Medical Therapy for Gallstone Disease

The prevailing public perception of open cholecystectomy as a procedure that results in pain, disability, and a disfiguring scar engendered many attempts in the 1980s and 1990s at nonoperative treatment of gallstones (Schoenfield & Lachin, 1981; Schoenfield et al, 1990). In addition, an understanding of the chemistry of gallstones led to numerous attempts to develop agents that could dissolve cholesterol gallstones. By the mid-1980s, ursodeoxycholic acid was made commercially available for oral administration, and its use was described in several clinical studies. Unfortunately, the indications for this agent were limited, and the 40% rate of complete gallstone dissolution in this highly selected group was disappointing (Roda et al, 1982). In the late 1980s gastroenterologists and interventional radiologists tried to increase this dissolution rate by attempting direct contact dissolution of gallstones. The biliary tree was accessed percutaneously, and methyl tert-butyl ether (MTBE) was instilled in the gallbladder. This therapy was invasive and had significant side effects, thus it was rapidly abandoned (Thistle et al, 1989).

In the early 1980s, extracorporeal shock wave lithotripsy (ESWL) was shown to be efficacious therapy for kidney stones. Others extrapolated that shock wave therapy might also break gallstones into smaller fragments that could then be more effectively dissolved. A brief flurry of interest and activity in the use of ESWL for gallstones followed, but the selection criteria limited this to fewer than 20% of gallstone patients. Despite strict selection criteria, the efficacy of treatment at 6 months was only 22%, and the gallstone recurrence rate of 10% per year for the first 5 years left much to be desired (Sackmann et al, 1990).

These disappointing results with therapies that dissolve or fragment gallstones while leaving the gallbladder in situ reinforced the concept that cholecystectomy was the only therapy that cured symptomatic cholelithiasis immediately and permanently. At the same time that the poor results of ESWL were being disseminated, a revolutionary new means of gallbladder removal was being developed.

Laparoscopic Cholecystectomy

The technique of laparoscopy (lapara, the flank; skopein, to examine) was initially developed near the outset of the twentieth century. However, until the 1960s, its use was strictly limited to diagnostic procedures within the peritoneal cavity. Gynecologists first used laparoscopic techniques to perform tubal ligation. By that time, the laparoscopic optics, light sources, and carbon dioxide insufflators had been markedly improved, but the eyes of the surgeon were wedded to the eyepiece of the laparoscope during performance of the operation. Despite this limitation, Dr. Kurt Semm of Kiehl, Germany, the father of “pelviscopy,” performed the first laparoscopic appendectomy in 1980 (Semm, 1982). By 1983, Semm stated that “laparoscopic cholecystectomy and the bowel anastomosis under laparoscopic vision had moved into the domain of the possible” (Manegold, 1985). Two years later, a German surgeon named Eric Muhe working in Böblingen, West Germany, performed the first laparoscopic cholecystectomy (Litynski, 1996). He used a modified operating laparoscope placed at the umbilicus after establishing pneumoperitoneum. Muhe later changed his technique to perform cholecystectomies through a small, open tube placed in the right upper quadrant without pneumoperitoneum. Despite presenting his initial work at the congress of the German Surgical Society in 1986, Muhe’s approach was rejected by German surgeons and largely forgotten. In 1987 a French surgeon, Phillipe Mouret of Lyon, France, performed laparoscopy on a woman with both gallstones and a gynecologic disorder. He performed the first video laparoscopic cholecystectomy by using a camera attached to the laparoscope, thereby allowing the entire operating team to view the operative field. As he was in private practice, few other surgeons learned of his work initially, but word spread within France. The following year both François DuBois in Paris and Jacques Perissat in Bordeaux, working in academic centers, performed laparoscopic cholecystectomy. Relatively soon thereafter, two groups of general surgeons in the southern United States performed laparoscopic cholecystectomy. They used a laser to dissect the gallbladder away from the liver bed, as it was thought that monopolar electrocautery used within the closed abdomen was potentially a hazard for combustion. The first publication of the “laparoscopic laser cholecystectomy” was published in the industry publication “Laser Practice Report” by Reddick in December 1988, whereas DuBois and colleagues published their first 36 cases (in English) in 1990.

All of these early pioneers in laparoscopic cholecystectomy used a four-port technique with the laparoscope placed at the umbilicus, albeit the French surgeons stood between the patient’s legs, and the Americans worked from the patient’s left side. Word of this new laparoscopic operation spread relatively rapidly after its introduction at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) meeting in Louisville in April 1989, and the subsequent American College of Surgeons meeting in Atlanta in October 1989. Given that cholecystectomy makes up nearly a third of the work in many general surgeons’ practices, surgeons in the United States feverishly attempted to learn this technique for a competitive advantage. Numerous courses sprang up across the United States and Europe. Many of these courses were sponsored by industry and provided little hands-on experience for surgeons who generally were poorly trained in basic laparoscopic techniques. It must be remembered that laparoscopy differs significantly from traditional open surgery in several important ways: 1) a satisfactory pneumoperitoneum of carbon dioxide gas must be established in the abdominal cavity; 2) the laparoscopic image of the operative field is controlled by someone other than the surgeon, and this image is highly magnified and two-dimensional; 3) the surgeon views a video screen, rather than the operative field itself; and 4) the laparoscopic ports act as a fulcrum, so the tips of the instruments move in the direction opposite the surgeon’s hands. Given these and other differences, it is not surprising that a learning curve effect was quickly recognized, whereby the incidence of bile duct injuries was much higher in a surgeon’s early cases compared with later in his or her experience (Meyers & Southern Surgeons Club, 1991).

Despite the increased incidence of bile duct injury, which was not initially acknowledged, the visible evidence of diminished incision length and anecdotal reports of less postoperative pain rapidly caught the eye of the lay public. Articles appeared in newspapers and news magazines touting the advantages of “minimally invasive surgery,” “minimal access surgery,” and other monikers such as “belly button surgery,” “laser surgery,” and so on, with the result that those who required cholecystectomy demanded that the operation be performed laparoscopically.

Going from an unheard of procedure in 1988 to one that had become the subject of numerous published case series by 1992, the adoption rate of this technology in the United States was unprecedented. In 1992, the National Institutes of Health (NIH) organized a consensus development conference titled “Gallstones and Laparoscopic Cholecystectomy,” which was sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases and the NIH office of Medical Applications of Research. At the conclusion of the conference, it was determined that laparoscopic cholecystectomy “provides a safe and effective treatment for patients with symptomatic cholelithiasis” and “provides distinct advantages over open cholecystectomy” but that “the outcome of laparoscopic cholecystectomy is influenced greatly by the training, experience, skill, and judgment of the surgeon performing the procedure” (Gollen et al, 1993).

It was also in 1992 that the first of several small prospective randomized trials comparing laparoscopic to open cholecystectomy was published. Each of these showed that the laparoscopic approach was associated with less pain, shorter hospitalization, and a more rapid return to full activity (Barkun et al, 1992). Coincidentally, 1992 was also the year in which a publication of a large series of laparoscopic cholecystectomies first suggested that this technique may become the new gold standard for performance of the operation (Soper et al, 1992b). By contrast, a relatively large randomized trial comparing laparoscopic with open cholecystectomy using a minilaparotomy showed no difference in many standard outcome measures (Majeed et al, 1996).

Over the ensuing years, a number of trials confirmed what had previously been shown in the open cholecystectomy literature. The aphorism “get it while it’s hot” could be used to describe the preferred approach to laparoscopic cholecystectomy for acute cholecystitis: prospective randomized trials showed that early cholecystectomy resulted in fewer complications and shorter hospitalization than interval cholecystectomy (Lo et al, 1998). Intraoperative cholangiography was performed on a selective basis by the majority of practicing surgeons, despite several population-based studies showing decreased rates of bile duct injury when performed by surgeons using cholangiography routinely during laparoscopic cholecystectomy (Flumm & Massarweh, 2007). Numerous reports were published concerning the causes of bile duct injury during laparoscopic cholecystectomy and the means by which these injuries could be minimized, including dissecting “the critical view of safety” before clipping or dividing the cystic structures (Strasberg et al, 1995).

Previous Abdominal Surgery

Intraabdominal adhesions secondary to previous abdominal surgery can tether underlying viscera and consequently increase the risk of hollow organ injury during placement of laparoscopic trocars (Wolfe et al, 1991). Previous lower abdominal operations typically add little difficulty in performing cholecystectomy, but patients with previous upper abdominal operations, especially in the right upper quadrant, present much more difficulty in gaining access to the area around the gallbladder. To diminish the risk of intraperitoneal injury, we routinely use the open Hasson technique for placement of the initial trocar. Other surgeons advocate the use of the Veress needle and percutaneous insertion of the initial trocar at a site remote from the abdominal wall scars. Once the initial trocar is placed, additional trocars are placed under direct laparoscopic visualization in an area free of adhesions. Some degree of laparoscopic adhesiolysis may be necessary to allow optimal port placement. Although early series demonstrated that previous abdominal surgery with the accompanying risk of adhesions was a predictor of conversion, it is clear that laparoscopic cholecystectomy may be performed safely on most of these patients.

