Laparoscopic Cholecystectomy

Published on 11/04/2015 by admin

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Last modified 11/04/2015

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CHAPTER 12 Laparoscopic Cholecystectomy

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

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