Laparoscopic Cholecystectomy

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CHAPTER 12 Laparoscopic Cholecystectomy

E. Carter Paulson, Robert E. Roses, Jon B. Morris

Case Study

A 45-year-old female presents to the emergency department after several hours of persistent right upper abdominal pain, which became more severe after she ate dinner. She localizes the pain to the epigastrium and right upper quadrant and notes radiation to the right scapula. She recalls several less severe episodes of pain in a similar distribution over the previous year, typically after ingestion of fatty meals. These episodes usually resolved within 1 hour.

Her sclera are anicteric. Her abdomen is soft and nondistended. The right upper abdomen under the costal margin is exquisitely tender on palpation.

Laboratory evaluation is remarkable for mild leukocytosis. Other laboratory data, including liver function tests and pancreatic enzymes, are normal.

A right upper quadrant ultrasound is obtained, which shows gallstones and gallbladder wall thickening (Fig. 12-1). The common bile duct (CBD) is visualized and is of normal caliber.

image

Figure 12-1 Gallbladder ultrasound demonstrating diffuse gallbladder wall thickening and shadowing from an impacted gallstone (arrow).

(From Goldman L, Ausiello DA: Cecil Medicine, 23rd ed. Philadelphia, Saunders, 2008.)

BACKGROUND

The gallbladder is a pear-shaped organ located on the undersurface of the liver. The gallbladder functions as a concentrating reservoir for bile, which it delivers to the duodenum in response to meals. Gallbladder stones (cholelithiasis) and the complications associated with them are largely responsible for making cholecystectomy the most frequently performed gastrointestinal operation in the United States; approximately 700,000 cholecystectomies are performed annually.

The pathogenesis of cholesterol gallstones is multifactorial and involves excess cholesterol production by the liver as well as disordered gallbladder mucosal and motor function. Biliary sludge, a mixture of cholesterol crystals, calcium bilirubinate granules, and a mucin gel matrix, is observed frequently during prolonged fasting states. Mucin–bilirubin complexes are often found at the center of cholesterol stones, suggesting that sludge represents a precursor to stone formation.

Gallstones result from cholesterol supersaturation of bile. The primary components of bile (bile acids, phospholipids, and cholesterol) are normally maintained in solution in micelles. Cholesterol excess beyond a critical concentration may result in precipitation and stone formation. Although the majority of gallstones are composed of cholesterol (80%), a minority are composed of calcium bilirubinate and calcium palmitate, and are known as pigment gallstones. Pigment stones may be classified as black, usually associated with hemolytic conditions or cirrhosis, or brown, associated with disorders of biliary motility and bacterial infections.

Gallstones are common and are usually asymptomatic. Indeed, over a 20-year period, two thirds of individuals with gallstones remain asymptomatic. The remaining one third of individuals will either have pain (biliary colic) from transient obstruction of the cystic duct (the route of bile efflux from the gallbladder) or one of several complications of cholelithiasis. These complications include acute cholecystitis, choledocholithiasis with or without cholangitis, gallstone pancreatitis, and gallstone ileus. In general, cholecystectomy is not recommended for adults who have asymptomatic gallstones found on imaging or during surgery for another indication. Biliary colic and complicated gallstone disease, however, are indications for cholecystectomy and are discussed in more detail below.