Cirrhosis

Cirrhosis (see Chapter 70B) results in a brittle, friable, heavy liver that may be difficult to retract in the cephalad direction, limiting exposure of the porta hepatis and gallbladder. Cirrhosis also may be accompanied by decreased synthetic function of the liver, resulting in coagulopathy and portal hypertension. Coagulopathies should be reversed before performance of laparoscopic cholecystectomy.

The ability to achieve effective hemostasis laparoscopically is significantly compromised compared with that of open exposure. Portal hypertension and aberrant portosystemic venous collateralization may lead to exsanguinating hemorrhage from small veins in the liver bed and porta hepatis or from large veins in the abdominal wall (e.g., a recanalized umbilical vein) at risk for laceration during trocar puncture. Laparoscopic cholecystectomy may be attempted with care in these patients by experienced surgeons. Various hemostatic agents and energy sources need to be available in case bleeding develops; the argon cautery device can be quite useful. Prompt conversion to an open procedure is recommended in the face of unusual bleeding, regardless of the stage of the operation (Soper, 1993). Additionally, particular care should be taken in making watertight closures for all incisions to minimize postoperative ascitic leak (Poggio et al, 2000).

Cardiopulmonary Disease

Preexisting cardiac conditions mandate vigilant intraoperative observation for significant arrhythmias known to be associated with establishment of a carbon dioxide pneumoperitoneum, including bradycardia and ventricular ectopy. In patients with cardiac pacemakers, alternative energy sources, such as bipolar electrosurgery or ultrasonic coagulation, should be used because of known interference problems caused by monopolar electrosurgical devices.

Most patients undergoing laparoscopic cholecystectomy exhibit mildly elevated Pco₂ (Liu et al, 1991). Chronic obstructive pulmonary disease may predispose patients to carbon dioxide retention disproportionate to the measured end-tidal value during laparoscopic cholecystectomy (Wittgen et al, 1991). Prudent measures in these patients include obtaining preoperative pulmonary function tests, making arterial blood gas determinations, and maximizing pulmonary function by smoking cessation and bronchodilator therapy. An intraoperative arterial catheter also should be placed to allow frequent measurement of Pco₂ and pH. Hypercarbia may manifest as hypertension, tachycardia, or ventricular arrhythmias; these should be addressed by immediate evacuation of the pneumoperitoneum and stabilization. Gradual reestablishment of the pneumoperitoneum with a low pressure limit may be attempted, but the procedure should be terminated or converted to open if the hypercarbia recurs and is refractory to continued pneumoperitoneum.

Morbid Obesity

Morbid obesity was initially a relative contraindication to laparoscopic cholecystectomy primarily because of thickness of the abdominal panniculus relative to the length of early trocar and sheath designs, making institution and maintenance of a pneumoperitoneum problematic if not impossible. Various instrument manufacturers have since developed longer trocars to obviate this problem. The extra thickness of the wall inhibits the mobility of the trocars; therefore the trocars should be placed at the angle most likely to be used during the cholecystectomy. Longer trocars are also needed to traverse the abdominal wall to avoid trocar displacement and subsequent insufflation within the abdominal wall and subcutaneous emphysema. Longer instruments may be required to reach the gallbladder, and the initial umbilical trocar may need to be placed at a supraumbilical position.

Other challenging factors associated with morbid obesity include the presence of an enlarged, friable, fatty liver and an increased amount of adipose tissue around the gallbladder and in the area of the triangle of Calot. The surgeon should not hesitate to place additional trocars if needed (Schirmer et al, 1992). Retrospective and prospective studies have shown modestly increased operative times with performance of minimally invasive procedures in obese patient groups (Schirmer et al, 1992; Underwood et al, 1998). Today, laparoscopic cholecystectomy is commonly performed in morbidly obese patients and seems to offer the same advantages as in nonobese patients; it may also offer advantages more specific to obese patients, such as a decrease in wound infections, incisional hernias, and thrombotic complications (Miles et al, 1992; Talamini & Gadacz, 1992). Rather than being contraindicated in morbidly obese patients, laparoscopic cholecystectomy may become the preferred mode of therapy for these patients.

Pregnancy

Pregnancy is a controversial relative contraindication to laparoscopic cholecystectomy because of the unknown effects of prolonged carbon dioxide pneumoperitoneum on the fetus. It is generally accepted that elective laparoscopic cholecystectomy for biliary colic should be deferred until after pregnancy if possible. If necessary, laparoscopic cholecystectomy should be restricted to the second trimester, after organogenesis is complete and before the size and height of the uterine fundus cause it to encroach on the operative field. In the right upper quadrant, an open insertion of the initial port or alternative location of the initial port should be used to avoid injury to the gravid uterus, and the insufflation pressure should be limited to less than 12 mm Hg to avoid respiratory embarrassment and decreased vena caval return. The patient should be positioned in the left lateral decumbent position to minimize compression of the vena cava, and maternal hyperventilation with close monitoring of end-tidal carbon dioxide should be undertaken to prevent fetal acidosis. When visualization of the biliary tree is required, laparoscopic ultrasound (LUS) is used in place of cholangiography to avoid fetal radiation exposure. Finally, perioperative consultation with an experienced obstetrician is advisable, as is perioperative monitoring of the fetal heart.

Studies have shown that laparoscopic cholecystectomy can be performed safely during pregnancy, but only with great care (Soper et al, 1992a); A retrospective cross-sectional analysis of hospital discharge data from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database was conducted to study outcomes after cholecystectomy during pregnancy (Kuy et al, 2009). In this study, 9714 pregnant women who underwent cholecystectomy experienced significantly higher surgical, maternal, and fetal complication rates, lengths of stay, and costs with open cholecystectomy compared with laparoscopic surgery (Kuy et al, 2009). This may reflect the reasons for choosing an open cholecystectomy—such as prior surgery, gangrenous gallbladder, or trimester of pregnancy—rather than a true difference in complication rates between the procedures. High-volume surgeons, defined as those providers above the 75th percentile based on the annual number of cholecystectomies performed, had significantly lower rates of surgical complications.

Laboratory Test and Imaging Studies

Patients undergoing elective laparoscopic cholecystectomy for biliary colic should have preoperative liver function tests (LFTs). Elevations in these tests suggest the presence or recent passage of CBD stones. In patients with cholecystitis, LFTs are not typically elevated, because the obstruction is limited to the gallbladder; if present, elevated LFTs should raise concerns about complicating conditions such as cholangitis, choledocholithiasis, or Mirizzi syndrome (a gallstone impacted in the distal cystic duct causing extrinsic compression of the CBD; see Chapter 35).

In a patient with typical biliary colic, the only diagnostic study necessary before laparoscopic cholecystectomy is an abdominal US revealing gallstones. US shows the size and number of stones, the thickness of the gallbladder wall, the presence or absence of pericholecystic fluid, and the diameter of the CBD and other components of the biliary ductal system (see Chapter 13). Other nonbiliary disorders, such as hepatic lesions or steatosis, masses in the pancreas, or renal tumors, also may be diagnosed. When US results are negative despite typical biliary symptoms, cholecystokinin-stimulated biliary scintigraphy showing a low gallbladder ejection fraction with or without pain reproduction suggests acalculous cholecystitis or gallbladder dyskinesia (Soper, 1993).

If a patient with gallstones has atypical symptoms, however, a more extensive workup that includes upper gastrointestinal contrast radiography or endoscopy, computed tomography (CT), or cardiac and pulmonary evaluation may be appropriate to rule out significant nonbiliary disease processes. Magnetic resonance cholangiopancreatography (MRCP) may be useful to evaluate the common duct in patients with mild elevations of their transaminases or mild CBD dilatation on US (see Chapter 17). Additionally, if a patient has a dilated CBD, CBD stones, or jaundice, consideration should be given to a preoperative endoscopic retrograde cholangiopancreatography (ERCP) with clearing of the stones followed by laparoscopic cholecystectomy (see Chapter 18).

