room nurse discuss proper

procedures while performing a laparoscopiccholecystectomy surgery.
 Laparoscopic cholecystectomy requires several small incisions in the abdomen to
allow the insertion of operating ports, small cylindrical tubes approximately 5-10 mm in
diameter, through which surgical instruments and a video camera are placed into
the abdominal cavity. The camera illuminates the surgical field and sends a magnified
image from inside the body to a video monitor, giving the surgeon a close-up view of the
organs and tissues. The surgeon watches the monitor and performs the operation by
manipulating the surgical instruments through the operating ports. To begin the
operation, the patient is anesthetized and placed in the supine position on the operating
table. A scalpel is used to make a small incision at the umbilicus. Using either a Veress
needle or Hasson technique the abdominal cavity is entered. The surgeon inflates the
abdominal cavity with carbon dioxide to create a working space. The camera is placed
through the umbilical port and the abdominal cavity is inspected. Additional ports are
placed inferior to the ribs at the epigastric, midclavicular, and anterior axillary positions.
The gallbladder fundus is identified, grasped, and retracted superiorly. With a second
grasper, the gallbladder infundibulum is retracted laterally to expose and open Calot's
Triangle (the area bound by the cystic artery, cystic duct, and common hepatic duct). The
triangle is gently dissected to clear the peritoneal covering and obtain a view of the
underlying structures. The cystic duct and the cystic artery are identified, clipped with
tiny titanium clips and cut. Then the gallbladder is dissected away from the liver bed and
removed through one of the ports. This type of surgery requires meticulous surgical skill,
but in straightforward cases can be done in about an hour.

Recently, this procedure is performed through a single incision in the patient's

umbilicus. This advanced technique is called Laparoendoscopic Single Site Surgery or
"LESS".
Procedural Risks and Complications
Laparoscopic cholecystectomy does not require the abdominal muscles to be cut,
resulting in less pain, quicker healing, improved cosmetic results, and fewer
complications such as infection and adhesions. Most patients can be discharged on the
same or following day as the surgery, and most patients can return to any type of
occupation in about a week.

An uncommon but potentially serious complication is injury to the common bile

duct, which connects the gallbladder and liver. An injured bile duct can leak bile and
cause a painful and potentially dangerous infection. Many cases of minor injury to the
common bile duct can be managed non-surgically. Major injury to the bile duct, however,
is a very serious problem and may require corrective surgery. This surgery should be
performed by an experienced biliary surgeon.

Abdominal peritoneal adhesions, gangrenous gallbladders, and other problems

that obscure vision are discovered during about 5% of laparoscopic surgeries, forcing
surgeons to switch to the standard cholecystectomy for safe removal of the
gallbladder. Adhesions and gangrene, of course, can be quite serious, but converting to
open surgery does not equate to a complication.

A Consensus Development Conference panel, convened by the National Institutes

of Health in September 1992, endorsed laparoscopic cholecystectomy as a safe and
effective surgical treatment for gallbladder removal, equal in efficacy to the traditional
open surgery. The panel noted, however, that laparoscopic cholecystectomy should be
performed only by experienced surgeons and only on patients who have symptoms of
gallstones.

In addition, the panel noted that the outcome of laparoscopic cholecystectomy is

greatly influenced by the training, experience, skill, and judgment of the surgeon
performing the procedure. Therefore, the panel recommended that strict guidelines be
developed for training and granting credentials in laparoscopic surgery, determining
competence, and monitoring quality. According to the panel, efforts should continue
toward developing a noninvasive approach to gallstone treatment that will not only
eliminate existing stones, but also prevent their formation or recurrence.
 One common complication of cholecystectomy is inadvertent injury to an
anomalous bile duct known as Ducts of Luschka, occurring in 33% of the population. It is
non-problematic until the gall bladder is removed, and the tiny supravesicular ducts may
be incompletely cauterized or remains unobserved, leading to biliary leak post
operatively. The patient will develop biliary peritonitis within 5 to 7 days following
surgery, and will require a temporary biliary stent. It is important that the clinician
recognize the possibility of bile peritonitis early and confirm diagnosis via HIDA scan to
lower morbidity rate. Aggressive pain management and antibiotic therapy should be
initiated as soon as diagnosed.

Biopsy
After removal, the gall bladder should be sent for biopsy. (Pathological
examination) to confirm the diagnosis and look for an incidental cancer. If cancer is
present, a reoperation to remove part of the liver and lymph nodes will be required in
most cases.

Long-Term Prognosis
A minority of the population, from 5% to 40%, develop a condition
called postcholecystectomy syndrome, or PCS. Symptoms can include gastrointestinal
distress and persistent pain in the upper right abdomen.

As many as twenty percent of patients develop chronic diarrhea. The cause is

unclear, but is presumed to involve the disturbance to the bile system. Most cases clear
up within weeks, though in rare cases the condition may last for many years. It can be
controlled with drugs.
 Written Report
Of
CHOLECYSTECTOMY

Submitted by : Jessa Marie G. Fajardo

Submitted to : Mr. Palacios