INDICATIONS FOR CHOLECYSTECTOMY

I. Biliary colic (pain associated with transient obstruction of the cystic duct) is the most common indication for cholecystectomy. Episodes of biliary colic typically persist for 1 or more hours and may last as long as 24 hours. These episodes are characteristically precipitated by ingestion of fatty meals, although this is not always the case. Patients with symptomatic cholelithiasis are believed to be at higher risk for gallstone-related complications than are patients without symptoms. In addition to bringing about the resolution of symptoms, cholecystectomy in these patients serves to prevent the potential complications that comprise the other indications for this operation. Cholecystectomy is performed electively in patients with biliary colic, although severe or frequent symptoms may necessitate prompt intervention.
II. Acute Calculous Cholecystitis: More than 90% of cases of acute cholecystitis are related to gallstones. Persistent cystic duct obstruction leads to gallbladder distention and inflammation. Gallbladder ischemia and necrosis represent an endpoint of this process in severe cases. Patients typically present with persistent right upper quadrant pain, with or without nausea and vomiting. Murphy’s sign, which is positive when a patient halts inspiration when the right upper quadrant of the abdomen is palpated, is characteristic. In rare instances, cholecystitis may present with systemic signs of sepsis. Cholecystectomy is the first-line treatment for acute cholecystitis and should be performed promptly after the diagnosis is confirmed. In selected cases, such as in the unstable or high-risk patient, cholecystostomy (drainage of the gallbladder) may be used as a temporizing measure. This procedure is commonly performed by interventional radiologists under fluoroscopic guidance, thus avoiding some of the risks associated with general anesthesia and conventional surgical management.
III. Choledocholithiasis: The preoperative evaluation of patients with calculous gallbladder disease should identify patients at risk for CBD stones. Signs and symptoms of choledocholithiasis may include jaundice, light-colored stools, dark-colored urine, elevated liver function test, and a dilated CBD on ultrasound (US) (>5 mm). Options for the evaluation and management of suspected choledocholithiasis include endoscopic retrograde cholangiopancreatography (ERCP), magnetic resonance cholangiopancreatography (MRCP), and intraoperative cholangiography at the time of cholecystectomy. Patients with choledocholithiasis may also present with cholangitis, a bacterial infection of the biliary ducts. The signs and symptoms of cholangitis include Charcot’s triad (fever, jaundice, and abdominal pain) and Reynold’s pentad (fever, jaundice, abdominal pain, hypotension, and mental status changes). The primary management of cholangitis is nonsurgical. Most cases resolve with antibiotics and supportive care. Gallstone-associated cholangitis that does not resolve after the initiation of medical management warrants endoscopic or percutaneous cholangiography, with biliary drainage and stone clearance, if possible. In rare circumstances, CBD exploration and T-tube (drain) placement may be lifesaving when other options are not feasible or have been unsuccessful.
IV. Gallstone Pancreatitis: Gallstones are responsible for the majority of cases of acute pancreatitis. Obstruction of the pancreatic duct by a CBD stone may resolve spontaneously after the passage of the stone into the duodenum. Worsening pancreatitis, however, sometimes reflects impaction of a common duct stone and persistent pancreatic duct obstruction. ERCP with stone extraction and sphincterotomy is the diagnostic and treatment modality of choice in patients with suspected gallstone pancreatitis, particularly when clinical indicators, including elevated levels of pancreatic enzymes, do not improve. Cholecystectomy should be performed after resolution of the symptoms of pancreatitis and normalization of pancreatic enzyme levels, but before hospital discharge. This recommendation is predicated on a high reported incidence of recurrent pancreatitis during the initial months after a first attack of gallstone pancreatitis.
V. Biliary dyskinesia resembles biliary colic in symptoms. The diagnosis is made when gallbladder imaging (US, CT scan) does not show gallstones. Cholescintigraphy (HIDA) demonstrating a decreased gallbladder ejection fraction confirms the diagnosis. Between 85% and 95% of patients with a low gallbladder ejection fraction and characteristic symptoms report improvement after cholecystectomy.
VI. Acute acalculous cholecystitis clinically resembles acute calculous cholecystitis. The pathogenesis of cholecystitis in the absence of stone disease is poorly understood, but acalculous cholecystitis most often afflicts the critically ill. Cholecystectomy is curative. Cholecystotomy, however, is frequently an appropriate management strategy in these patients, given their frequent high degree of acuity and the efficacy and potentially definitive nature of simple drainage of the gallbladder in the absence of gallstones.
VII. Gallstone ileus is a mechanical obstruction of the gastrointestinal tract. It is caused by the passage of a large-diameter gallstone through a spontaneous biliary–enteric fistula (most often between the gallbladder and the duodenum). Gallstone ileus most commonly affects elderly patients and mandates a laparotomy to relieve the bowel obstruction (usually with enterolithotomy). Cholecystectomy and biliary–enteric fistula take-down may be performed at the time of laparotomy or, if inflammation precludes safe dissection during the initial operation or the patient is unstable, at a subsequent time.
VIII. Gallbladder cancer is an aggressive malignancy that largely afflicts the elderly and is more common in women than in men. Unfortunately, most patients with gallbladder cancer have unresectable disease at the time of presentation, and the estimated 5-year survival rate among all patients with this malignancy is less than 15%. In the setting of suspected carcinoma of the gallbladder, open abdominal exploration should be undertaken. This approach facilitates an evaluation for metastatic disease and facilitates radical cholecystectomy (en bloc resection of the gallbladder and adjacent liver as well as regional lymphadenectomy), in the event that no metastases are identified. Importantly, suspicion of gallbladder cancer during laparoscopic cholecystectomy should prompt conversion to an open operation.