Antibiotics

Routine preoperative antibiotic administration for elective laparoscopic cholecystectomy is controversial, with strong opinions on both sides. A recent meta-analysis of randomized controlled trials concluded that prophylactic antibiotics do not prevent infections in low-risk patients undergoing laparoscopic cholecystectomy; the usefulness of prophylaxis in high-risk patients—those older than 60 years and those with diabetes, acute colic within 30 days of operation, jaundice, acute cholecystitis, or cholangitis—remains uncertain (Choudhary et al, 2008). The most recent randomized, prospective study included in the above-mentioned meta-analysis showed no difference in the postoperative wound infection rate, although the control group had a 1.5% infection rate, and the antibiotic group had a 0.7% infection rate; however, because there was a total of 277 patients in the study, a type II error might have been made (Chang et al, 2006). Among papers that suggest a benefit of antibiotic prophylaxis is a recent randomized study that found fewer wound infections with ampicillin-sulbactam versus cefuroxime, particularly for infection caused by Enterococcus in the setting of high-risk patients undergoing elective cholecystectomy (Dervisoglou et al, 2006).

Accordingly, the routine use of antibiotic prophylaxis remains controversial. However, patients at high risk for having bacterial contamination of the bile should be given prophylactic antibiotics. These patients include those with acute cholecystitis, prior biliary tree instrumentation, choledocholithiasis, or those who are older than 70 years. Patients who are immunosuppressed and those with prosthetic devices also should receive preoperative antibiotics. Prophylactic antibiotics should be given within 1 hour of the skin incision, and the patient should be redosed if the procedure lasts more than 4 hours. The recommended antibiotics are cefazolin (1 to 2 g intravenously) or, in patients allergic to penicillins and cephalosporins, clindamycin plus one of either ciprofloxacin, levofloxacin, gentamicin, or aztreonam.

Deep Venous Thromboembolism Prophylaxis

The increased intraabdominal pressure as a result of pneumoperitoneum, reverse Trendelenburg position, and systemic vasodilation associated with general anesthesia in laparoscopic cholecystectomy may confer theoretical increased risk of deep venous thromboembolism (DVT). Despite scientific studies that demonstrate diminished venous outflow in femoral veins of patients undergoing laparoscopic procedures, implying venous stasis, no study to date has demonstrated a decrease in DVT with pharmacologic prophylaxis (unfractionated or low-molecular-weight heparin). Given the low rate of DVT in this patient population, an appropriately powered study designed to show a benefit of prophylaxis would require a vast number of patients. In the absence of convincing evidence in the literature, we recommend DVT prophylaxis with calf-length pneumatic compression devices in all patients undergoing laparoscopic cholecystectomy. In patients with additional risk factors—previous DVT, cancer, obesity, exogenous estrogens, projected operating time longer than 2 hours, age over 40 years—we recommend the addition of pharmacologic prophylaxis.

Operating Room Setup

Using the “American” technique, the surgeon stands to the left of the patient, the first assistant stands to the patient’s right, and the laparoscopic video camera operator stands to the left of the surgeon (Fig. 34.1). In the “French” technique, the patient’s legs are abducted, and the surgeon stands between them. The camera operator always must maintain the proper orientation of the camera and keep the operating instruments in the center of the video image. Following all instruments as they enter or exit the operative field is a matter of surgeon preference. Sharp instruments should never be moved intracorporeally unless they are under direct videoscopic vision.

FIGURE 34.1 Room setup for laparoscopic cholecystectomy.

Pneumoperitoneum

A working space, generally provided by a pneumoperitoneum, is essential for the surgeon to both view and operate within the abdominal cavity. Carbon dioxide has the advantage of being noncombustible and rapidly absorbed from the peritoneal cavity; however, it may lead to hypercarbia in patients with significant cardiopulmonary disease (Fitzgerald et al, 1992). Pneumoperitoneum can be established by either a closed or an open technique. In the closed technique, carbon dioxide is insufflated into the peritoneal cavity through a Veress needle placed blindly into the abdominal cavity; the needle is subsequently replaced with a laparoscopic port. In the open technique, a laparoscopic port is inserted under direct vision into the peritoneal cavity via a small incision; pneumoperitoneum is established only after ensuring definitive and safe peritoneal entry. Both techniques have advantages and disadvantages, and surgeons performing laparoscopic cholecystectomy should learn both techniques and use them selectively.

For the closed technique, the surgeon should perform various tests to ensure the safety of the needle insertion before insufflation. A syringe containing 5 mL of normal saline solution is attached to the end of the needle to aspirate and show the absence of blood, urine, or enteric contents. If any one of the aforementioned fluids is recovered, the needle should be removed and its position changed. If no fluid is aspirated, an assessment is made of the ease with which saline solution flows by gravity into the zero-pressure abdominal cavity, or the “drop test.” This test is done either by instilling a few drops of saline solution into the hub of the needle or by removing the barrel of the syringe. Manually elevating the abdominal wall near the needle site decreases intraabdominal pressure and enhances free flow; the fluid flows much more slowly, or not at all, if the needle is in an extraperitoneal position.

Insufflator tubing is connected to the Veress needle, and carbon dioxide is insufflated at a low flow rate of approximately 1 L/min. The initial pressure of the abdomen is usually 2 to 6 mm Hg and should not increase appreciably during the early phase of insufflation. Asymmetric distension, a rapid increase in pressure with low insufflated volume, or an initial pressure greater than 10 mm Hg suggests that the needle is not in the proper position. The abdomen should be serially percussed to confirm symmetric tympany associated with insufflation. The abdomen is fully insufflated with the upper pressure limit set at 12 to 15 mm Hg; this usually requires 3 to 6 L of carbon dioxide, depending on the size of the abdominal cavity and degree of muscle relaxation. If intraabdominal pressures exceed 20 mm Hg, central venous pressures and blood pressures decrease because of decreased venous return and diminished cardiac output (Chui et al, 1993; Sharma et al, 1997). Studies also have shown direct negative effects on urine output relative to increased intraabdominal pressures (McDougall et al, 1996, 1997).

During the initial period of insufflation, the patient must be monitored closely for signs of gas embolism (hypotension, decreased oxygen saturation, decreased end-tidal carbon dioxide, “mill-wheel” heart murmur), vagal reaction (hypotension, bradycardia), ventricular arrhythmias, and hypercarbia with acidosis. Most of these complications require immediate treatment by desufflation followed by gradual reestablishment of the pneumoperitoneum after the patient’s condition has stabilized. Gas embolism results in an “air lock” right ventricular outflow obstruction with a dramatic decrease in end-tidal carbon dioxide concentration. When suspected, this problem should be treated by placing the patient in a steep Trendelenburg and left lateral decubitus position followed by insertion of a central venous catheter to aspirate the carbon dioxide from the apex of the right ventricle (Chui et al, 1993; Hanney et al, 1995; Lantz & Smith, 1994; Sharma et al, 1997).

After the pneumoperitoneum is established, the Veress needle is replaced with a trocar/port through a periumbilical incision into which the laparoscope may be inserted. This port is inserted carefully while manually elevating the abdominal wall to avoid iatrogenic injury to intraabdominal viscera or retroperitoneal structures.

Using the open technique, the pneumoperitoneum is established similarly to an open diagnostic peritoneal lavage. A 1.5-cm skin incision is made in the infraumbilical or supraumbilical skin fold. Dissection of the subcutaneous tissue is performed at the base of the umbilical raphe to reach the fascia rapidly, even in obese patients, because this is the thinnest part of the abdominal wall. Kocher clamps are applied to both sides of the linea alba, and a small vertical incision is made to gain access to the peritoneal cavity. A finger is placed into the wound to ensure that the free peritoneal cavity has been entered and to sweep away any adhesions that may be present. If a Hasson trocar (Weck & Co, Research Triangle Park, NC) is available, two sutures are placed on both sides of the fascial incision and are tied to the wings of the wedge-tipped sheath after it is inserted into the peritoneal cavity under direct vision (Fig. 34.2). Alternatively, standard laparoscopic sheaths can be used after placing two concentric polypropylene purse-string stitches around the fascial incision. After removing the sheath at the conclusion of the procedure, the outer purse-string suture is removed, and the inner one is tied. Open insertion of the initial port takes a few minutes longer than its closed counterpart. Extraction of the gallbladder at the conclusion of the operation is easier, however, which equalizes the time differential of the two access techniques.

FIGURE 34.2 A, Reusable Hasson trocar/cannula. B, Securing the Hasson cannula to the abdominal fascia. The fascial stay sutures are wound around the wings of the cannula to secure it in place and seal the fasciotomy and peritoneotomy.

(Courtesy Quality Medical Publishing, St Louis, MO.)

Port Placement and Exposure

Depending on the surgeon’s preference, a 5- or 10-mm laparoscope is inserted into the abdomen through the umbilical port. The area immediately posterior to the umbilicus is viewed initially to ensure that there is no injury as a result of trocar insertion. Thorough intraabdominal visual exploration is performed; the pelvic viscera are examined for pathologic abnormalities before evaluating the upper abdomen, and the anterior surface of the intestines, the omentum, and the stomach also are examined for disease. The patient is placed in a reverse Trendelenburg position of 30 degrees while rotating the table to the left by 15 degrees. This maneuver allows the colon and duodenum to fall away from the liver edge. The falciform ligament and both lobes of the liver are examined carefully for abnormalities. The gallbladder usually can be seen protruding beyond the edge of the liver.

Two small accessory subcostal ports are placed under direct vision. The first 5-mm trocar is placed along the right anterior axillary line between the twelfth rib and the iliac crest. A second 5-mm port is inserted in the right subcostal area in the midclavicular line. Grasping forceps are placed through these two ports to secure the gallbladder. The assistant manipulates the lateral grasping forceps, which are used to elevate the liver and expose the fundus of the gallbladder. The surgeon uses dissecting forceps to raise a serosal fold in the most dependent portion of the fundus. The assistant’s heavy grasping forceps are locked onto this fold using either a spring or a ratchet device. With these axillary grasping forceps, the fundus of the gallbladder is pushed in a lateral and cephalad direction, rolling the entire right lobe of the liver cranially; this maneuver is complicated in patients with a fixed, cirrhotic liver or a heavy, friable liver resulting from fatty infiltration.

In patients with few adhesions to the gallbladder, pushing the fundus cephalad exposes the entire gallbladder, cystic duct, and porta hepatis. Most patients have adhesions between the gallbladder and the omentum, hepatic flexure, or duodenum; these are generally avascular and may be lysed bluntly by grasping them with dissecting forceps at their site of attachment to the gallbladder wall and gently stripping them down toward the infundibulum. After exposing the infundibulum, blunt grasping forceps placed through the midclavicular trocar are used to grasp and place traction on the neck of the gallbladder. The operative field is established, and the final working port is inserted.

A final operating trocar/port is placed through an incision in the midline of the epigastrium. This trocar usually is inserted approximately 5 cm below the xiphoid process, but the precise position and angle depend on the location of the gallbladder and the size of the medial segment of the left lobe of the liver. When the appropriate position for this trocar is hard to determine, a Veress needle may be placed first at the proposed site to ascertain whether its location and angle of insertion seen through the laparoscope are optimal. The trocar is inserted in a controlled fashion, angling its tip just to the right of the falciform ligament, aiming toward the gallbladder. Dissecting forceps are inserted and directed toward the gallbladder neck. The orientation of the laparoscope is generally parallel to that of the cystic duct when the fundus is elevated, whereas the instruments placed through the other three ports enter the abdomen at right angles to this plane (Figs. 34.3 and 34.4).

FIGURE 34.3 Positions for insertion of the initial (A) and accessory sheaths (B through D).

FIGURE 34.4 Diagram of the abdomen after the creation of a pneumoperitoneum and the insertion of laparoscopic instruments.

Dissection

A grasping instrument on the infundibulum exerts traction on the gallbladder away from the CBD in a superior and lateral direction. Fine-tipped dissecting forceps are used to dissect away the overlying fibroareolar structures from the infundibulum of the gallbladder. This is done with a blunt stripping action, always starting on the gallbladder and stripping the tissue toward the porta hepatis (Fig. 34.5). The dissection should begin on a known structure (e.g., the gallbladder), rather than in an unknown area, to avoid damage to the underlying structures, such as the bile duct or the hepatic artery.

FIGURE 34.5 The omentum and adhesions are bluntly divided by carefully pulling them away with atraumatic grasping forceps.

It is important to identify clearly the structures forming the sides of the triangle of Calot (i.e., cystic duct, cystic artery, and common hepatic duct), the standard ventral aspect, and its reverse (dorsal) aspect (Fig. 34.6). Distinction is made here with the hepatocystic triangle proper, which is the ventral aspect of the area bounded by the gallbladder wall and cystic duct, the liver edge, and the common hepatic duct; the cystic artery and the triangle of Calot lie within this space. The hepatocystic triangle is maximally opened and converted into a trapezoid shape by retracting the infundibulum of the gallbladder inferiorly and laterally, while maintaining the fundus under traction in a superior and medial direction. A lymph node usually lies adjacent to the cystic artery, and occasionally it is necessary to use a brief application of electrosurgical coagulation to obtain hemostasis as the lymph node is bluntly swept away. To expose the reverse of Calot’s triangle, the infundibulum of the gallbladder is pulled in a superior and medial direction (see Fig. 34.6).

FIGURE 34.6 Proper gallbladder retraction for exposure of Calot’s triangle (A) and reverse Calot’s triangle (B).

(Courtesy Quality Medical Publishing, St Louis, MO.)

After clearing the structures from the apex of the triangle, the junction between the infundibulum and the origin of the proximal cystic duct can be identified clearly. The strands of peritoneal, lymphatic, and neurovascular tissue are stripped away from the cystic duct to clear a segment from the surrounding tissue. Curved dissecting forceps are helpful in creating a window around the posterior aspect of the cystic duct to skeletonize the duct itself. Alternatively, the tip of the hook cautery can be used to encircle and expose the duct. It is generally unnecessary and potentially harmful to dissect the cystic duct down to its junction with the CBD.

Next, the cystic artery is separated from the surrounding tissue by similar blunt dissection. If the cystic artery crosses anterior to the duct, the artery may require dissection and division before approaching the cystic duct. The neck of the gallbladder is dissected away from its liver bed, leaving only two structures entering the gallbladder: the cystic duct and artery. No structure should be divided until the cystic duct and cystic artery are unequivocally identified. This is the “critical view” of safety (Fig. 34.7) essential to prevent bile duct injury during laparoscopic cholecystectomy (Strasberg et al, 1995).

FIGURE 34.7 Critical view. Hepatocystic triangle is dissected free of all tissue except for the cystic duct and artery, and the base of the liver bed is exposed. When this view is achieved, the two structures entering the gallbladder can only be the cystic duct and artery.

Intraoperative Evaluation for Choledocholithiasis

After initially dissecting the proximal cystic duct, the CBD should be imaged if there is any concern for choledocholithiasis or any question regarding the biliary anatomy. This can be achieved by radiographic intraoperative cholangiography (IOC) or intracorporeal LUS (see Chapter 21). Before either procedure, a clip is applied high on the cystic duct at its junction with the gallbladder to prevent stones from migrating down the duct. To perform IOC, the anterolateral wall of the cystic duct is incised, and dissecting forceps are used to compress the cystic duct gently and systematically back toward the gallbladder, “milking” stones away from the CBD and out the ductotomy (Figs. 34.8 and 34.9). A 4- to 5-Fr catheter is inserted into the duct through a hollow, 5-mm metal tube that has an appropriate gasket to prevent carbon dioxide leakage around the catheter itself. The cholangiography catheter is inserted into the cystic duct, and a clip is applied loosely to secure the catheter in place (Fig. 34.10). If the introducer has grasping jaws, it can be used to secure the catheter into the duct (Fig. 34.11). Alternatively, catheters equipped with balloons proximal to the tip may be used for fixation.

FIGURE 34.8 After a clip is placed across the junction of the gallbladder with the cystic duct, and a cystic ductotomy is made on the anterior side, the cystic duct is gently “milked” back toward the ductotomy.

FIGURE 34.9 A cystic duct stone is “milked” out of the ductotomy.

FIGURE 34.10 Cystic duct cholangiography can be performed with a catheter clipped into place.

FIGURE 34.11 Alternatively, a cholangiogram catheter can be held in place with a clamp.

Cholangiography can be performed by either real-time fluoroscopy (dynamic IOC) or by obtaining two standard radiographs (static IOC) after injecting 5 mL and 10 mL of water-soluble contrast medium (Figs. 34.12 and 34.13). The films should be inspected for the following: 1) the length of cystic duct and location of its junction with the CBD, 2) the size of the CBD, 3) the presence of intraluminal filling defects, 4) free flow of contrast material into the duodenum, and 5) anatomy of the extrahepatic and intrahepatic biliary tree. After the cholangiocatheter is removed, the cystic duct is doubly clipped below the ductotomy, with care taken to avoid the wall of the CBD, and divided. The posterior jaw of the clip applier must be visualized before applying each clip to avoid injury to the surrounding structures. Great care should be taken so that the CBD is not “tented up” into the clip. If the cystic duct is particularly large or friable, it may be preferable to replace one of the clips with a hand-tied or preformed suture.

FIGURE 34.12 Intraoperative cholangiogram showing absence of a bile duct calculus with free flow of contrast medium into the duodenum.

(From Blumgart LH, Fong Y [eds], 1997: Surgery of the Liver and Biliary Tract CD-ROM. Philadelphia, Churchill Livingstone.)

FIGURE 34.13 Intraoperative cholangiogram showing a filling defect of the distal common bile duct. The defect has a characteristic “meniscus” appearance, and there is no flow of contrast medium into the duodenum.

(From Blumgart LH, Fong Y [eds], 1997: Surgery of the Liver and Biliary Tract CD-ROM. Philadelphia, Churchill Livingstone.)