PREOPERATIVE EVALUATION

In addition to a review of standard preoperative studies, reassessment of all studies obtained in evaluating a patient with gallbladder pathology is essential because laboratory data and study results significantly influence management (Fig. 12-2). Of particular importance are:

I. Liver function tests (LFTs), which include alanine aminotransferase, aspartate aminotransferase, bilirubin, alkaline phosphatase, and pancreatic enzymes (amylase and lipase), are essential to the evaluation of biliary pathology. Elevation of LFTs, particularly serum bilirubin, are predictive of CBD stones. Decisions to obtain a preoperative MRCP or ERCP or to perform an intraoperative cholangiogram at the time of cholecystectomy are sometimes predicated on these values. Elevated pancreatic enzymes are indicative of pancreatitis. These levels should be allowed to normalize before cholecystectomy, and interrogation of the CBD, whether by MRCP, ERCP, or intraoperative cholangiogram, is performed in conjunction with cholecystectomy after gallstone pancreatitis.

image

Figure 12-2 Algorithm for the evaluation of right upper quadrant pain suspicious for either biliary colic or acute cholecystitis, the two most common indications for cholecystectomy. CBC, complete blood count; ERCP, endoscopic retrograde cholangiopancreatography; LFT, liver function test; MRCP, magnetic resonance cholangiopancreatography; PT, prothrombin time; PTT, partial thromboplastin time.

Should your patient undergo preoperative ERCP or additional imaging to evaluate the common bile duct?

II. Abdominal Ultrasound: In addition to documenting the presence of gallstones, notable findings on preoperative US include pericholecystic fluid, gallbladder wall thickening, and a sonographic Murphy’s sign, all of which are consistent with cholecystitis. A dilated CBD is suggestive of the presence of, or recent passage of, a CBD stone.
III. Cholescintigraphy (HIDA): This noninvasive modality can provide important diagnostic information and is most frequently obtained when acute cholecystitis is suspected, but US findings are equivocal. Technetium-labeled analogues of iminodiacetic acid are administered intravenously. These compounds are rapidly excreted into the biliary tract. Enhancement of the liver, gallbladder, CBD, and duodenum within 1 hour is anticipated under normal circumstances. Nonvisualization of the gallbladder, with filling of the CBD and duodenum, suggests cystic duct obstruction and is consistent with acute cholecystitis.
IV. CT scan is frequently obtained in the evaluation of nonspecific abdominal pain. Although it is not sensitive for the detection of gallstones, it is sensitive for the diagnosis of acute cholecystitis.

COMPONENTS OF THE PREOCEDURE AND APPLIED ANATOMY

Patient Positioning and Preparation

I. The patient is placed in the supine position with the arms extended.
II. The abdomen is prepared to the xiphoid superiorly, to the pubic bone inferiorly, and to the midaxillary lines laterally.

Preoperative Considerations

I. Prophylactic antibiotics for elective laparoscopic cholecystectomy are advocated by some surgeons. Antibiotics are routinely administered to patients with acute cholecystitis at the time of admission and should be continued throughout the perioperative period.
II. Urinary catheter placement before cholecystectomy is often unnecessary. If conversion to an open cholecystectomy is likely or if there is reason to believe that the procedure will take longer than usual, urinary catheter placement should be considered.