Evaluation of the CBD by LUS is an alternative to cholangiography. Several studies performed at open cholecystectomy reported LUS to be more accurate than IOC in assessing the CBD for stones (97% to 99% vs. 89% to 94%; Machi et al 1993a, 1993b; Orda et al, 1994a, 1994b). Although few surgeons have adopted US for this purpose, LUS has been used in several centers during laparoscopic cholecystectomy and is gaining popularity (Jakimowicz, 1993; John et al, 1994; McIntyre et al, 1994; Orda et al, 1994a, 1994b; Steigmann et al, 1994). With LUS, the transducer has a higher frequency with improved resolution compared with that used with transabdominal US. In experienced hands, LUS seems to be as accurate as cholangiography for showing choledocholithiasis, but it can be performed more rapidly (Steigmann et al, 1995). In a prospective multicenter trial with 209 laparoscopic cholecystectomy patients, the time to perform LUS (7 ± 3 min) was significantly less than that of IOC (13 ± 6 min; Steigmann et al, 1995). The study showed that LUS was more sensitive for detecting stones but that IOC was better in delineating intrahepatic anatomy and defining anatomic anomalies of the ductal system. The authors concluded that the two methods of ductal imaging were complementary. Despite these promising data, more clinical experience is needed to establish the appropriate role of LUS for the detection of choledocholithiasis during laparoscopic cholecystectomy (Soper, 1997; Wu et al, 1998a).

Completion of Cholecystectomy

After clip ligation and division of the cystic duct, the cystic artery is dissected from the surrounding tissue for an adequate distance to permit placement of three clips. The surgeon must ascertain that the structure is the cystic artery and not the right hepatic artery, looping up onto the neck of the gallbladder, or an accessory or replaced right hepatic artery (see Chapter 1B). After an appropriate length of cystic artery has been dissected free, it is clipped proximally and distally before its transection. Electrocautery should not be used for this division, because the current may be transmitted to the proximal clips and lead to subsequent necrosis and hemorrhage. A common error is to dissect and divide the anterior branch of the cystic artery, mistaking it for the main cystic artery; this may result in hemorrhage from the posterior branch during dissection of the gallbladder fossa.

The ligated stumps of the cystic duct and the artery are examined to ensure that there is no leakage of either bile or blood and that the clips are placed securely; they should compress the entire lumen without impinging on adjacent tissues. A suction-irrigation catheter is used to remove any debris or blood that has accumulated during the dissection. Separation of the gallbladder from its hepatic bed is initiated using an electrosurgical probe to coagulate small vessels and lymphatics. While maintaining cephalad traction on the fundus of the gallbladder with the axillary forceps, the midclavicular forceps pulls the neck of the gallbladder anterosuperiorly and then alternatively medially and laterally to expose and place the tissue connecting the gallbladder to the fossa under tension (Fig. 34.14). An electrocautery spatula or hook is used in a gentle sweeping motion with low power (25 to 30 W) to coagulate and divide the tissue. Intermittent blunt dissection facilitates exposure of the proper plane.

FIGURE 34.14 Separation of the gallbladder from its bed by dissection with a blunt-tipped thermal energy probe. The neck of the gallbladder is placed on traction in a superior direction, then twisted to the left and right to place tension on the junction between the gallbladder and the hepatic fossa.

Dissection of the gallbladder fossa continues from the infundibulum to the fundus, progressively moving the midclavicular grasping forceps cephalad to allow maximal countertraction. The dissection proceeds until the gallbladder is attached by only a thin bridge of tissue. At this point, before completely detaching the gallbladder, the hepatic fossa and porta hepatis are inspected again for hemostasis and bile leakage. Small bleeding points are coagulated, and the right upper quadrant is liberally irrigated and aspirated dry while checking for any residual bleeding or bile leakage. The final attachments of the gallbladder are divided, and the liver edge is examined again for hemostasis.

After the cholecystectomy has been performed, the gallbladder must be removed from the abdominal cavity. If the stone burden is small, the gallbladder can be extracted at the subxiphoid port site. Usually, the gallbladder is most easily removed at the umbilical port site, where there are no muscle layers anterior to the fascial plane. Also, if the fascial opening needs to be enlarged because of large or numerous stones, extension of the umbilical incision causes less postoperative pain and has better cosmesis than does enlarging the subxiphoid incision. The laparoscope is removed from the umbilical port and placed through the epigastric port. Large, claw-like grasping forceps are introduced through the umbilical port to grasp the infundibulum of the gallbladder. The forceps, trocar, and gallbladder neck are retracted as a unit through the umbilical incision, and the neck of the gallbladder is exteriorized through the anterior abdominal wall with the fundus remaining within the abdominal cavity.

If the gallbladder is not distended with bile or stones, it can be withdrawn with gentle traction. In most cases, a suction catheter introduced through an incision in the gallbladder neck is used to aspirate bile and small stones. Stone forceps also can be placed into the gallbladder to extract or crush calculi if necessary (Fig. 34.15). Occasionally, the fascial incision must be extended to extract larger stones or thick-walled gallbladders. After the gallbladder is extracted, the operator’s finger is used to occlude the port entry site. If any question concerning hemostasis or contamination of the right upper quadrant remains, the umbilical port can be replaced under direct vision, and the upper part of the abdomen can be copiously irrigated and aspirated again. If not, all laparoscopic ports are removed after allowing escape of the carbon dioxide.

FIGURE 34.15 Gallstones contained within the fundus may be crushed or removed after delivering the neck of the gallbladder through the umbilical incision.

Each incision is infiltrated with bupivacaine for postoperative analgesia, and the fascia of the umbilical incision is closed with one or two large, absorbable sutures. Closure of the subxiphoid fascia is optional, because visceral herniation is unlikely to occur owing to the oblique entry angle of the trocar into the abdominal cavity and its location anterior to the falciform ligament. The skin of the subxiphoid and umbilical incisions is closed with subcuticular absorbable sutures. The skin incisions at both 5-mm port sites can be closed with adhesive strips or skin closure adhesives. The orogastric tube is removed in the operating room, and the patient is transferred to the postanesthesia care unit.

Intraoperative Treatment of Common Bile Duct Stones

The reported incidence of CBD stones found during laparoscopic cholecystectomy ranges from 3% to 10% (see Chapters 30 and 34 through 37) (Barkun et al, 1993; Frazee et al, 1993). It is unclear whether uncomplicated and asymptomatic choledocholithiasis requires treatment. Autopsy series have shown that many patients with silent gallbladder stones also harbor silent CBD stones (Crump, 1931). Smaller stones are known to pass through the ampulla of Vater, as shown by stool analysis in patients with acute pancreatitis (see Chapter 53) or acute biliary colic (Acosta & Ledesma, 1974; Kelly, 1980). In one study, the rate of symptoms or complications in patients with retained CBD stones after cholecystectomy was 94%, with a mortality rate of 3% over 5 years (Hicken & McAllister, 1964). It is unclear what stone size precludes passage or which indicators predict complications of cholangitis (see Chapter 43) or pancreatitis if the stones are left in situ.

It is generally recommended to treat choledocholithiasis when it is discovered intraoperatively; options include laparoscopic CBD management, open CBD exploration, and postoperative endoscopic or percutaneous transhepatic stone extraction. In the current state of evolving techniques, and in the absence of definitive prospective randomized trials guiding the management of patients with choledocholithiasis, the technical expertise of the local physicians is a major determining factor in CBD stone management.

Laparoscopic CBD exploration can take the form of accessing the CBD through the cystic duct (transcystic technique) or directly incising and opening the CBD with stone retrieval (laparoscopic choledochotomy). In the transcystic duct approach, stones smaller than 4 mm often can be flushed through the ampulla into the duodenum, a technique that is facilitated by pharmacologic relaxation of the sphincter of Oddi using sublingual nitroglycerin or intravenous glucagon. When these simple methods fail, a helical stone basket can be passed over a guidewire through the cystic duct and into the CBD to extract stones under fluoroscopic guidance (Fig. 34.16) (Hunter, 1992).

FIGURE 34.16 Transcystic retrieval of common bile duct stones using a helical basket under fluoroscopy.

If attempts at transcystic basket extraction fail, the next step is to insert a 7- to 8-Fr choledochoscope to remove the stones under direct vision. If the CBD stone is larger than the lumen of the cystic duct, the duct should be balloon dilated first to a maximum of 8 mm in diameter, but never larger than the internal diameter of the CBD (Hunter & Soper, 1992). The choledochoscope is passed into the peritoneal cavity through the midaxillary port, using a sheath to prevent damage to the scope by the port’s valve. The choledochoscope is inserted through the cystic duct into the CBD under direct vision. The lumen of the duct is optimally visualized by continuously infusing saline through the biopsy channel. Under visual guidance, the tip of a Segura-type stone basket is advanced beyond the stone and opened. As the basket is pulled backward and rotated, the stone is ensnared (Fig. 34.17; Jones & Soper, 1996).

FIGURE 34.17 Transcystic choledochoscopy. The flexible choledochoscope is passed into the common bile duct through the cystic duct. Under direct vision, the basket is advanced distal to the stone and opened. Inset, As the basket is withdrawn through the working channel of the choledochoscope, the stone is ensnared. The basket, stone, and choledochoscope are removed as a unit.

A completion cholangiogram should always be performed to ascertain clearance of the duct. Because of tissue edema secondary to ductal dilation and manipulation, the cystic duct stump is ligated, rather than clipped, for added security. Successful extraction has been reported in 67% to 96% of patients treated in most series (Table 34.3; Bagnato, 1993; DePaula et al, 1994; Dion et al, 1994; Ferzli et al, 1994; Franklin et al, 1994; Hunter, 1992; Petelin, 1993; Phillips et al, 1994). Complications such as infection and pancreatitis have been reported in 5% to 10% of patients, with a mortality rate of 1% to 2%. The duration of hospitalization after an uncomplicated transcystic duct stone extraction is the same as that for laparoscopic cholecystectomy alone, averaging 1 to 2 days. The main advantage of the transcystic approach is that it avoids the need to incise the CBD, with subsequent suture closure and placement of a T-tube. Poor candidates for transcystic extraction techniques are patients with large or multiple CBD stones, patients with stones in the proximal ductal system, and patients with small or tortuous cystic ducts.

If the transcystic approach fails, we recommend direct incision of the CBD laparoscopically. Indications for laparoscopic choledochotomy are stones that are multiple, large, or positioned within the proximal bile ducts in patients with a CBD diameter larger than 8 to 10 mm (Dion et al, 1994; Phillips et al, 1994). Stay sutures usually are placed on either side of the midline of the CBD wall to allow anterior traction on the duct. A longitudinal choledochotomy is made on the distal CBD, with adequate length to allow easy placement of a choledochoscope and removal of the largest stone. Stones are removed under endoscopic visualization, and an appropriate-size T-tube is placed in the duct. The ductotomy is closed with fine absorbable sutures using intracorporeal suturing techniques, and the T-tube is exteriorized through the lateral port site. The patient generally is discharged 2 to 4 days postoperatively and returns for a final T-tube cholangiogram and removal of the T-tube at 14 to 21 days postoperatively. Retained stones shown by T-tube cholangiography may be effectively removed percutaneously after allowing maturation of the T-tube tract. Percutaneous extraction is successful in more than 95% of patients with retained stones (Burhenne, 1980).

Overall, laparoscopic choledochotomy is successful in more than 90% of patients, with a minor morbidity rate of 5% to 10% and a mortality rate of 1% to 2% (see Table 34.3). Complications of this technique include laceration of the CBD, bile leakage, sewn-in T-tubes, and postoperative CBD strictures (Dion et al, 1994). Many surgeons have not mastered laparoscopic suturing to the point that they feel comfortable closing the choledochotomy, for fear of a resultant stricture. Nevertheless, advantages of the direct laparoscopic approach are that every portion of the ductal system can be accessed, and stone size is unimportant. The alternative approach of open operation with exploration of the CBD with or without choledochoduodenostomy should always be considered in difficult cases (see Chapters 29 and 35).

The possibility of finding CBD stones and the means by which they can be treated must be discussed with the patient before operation to formulate a plan of therapy. Many surgeons routinely leave CBD stones in place during laparoscopic cholecystectomy for planned postoperative endoscopic removal (see Chapter 27). Factors favoring postoperative endoscopic therapy include the presence of small, nonobstructing duct stones; a patient with significant comorbidities, making a prolonged operation risky; and a small CBD prone to postoperative stricture. In resorting to postoperative endoscopic retrograde cholangiography and sphincterotomy, the goals of minimally invasive surgery are maintained with a rapid return to full activity. Relying on postoperative endoscopic sphincterotomy (ES) subjects the patient to an additional procedure, with its associated morbidity and possibly a second operation if endoscopic stone extraction fails. In experienced hands, ES has an overall failure rate for stone clearance of 5% to 10% (Cotton, 1993).

Leaving a transcystic catheter in the CBD at the time of laparoscopic cholecystectomy may decrease the likelihood of failure by allowing a guidewire to be passed into the duodenum to facilitate cannulation of the CBD (Deslandres et al, 1993). It is reasonable to submit a patient to postoperative endoscopic stone extraction when the endoscopic expertise is high, whereas an open CBD exploration should be strongly considered when only an inexperienced endoscopist is available in the local setting. The expertise of the laparoscopist and the endoscopist are critical determinants of the means by which CBD stones are managed (Cotton, 1993).

Acute Cholecystitis

Numerous reports indicate that laparoscopic cholecystectomy can be done safely for patients with acute cholecystitis (Prakash et al, 2002; Suter & Meyer, 2001). There is a higher rate of conversion in the setting of acute cholecystitis; in particular, after 72 hours, the rate of conversion increases significantly (Madan et al, 2002).

The timing of laparoscopic cholecystectomy for acute cholecystitis has been a long-standing matter of debate. Based on several prospective studies, early surgical intervention has economic, social, and medical benefits and is the preferred approach for experienced laparoscopic surgeons in the management of acute cholecystitis (Feldman et al, 2002). Our practice is to proceed with laparoscopic cholecystectomy immediately after the diagnosis of acute cholecystitis has been made. In a patient who is seen after 72 hours of symptoms, a laparoscopic cholecystectomy is attempted only if the patient has no preexisting medical conditions that preclude an open cholecystectomy. If the patient does have significant comorbid illnesses, we continue with antibiotic therapy and possibly a percutaneous cholecystostomy tube (see Chapter 32) and subsequent elective laparoscopic cholecystectomy 6 to 8 weeks later.

Intervention during the early phase reveals an inflamed, thick-walled, tensely distended organ. To gain adequate traction on the gallbladder with the grasping forceps, it may be necessary to decompress the gallbladder by aspirating its contents with a large-gauge needle. As long as the inflammation is limited to the gallbladder, laparoscopic cholecystectomy is usually technically feasible. If inflammation extends to the porta hepatis, however, great care must be taken in proceeding with the operation. The normally thin, minimally adherent tissue that invests the cystic duct and artery is markedly thickened and edematous and may not separate readily from these structures with the usual blunt dissection techniques. The duct wall also may be edematous, making its external diameter similar to the gallbladder neck and CBD. If the anatomy is unclear, cholangiography must be performed before clipping or dividing tissue.

When acute inflammation has been present for several days or weeks before operation, the pericholecystic tissue planes may be obliterated by thick, “woody” tissue that is difficult to dissect bluntly. In these cases, some authors recommend attempting a fundus-first technique and possibly even a subtotal cholecystectomy (Beldi & Glattli, 2003; Mahmud et al, 2002). Subtotal cholecystectomy involves transecting the infundibulum as close to the cystic duct as possible and extracting all stones. The gallbladder neck is then sutured closed if possible, and a drain is placed in the gallbladder bed. This transection of an edematous, friable wall may be facilitated by using the ultrasonic shears. The surgeon must be comfortable in his or her ability to safely perform the procedure laparoscopically; however, the decision to convert to an open procedure should not be considered a complication but rather good surgical judgment based on the existing anatomy, local conditions, and the surgeon’s experience and confidence in his or her ability to complete the procedure using minimal-access techniques.

In a gallbladder densely adherent to the liver, where the plane between the two is obliterated, or in the presence of portal hypertension, it may be preferable to leave the back wall of the gallbladder intact and fully cauterize its mucosa (Beldi & Glattli, 2003). An active suction drain should be left beneath the liver if the integrity of the cystic duct closure is in question or with any suspicion of bile leakage from the gallbladder bed. We do not place a drain to monitor for bleeding.

Several authors have reported performing laparoscopic cholecystectomy in the face of acute inflammation with success, but with a higher conversion rate than for elective laparoscopic cholecystectomy (Cooperman, 1990; Hermann, 1990; Rattner et al, 1993; Reddick et al, 1991; Unger et al, 1991). Lo and colleagues (1996) reported in their prospective study that despite longer operative times and postoperative stays for early laparoscopic cholecystectomy in patients with acute cholecystitis (treatment within 5 days) versus delayed laparoscopic cholecystectomy (initial conservative treatment followed by laparoscopic cholecystectomy 3 to 4 months later), the advantage of early laparoscopic cholecystectomy was the reduction in the total hospital stay, from 15 to 7 days.