Port Placement

In general, laparoscopic cholecystectomy is performed through four operative ports (Fig. 12-3).

image

Figure 12-3 Port placement for laparoscopic cholecystectomy.

(From Cameron J: Atlas of Surgery, vol 2. Philadelphia, Decker, 1994.)

I. Placement of the Umbilical Port

A. Access to the abdomen may be obtained with a “blind” percutaneous technique using a Veress needle or an open technique. Although each approach has its proponents, the open technique is more commonly used. It is important to note that the open technique is mandatory for patients who are pregnant or have had previous abdominal surgery.

Has your patient had previous abdominal surgery?

B. Open technique umbilical port placement

1. A horizontal incision is made above the umbilicus.
2. Subcutaneous soft tissue is bluntly dissected to expose the anterior rectus muscle fascia.
3. The fascia and underlying peritoneum are divided at the midline under direct vision.
4. Fascial sutures are placed to secure the port and minimize CO2 leakage and loss of pneumoperitoneum.
5. The port is inserted through the incision with a blunt-tipped trocar.
6. CO2 is insufflated through the port. The abdomen should distend symmetrically and become uniformly tympanic. If this does not happen, extraperitoneal port placement should be suspected.
7. The laparoscope is inserted through the umbilical port, and the peritoneal cavity is surveyed.

II. Placement of the Remaining Ports

A. After the laparoscope is inserted, the remaining three ports are inserted under direct intra-abdominal visualization. A cutting (sharp) introducer is used to penetrate the fascia and enter the peritoneal cavity.
B. Epigastric port placement

1. An epigastric port serves as the main operating port for the case.
2. The port is usually placed at the midline at the approximate level of the gallbladder on the abdominal wall and angled to the right of the falciform ligament on insertion into the peritoneal cavity.

C. First (medial) accessory port placement

1. This port is used for retraction of the gallbladder fundus.
2. The port is generally placed at the midclavicular line, just beneath the costal margin.

D. Second (lateral) accessory port placement

1. The second port is used for retraction of the gallbladder infundibulum.
2. The port is generally placed at the anterior axillary line, halfway between the costal margin and the anterior superior iliac spine.

Exposure

I. Clear visualization of the gallbladder is sometimes obscured by adhesions involving the gallbladder, liver edge, omentum, duodenum, and colon. When possible, these adhesions should be gently dissected away from the gallbladder without the use of electrocautery to avoid injury to adjacent organs.
II. The fundus of the gallbladder is grasped, and the gallbladder is retracted cephalad toward the patient’s left shoulder.
III. With a second instrument, the gallbladder is grasped near the infundibulum, and lateral and inferior traction is applied. This maneuver allows for exposure of the triangle of Calot and increases the angle between the cystic duct and the CBD, allowing for safer dissection (Fig. 12-4).

image

Figure 12-4 The gallbladder sits on the undersurface of the liver within the gallbladder fossa. It is partially covered by the peritoneum. The gallbladder may be divided into the fundus, body (corpus), infundibulum, and neck. The gallbladder empties into the cystic duct, which joins the common hepatic duct to form the common bile duct. The cystic artery, which supplies the gallbladder, is most often a branch of the right hepatic artery and runs medial and parallel to the cystic duct. The artery courses through the triangle of Calot, the space bounded by the liver edge, the cystic duct, and the common hepatic duct.

(From Townsend CM, Beauchamp RD, Evers BM, Mattox KL [eds]: Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice, 17th ed. Philadelphia, Saunders, 2004.)

The triangle of Calot is the space bounded by the liver edge, the cystic duct, and the common hepatic duct.

IV. Exposure is further facilitated by elevating the head of the bed (reverse Trendelenburg positioning), with the left side of the table down.