Rattner and associates (1993) retrospectively reviewed 20 patients who underwent attempted laparoscopic cholecystectomy for acute cholecystitis and examined factors that were predictive of a successful procedure. Seven of the 20 patients (35%) required conversion to open cholecystectomy. The interval from admission to cholecystectomy in the successful cases was 0.6 days versus 5 days in the cases requiring conversion to open cholecystectomy. Converted cases also had a significantly higher white blood cell count, alkaline phosphatase levels, and Acute Physiology and Chronic Health Evaluation (APACHE II) scores compared with cases involving successful laparoscopic cholecystectomy. US findings, such as gallbladder distension, wall thickness, and pericholecystic fluid, did not correlate with the success of laparoscopic cholecystectomy.

In a prospective study of 105 patients randomized to early laparoscopic cholecystectomy (within 24 hours of diagnosis of acute cholecystitis) versus delayed laparoscopic cholecystectomy (6 to 8 weeks later), no significant difference was found in conversion rate (early 21% vs. delayed 24%), postoperative analgesic requirement, or number of postoperative complications. The early group did have a longer operative time (123 minutes vs. 107 minutes, P = .04), but total hospitalization was shorter (8 days vs. 12 days, P = .001) (Lai et al, 1998). Laparoscopic cholecystectomy should be performed immediately after the diagnosis of acute cholecystitis. Delaying surgery allows inflammation to become more intense and neovascularized, increasing the technical difficulty of laparoscopic cholecystectomy.

Conversion to Open Operation

Surgeons performing laparoscopic cholecystectomy should not think of conversion to open operation as a failure but rather as mature judgment. A surgeon should not hesitate to convert to a traditional open cholecystectomy if the anatomy is unclear, complications arise, or reasonable progress cannot be made in a timely manner (Table 34.5). It is better to open one too many than to open one too few, even if it means a longer hospital stay for the patient. Some complications requiring laparotomy are obvious, such as massive hemorrhage, bowel perforation, or major injury to the bile duct. Open laparotomy allows the additional tool of manual palpation and tactile sensation and should be performed when the anatomy cannot be delineated because of inflammation, adhesions, or anomalies. Fistulae between the biliary system and bowel are rare but may require laparotomy for optimal management. The demonstration of potentially resectable gallbladder carcinoma (see Chapter 49) also dictates an open exploration. Finally, when CBD stones cannot be removed laparoscopically and are unlikely to be extracted endoscopically owing to Billroth II anastomosis, previously failed ERCP, or an inexperienced endoscopist, the procedure should be converted to open operation without hesitation.

Table 34.5 When to Convert from Laparoscopic to Open Cholecystectomy

Anatomic Variations

One of the most frequent anomalies is a right hepatic artery that loops up onto the infundibulum of the gallbladder (see Chapter 1B). This anomaly may be misidentified as the cystic artery, leading to injury to the hepatic artery (Berci & Sackier, 1994). The surgeon also occasionally notices only a small cystic artery on the medial aspect of the gallbladder; when this occurs, the surgeon should be alert for a posterior branch leading onto the dorsal aspect of the gallbladder. If great care is not taken, brisk hemorrhage may occur.

A short cystic duct is seen frequently and may be draining into the right hepatic duct or a low-entry right sectoral hepatic duct (2%) or common hepatic duct (1%), or it may connect the infundibulum with the CBD by a duct of only a few millimeters in length in 5% to 6% of cases (Berci, 1992; Reid et al, 1986). During open cholecystectomy, this is relatively easy to recognize, especially if the cholecystectomy is performed in a fundus-first fashion. During laparoscopic cholecystectomy, these ducts are in danger of being mistaken for a normal cystic duct and divided (Fig. 34.18; Meyers et al, 1996). The most dangerous variant is when the cystic duct joins a low-lying aberrant right sectoral duct. These injuries are underreported, because occlusion of an aberrant duct may be asymptomatic and even unrecognized. In addition to anomalous biliary ducts, accessory ducts may drain into the cystic duct or from the liver directly into the gallbladder (ducts of Luschka). Since the widespread use of laparoscopic cholecystectomy, there has been an increased occurrence of bile leaks from the so-called ducts of Luschka. It is likely that many of these bile leaks are due to dissection into the liver substance with injury to a normal, albeit superficial, intrahepatic biliary radicle.

FIGURE 34.18 With a short cystic duct at the junction of the common hepatic duct and the common bile duct, pulling the infundibulum can result in tenting of the common bile duct. This can mimic the appearance of the cystic duct.

Intraoperative Gallbladder Perforation

Perforation of the gallbladder with bile or stone leakage can be a nuisance, but it should not ordinarily require conversion to open cholecystectomy. Perforation may occur secondary to traction applied by the grasping forceps or electrosurgical thermal injury during removal of the gallbladder from its bed. In our experience, almost one third of the patients have had intraoperative spillage of bile or stones (Jones et al, 1995). Patients with a bile leak have not experienced an increased incidence of infection, prolongation of hospitalization or postoperative disability, or adverse long-term complications (mean follow-up of 41 months in 250 consecutive laparoscopic cholecystectomy patients). The only difference between patients with and without bile leakage was that the operating time for patients with a gallbladder perforation was approximately 10 minutes longer, presumably owing to the time spent cleaning up the operative field. When perforation does occur, the bile should be aspirated completely, and irrigation should be used liberally. The hole in the gallbladder is best secured with a grasping instrument and sutured or tied with an endoloop, and the stones should be retrieved and removed. Gallbladder spillage, when treated in this manner, results in no adverse short-term or long-term complications.

Escaped stones composed primarily of cholesterol pose little threat of infection. Pigment stones frequently harbor viable bacteria, however, and may lead to subsequent infectious complications if allowed to remain in the peritoneal cavity (Deziel et al, 1993). The long-term complications of retained stones, either intraabdominally with resultant abscess formation or intramurally with resultant port-site abscess, have not been prospectively studied, but case reports and case series in the surgical literature document a clear potential for long-term infectious complications (Carlin et al, 1995; Horton & Florence, 1998; Parra-Davila et al, 1998; Shocket, 1995; Zamir et al, 1999). The relative infrequency of these complications probably does not justify conversion to open operation in the face of spilled stones, but vigilance in avoidance of perforation, a careful search for escaped stones, and liberal use of a plastic retrieval bag for large and friable gallbladders are recommended (Zamir et al, 1999).

Biliary Injury

Of all the potential complications, biliary injuries have received the most attention; these are discussed at length elsewhere in this text (see Chapter 42A). Most series quote major bile duct injury rates of 0.30% or less during open cholecystectomy, whereas the incidence of bile duct injuries during laparoscopic cholecystectomy is 0.40% or higher (Strasberg et al, 1995). These injuries can cause major morbidity, prolonged hospitalization (Cates et al, 1993), high costs, and litigation (Asbun et al, 1993). In addition to aberrant anatomy and the surgeon’s inexperience, many reports mention acute or chronic inflammation with dense scarring, operative bleeding obscuring the field, or fat in the portal area contributing to biliary injuries (Adams et al, 1993; Davidoff et al, 1992; Moosa et al, 1992; Soper et al, 1993). The classic biliary injury occurs, however, when the CBD or a right hepatic duct is mistaken for the cystic duct and is divided between clips. Many surgeons attribute this misidentification to the direction of traction of the gallbladder (i.e., pulling the CBD and the cystic duct into alignment, making them appear to be one). Other contributing factors to misidentification are a short cystic duct; a large stone in the Hartmann pouch, making retraction and display of the cystic duct difficult; or tethering of the infundibulum to the CBD by acute or chronic inflammation (Figs. 34.19 and 34.20). Constant awareness of these potential misidentifications and technical causes of biliary injuries is the best method of prevention. If a bile duct injury occurs, an immediate repair should be performed with no hesitation in asking for the help of a surgeon experienced in biliary repair.

FIGURE 34.19 Severe acute cholecystitis or long-standing chronic cholecystitis may result in the cystic duct and infundibulum of the gallbladder becoming partially adherent or difficult to separate from the common bile duct itself.

FIGURE 34.20 With excessive traction on the neck of the gallbladder, the common bile duct (CBD) becomes tented and appears to be entering the gallbladder directly. The marked portion of the CBD is most vulnerable to injury during laparoscopic cholecystectomy.

A bile injury may also be unrecognized at the time of surgery but evident in the postoperative period. A postoperative bile leak occurs in less than 1% of cholecystectomies. Symptoms usually occur 4 to 10 days after surgery and consist of abdominal pain, fever, and abdominal distension. In this setting, it is mandatory to evaluate for biliary injury. Many postoperative bile leaks are considered minor biliary injuries, such as a cystic duct stump leak or an unclipped duct of Luschka. When a bile duct injury is discovered in the postoperative period, a coordinated effort by radiologists, endoscopists, and surgeons is necessary to optimize management (Strasberg et al, 1995). The initial diagnostic study should be US or CT of the abdomen. Fluid will typically be seen in the gallbladder fossa, hepatorenal recess, right gutter, and right subdiaphragmatic spaces. The biloma can be drained percutaneously, and the biliary anatomy should be evaluated with ERCP, which is preferred because it is both diagnostic and potentially theurapeutic. For example, a cystic duct stump leak can be treated successfully in the majority of cases with a temporary transsphincteric biliary stent.