Dissection

I. With a curved dissector, the peritoneum is stripped from the base of the gallbladder, beginning at the infundibulum and continuing medially toward the junction of the gallbladder and the cystic duct.
II. Surrounding tissue is bluntly dissected away from the cystic duct. The cystic artery, which is most often cephalad and posterior to the cystic duct, is exposed in similar fashion (Fig. 12-5).
image

Figure 12-5 Dissection.

(From Cameron J: Atlas of Surgery, vol 2. Philadelphia, Decker, 1994.)

Division of the Cystic Duct and Cystic Artery

I. Three surgical clips, two placed proximally and one placed distally, are applied to the exposed cystic duct.

THE CYSTIC DUCT AND ARTERY MUST BE CLEARLY DEFINED BEFORE THE APPLICATION OF SURGICAL CLIPS TO AVOID INADVERTENT COMMON BILE DUCT INJURIES.

II. The duct is divided sharply between the proximal and distal clips.
III. The same technique is used to divide the cystic artery.

Removal of the Gallbladder from the Liver Bed

I. The gallbladder is retracted downward and to the right to expose the plane between it and the gallbladder fossa.
II. Electrocautery is used to dissect the gallbladder free from the liver.
III. Toward the conclusion of the dissection, retraction of the gallbladder over the top of the liver to expose the plane of dissection between the posterior wall of the gallbladder and the liver is often helpful.
IV. Before division of the final attachments between the liver and the gallbladder, the liver bed is irrigated and inspected for ongoing bleeding (Fig. 12-6).

image

Figure 12-6 Removal of the gallbladder from the liver bed.

(From Cameron J: Atlas of Surgery, vol 2. Philadelphia, Decker, 1994.)

INSPECT THE GALLBLADDER FOSSA FOR ACTIVE BLEEDING BEFORE DIVISION OF THE FINAL ATTACHMENTS BETWEEN THE GALLBLADDER AND LIVER.

Extraction of the Gallbladder

I. The camera is inserted through the epigastric port.
II. If the gallbladder is small and intact, it can be removed directly through the umbilical port. Alternatively, it may be removed in a sterile bag, which is introduced through the umbilical port, closed around the gallbladder, and withdrawn (Fig. 12-7).
image

Figure 12-7 Extraction of the gallbladder.

(From Cameron J: Atlas of Surgery, vol 2. Philadelphia, Decker, 1994.)

Removal of the Ports and Closure of the Port Sites

I. The trocars are then removed sequentially under direct vision to evaluate for bleeding.
II. The fascia is reapproximated at the umbilical port site.
III. The four incisions are closed.

ADDITIONAL OPERATIVE CONSIDERATIONS

I. Routine or selective drainage of the gallbladder bed is advocated by some surgeons. The presence of a drain in the initial postoperative period may facilitate the early diagnosis of a bile leak or postoperative bleeding. When a drain is placed, the absence of bilious bloody drainage on the first postoperative day is frequently an indication for drain removal.
II. Although routine intraoperative cholangiography has its proponents, most surgeons apply this technique selectively. Most often, intraoperative cholangiogram is performed when a patient undergoing cholecystectomy has a history, signs, or symptoms consistent with choledocholithiasis (e.g., history of pancreatitis, elevated serum bilirubin level, dilated CBD by US), but has not undergone MRCP or ERCP preoperatively. In these instances, a cholangiogram consistent with CBD stones prompts either CBD exploration or, more often, postoperative ERCP.

Should your patient undergo an intraoperative cholangiogram?

III. The rate of conversion to open cholecystectomy during an elective laparoscopic cholecystectomy is 5%. This rate is significantly higher (30%) in the setting of acute cholecystitis, where inflammation can make the identification of normal anatomy and tissue planes, and the dissection, more challenging. Conversion to an open approach, usually performed through a right subcostal incision, may facilitate the identification of anatomic landmarks and allow for safer dissection and better hemostasis. Patients should be counseled about the possibility of conversion to open surgery in advance. Conversion to an open procedure should not be viewed as a complication, but as an important surgical option.

POSTOPERATIVE COURSE

I. After an uncomplicated laparoscopic cholecystectomy for biliary colic and gallstones, patients frequently feel well with limited analgesia and can tolerate a regular diet. Laparoscopic cholecystectomy for this indication is increasingly being performed as an outpatient procedure.
II. After laparoscopic cholecystectomy for acute cholecystitis, patients should be observed overnight. These patients can often tolerate a liquid diet, if not a regular diet, in the immediate postoperative period. If a drain is left in place and the drainage is nonbilious and nonbloody on the morning of the first postoperative day, it may be removed. Postoperative laboratory work is usually unnecessary in the absence of concerning postoperative symptoms.

Complications

A number of intraoperative and long-term complications are associated with laparoscopic cholecystectomy. In addition to the always present risks of surgical site infection and bleeding, these include:

I. Bowel Injuries: Bowel injuries can occur during port placement or during dissection of adhesions. Thermal injuries from the electrocautery device can occur at sites distant from the operative field due to arcing of the electrical current in the abdomen. Bowel injuries recognized at the time of surgery are repaired immediately. Those injuries that are discovered postoperatively usually mandate operative re-exploration.
II. CBD Injuries: CBD injuries are rare (<1%), but serious complications of laparoscopic cholecystectomy. CBD transection may result from misidentification of anatomic landmarks because of anomalous anatomy, inadequate exposure, or overaggressive retraction that brings the CBD and cystic duct into alignment. These injuries may or may not be evident at the time of surgery. They are frequently associated with significant short- and long-term morbidity and often mandate complex biliary reconstructive procedures.
III. Bile Leaks: Bile leaks most commonly emanate from the ducts of Luschka (cholecystohepatic ducts). These ducts form a communication between the gallbladder and the right lobe of the liver, and they can be transected when the gallbladder is dissected from the liver bed. The cystic duct stump may leak bile as a result of inadequate placement of surgical clips, because of clip failure or displacement, or from a traction injury. Patients may present with bilious output from a surgical drain or some combination of abdominal discomfort, leukocytosis, elevated LFTs, and fever. Depending on the patient’s clinical presentation, a suspected bile leak may be evaluated with US, cholescintigraphy, ERCP, laparoscopy, laparotomy, or some combination of these.

PROLONGED OR SEVERE ABDOMINAL PAIN AFTER CHOLECYSTECTOMY SHOULD RAISE SUSPICION FOR A BILE LEAK OR BILIARY OBSTRUCTION.

IV. Retained Gallstones: Retained gallstones are stones left in the cystic duct stump or biliary system after a laparoscopic cholecystectomy. Patients may present with signs or symptoms of choledocholithiasis as long as 2 years after cholecystectomy. A number of modalities allow for the diagnosis of retained stones, including cholescintigraphy, MRCP, and ERCP, which may also be therapeutic in this setting.

Postoperative Evaluation for Suspected Complications

Patients with postoperative symptoms, such as severe abdominal pain, a prolonged ileus, a persistent fever, or jaundice, should be carefully evaluated for a surgical complication. In addition to a thorough physical examination and basic laboratory work, the evaluation of these patients may include the following tests:

I. LFTs are frequently elevated in the setting of a bile leak, biloma (intraperitoneal bile collection), or choledocholithiasis.
II. Abdominal US frequently allows for identification of postoperative fluid collection, sometimes indicating a bile leak or postoperative abscess.
III. Cholescintigraphy frequently identifies bile leaks and obstruction from stones or aberrantly placed clips.
IV. In addition to diagnosing bile leaks and biliary duct obstruction with great sensitivity, ERCP is potentially therapeutic. Endoscopists can frequently retrieve retained CBD stones or stent the CBD to decrease pressure in the biliary tree, facilitating cystic duct stump leak closure.

SUGGESTED READINGS

Ahrendt SA, Pitt HA. Biliary tract. In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL, editors. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 17th ed. Philadelphia: Saunders; 2004:1597-1622.

Collins C, Maguire D, Ireland A, et al. A prospective study of common bile duct calculi in patients undergoing laparoscopic cholecystectomy: natural history of choledocholithiasis revisited. Ann Surg. 2004;239:28-33.

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