Bleeding

The incidence of uncontrollable bleeding from laparoscopic cholecystectomy is 0.1% to 1.9% and can occur from three distinct sites: 1) the liver, 2) arterial sources, and 3) port insertion sites. Significant bleeding from the liver bed is fairly common and is now appreciated to be from the often close proximity of the middle hepatic vein and its radicals to the gallbladder fossa in up to 10% to 15% of patients. Bleeding usually occurs during the final aspects of the removal of the gallbladder from the hepatic fossa and generally requires immediate conversion to open surgery to control profuse hemorrhage through stitch ligation, if initial attempts at laparoscopic hemostatic control fail. Arterial control issues involving the cystic artery can be identified immediately and controlled with clips, but only if anatomical landmarks can be safely ensured because of a high association with right hepatic arterial injury; such issues may also first be evident postoperatively as an acute hemodynamic decline requiring resuscitation, transfusions, and often reoperation—the culprit is usually a dislodged clip in this scenario. Finally, incision or trocar sites can bleed.

When a trocar injury to a major blood vessel is suspected, the patient must be opened immediately without removing the trocar, and the involved blood vessel must be isolated. In contrast, if the small-bore Veress needle enters a viscus or blood vessel, the operation generally can be completed, and the patient is monitored closely for signs of complications in the postoperative period. Additionally, bleeding may occur if a trocar lacerates a blood vessel within the abdominal wall, such as the epigastric artery or one of its branches. Before removal, each trocar should be visualized from the peritoneal aspect using the laparoscope. If significant hemorrhage is seen, it generally can be controlled with cautery or a through-and-through suture on each side of the trocar insertion site.

Bowel Injury

Inadvertent bowel injury has been described in approximately one to four patients in 1000 laparoscopic procedures. The injury typically occurs during insertion of the initial trocar, and it may occur with either the Veress or open technique. After the initial trocar is inserted, a brief inspection should be performed to evaluate for bowel injury. All other additional trocars should be placed under direct laparoscopic visualization and only in an area free of adhesions. The “protective” shield on disposable trocars is not a guarantee against perforation of intestine or major vessels, especially after previous abdominal operations. Trocar insertion should never be aimed toward the spine or the great vessels, and a hand should be used as a “brake” to prevent inadvertently introducing the trocar too far. Management of this complication is dictated by the clinical scenario. If the injury is identified at the time of surgery, conversion to an open procedure for repair is indicated, if it cannot be repaired through the laparoscope.

One of the most dreaded complications after any laparoscopic surgery is a missed enterotomy. Patients may present with trocar site pain, abdominal distension, diarrhea, leukopenia, and cardiovascular collapse from sepsis, typically within 96 hours of the procedure. If the patient is septic or has free air, an emergent laparotomy is indicated. When the presentation is more indolent and controlled, standard enterocutaneous fistula management with nutritional support and adequate drainage and wound care may be appropriate.

Postcholecystectomy Syndrome

The term postcholecystectomy syndrome (PCS; see Chapter 38) describes the presence of symptoms after cholecystectomy. These symptoms can represent either the continuation of symptoms thought to be caused by the gallbladder or the development of new symptoms normally attributed to the gallbladder. PCS also includes the development of symptoms caused by removal of the gallbladder and is caused by alterations in bile flow resulting from loss of the reservoir function of the gallbladder. Two types of problems may arise: The first is continuously increased bile flow into the upper gastrointestinal (GI) tract, which may contribute to esophagitis and gastritis. The second is related to the lower GI tract, where diarrhea and colicky lower abdominal pain may result. PCS affects about 10% to 15% of patients; however, it is usually a temporary diagnosis, and an organic or functional diagnosis is established in most patients after a complete workup (Jaunoo et al, 2010). Postoperative symptoms may occasionally be caused by retained CBD stones or stones in the cystic duct remnant. Initial workup includes LFTs and US. MRCP or ERCP may be indicated if a retained CBD stone is suspected. A thorough preoperative evaluation is essential to minimize PCS, and patients should be warned of the possibility of postoperative symptoms. Although attempts to preoperatively identify patients at increased risk for PCS have largely been unsuccessful, the consensus opinion holds that the more secure the preoperative diagnosis, the lower the risk of PCS.

Natural Orifice Translumenal Endoscopic Surgery Cholecystectomy

Over the past few years, many technical innovations have attempted to further minimize the field of laparoscopy. In 2004, peritoneoscopy was performed in an animal model by passing a flexible endoscope through the wall of the stomach and into the peritoneal cavity (Kalloo et al, 2004). This resulted in the concept of natural orifice translumenal endoscopic surgery (NOTES), with its general goal of minimizing trauma by eliminating incisions through the abdominal wall and utilizing natural orifices. Although a number of potential natural orifices can theoretically be used to access the abdominal cavity, clinical cases have thus far only used transgastric (TG) and transvaginal (TV) approaches. Human applications currently have been limited and have relied on laparoscopic-assisted or so-called hybrid techniques.

TG and TV cholecystectomy were both first described in humans in the United States in 2007. Compared with TG cholecystectomy, TV cholecystectomy is technically easier to perform because of the direct vision-guided access and a straight route to the upper abdomen. In addition, the TV route obviates the risk of gastric content leakage via an imperfectly closed gastrotomy access site. As a consequence, many more NOTES cholecystectomies have been performed in humans via a TV approach as opposed to a TG approach. All reports of NOTES cholecystectomy have highlighted the limits imposed by the inadequacy of current instrumentation, resulting in lack of exposure, fine dissection, and safe cystic duct ligation, therefore requiring a hybrid technique to perform the operation safely. In general, TV procedures take up to twice as long as standard laparoscopic operations, whereas TG operations triple the operating time. Few complications have been reported to date. Currently, NOTES remains investigational and is only performed at a few centers worldwide. Many of the limitations remain centered on instrument development, very few data exist to quantify postoperative pain and disability, and no prospective randomized trials comparing NOTES cholecystectomy to laparoscopic cholecystectomy have been done. Again, given the high bar that has been set for the results of laparoscopic cholecystectomy, it may be difficult to show a meaningful clinical advantage of NOTES cholecystectomy. However, the concept of NOTES has challenged surgeons to further advance surgery, and it continues to drive the development of new technology and techniques.

Single-Incision Laparoscopic Surgery Cholecystectomy

Single-incision laparoscopic surgery (SILS) cholecystectomy was first described in the Italian literature in the mid-1990s. Navarra and colleagues (1997) published the first case series of 30 patients who underwent what they described as “one-wound laparoscopic surgery.” Their method used three extracorporeal stay sutures and two 11-mm working ports in the umbilicus, and the incisions were connected at the end of the case to facilitate the removal of the gallbladder. The mean operative time was 123 minutes, and the mean postoperative stay was 1.8 days. These initial reports did not receive much attention, but recently a resurgence of interest in SILS has been seen with a concurrent rapid development of instrumentation.

SILS emphasizes the concept of surgery through one small transabdominal incision, rather than the standard multiple trocar sites, with theoretic benefits of less pain and better cosmesis. The allure of SILS is that the surgeon can use relatively standard laparoscopic instruments and skills without the technical difficulties associated with NOTES. As a result, SILS can be more readily implemented and is likely to have a higher degree of acceptance. Several small series have demonstrated the feasibility and safety of SILS cholecystectomy. However, because it is relatively new and in evolution, many techniques have been described, and no widely accepted standard exists.

Although SILS cholecystectomy provides an apparent cosmetic advantage by hiding the surgical scar in the umbilicus, other proposed benefits are yet to be determined. Concerns revolve around the surgeon’s limited ability to triangulate and to exercise traction and countertraction on tissue dissecting planes. In addition, the view is often in line with the camera, which may compromise depth perception and visualization. It is of paramount importance to maintain the same surgical principles and not to compromise visualization of the anatomic landmarks to avoid unnecessary complications, such as bile duct injuries. Supplemental stab incisions or extracorporeal stay sutures in the right upper quadrant are often needed to provide adequate retraction of the gallbladder and proper visualization of the triangle of Calot. Specialized instrumentation, such as reticulating instruments and multichannel ports, have been also developed to help overcome some of these limitations. Standard four-port laparoscopic cholecystectomy remains the gold standard treatment for benign gallbladder disease, but SILS cholecystectomy will continue to develop and may have a role in select groups of patients. Well-designed clinical trials powered adequately are needed to better understand the risk-benefit profile of SILS cholecystectomy.