Laparoscopic Cholecystectomy

Introduction

Laparoscopic cholecystectomy refers to the removal of the gallbladder through small incisions in the abdomen. Over 500,000 minimally invasive cholecystectomies are performed annually, with the majority being removed through a laparoscopic approach. This is the procedure of choice for patients with asymptomatic, symptomatic, and most forms of complicated gallbladder disease.

History

Professor Muhe of Boblingen, Germany performed the first laparoscopic cholecystectomy on September 12, 1985. His procedure involved the use of a side-viewing endoscope with an instrumentation channel inserted through the umbilicus after a pneumoperitoneum was established by a Veress needle technique. After six procedures using a pneumoperitoneum, he adapted the technique using an access channel and a 2.5 cm incision at the costal margin without the use of a pneumoperitoneum. His contributions were not well received in Germany or France, and his initial article was rejected by the American Journal of Surgery in 1990. In 1992, however, he received the German Surgical Society Anniversary Award with comments by then president Franz Gall as “one of the greatest achievements of German medicine in recent history.” He never published his work in English. SAGES recognized his early contributions in 1999, and he was invited to give the annual Karl Storz Lecture in New Technology which he entitled “The First Cholecystectomy: Overcoming the Roadblocks on the Road to the Future,” in San Antonio, Texas that year.

McKernan and Saye performed the first cholecystectomy in the United States in Marietta, Georgia on June 22, 1988. Along with Reddick and Olsen of Nashville, Tennessee, they were the primary teachers of the technique to thousands of surgeons over the next decade.

Other pioneers in laparoscopic cholecystectomy include: [1]

• Mouret (Lyon, France) 1987
• Dubois (Paris, France) April, 1988
• Reddick (US) September, 1988
• Berci (Australia) September, 1988
• Perissat (Bordeaux, France) November, 1988
• Cuschieri (UK) February, 1989

Indications

The indications for laparoscopic cholecystectomy do not differ from open cholecystectomy.[2,3]

Known Indications

Asymptomatic Gallbladder Disease

• Biliary Dyskinesia
• Immunocompromised patients with any form of gallbladder disease
• Patients awaiting organ transplantation
• Patients with sickle cell disease
• Gallbladder polyps > 1 cm
• Gallstones > 3 cm

Symptomatic Gallbladder Disease

• Symptomatic Cholelithiasis
• Acute Cholecystitis
• Symptomatic Chronic Cholecystitis

Complicated Gallbladder Disease

• Gallstone Pancreatitis – after pancreatitis has resolved
• Choledocholithiasis and concomitant cholangitis – after appropriate treatment for cholangitis and CBD stones
• Gangrenous Cholecystitis
• Acalculous Cholecystitis
• Mirizzi’s syndrome (Type I)

Relative Contraindications

• Previous abdominal surgery in epigastrium or right-upper quadrant
• End-stage liver disease
• Cholecystenteric fistula (e.g. gallstone ileus)
• Mirizzi’s syndrome (Type II)
• Calcified gallbladder wall (e.g. porcelain gallbladder)

Absolute Contraindications

• Known invasive gallbladder carcinoma
• Uncorrected coagulopathy
• Inability to tolerate general anesthesia or laparotomy

Preoperative Considerations

Current guidelines do not support routine antibiotic prophylaxis during elective laparoscopic cholecystectomy.[4] Standard precautions against deep venous thrombosis and intraoperative hypothermia are advised.

Specific Considerations

Pregnancy

The preferred approach to gallbladder disease requiring cholecystectomy during pregnancy is to attempt conservative management followed by an elective cholecystectomy months after delivery. If conservative management fails, the safety of both the mother and the baby are dependent on the timing of surgery. Operating during the first trimester confers risks of teratogenesis and miscarriage. Surgery during the second trimester is preferred as interventions during this period are associated with the fewest complications. The gravid uterus during the third trimester can prevent adequate visualization, while operative interventions during this period are also associated with increased risks of preterm labor and delivery.[5]

Acute Cholecystitis

Once the diagnosis is confirmed, patients should be rehydrated, and analgesics are administered. The role of antibiotics in acute cholecystitis has not been clearly established. If antibiotics are given, regimens consist of broad spectrum antibiotics such as piperacillin-tazobactam, ampicillin-sulbactam, or a fluoroquinolone with metronidazole. Given the inflammation, edema, and overall condition of the gallbladder and gallbladder fossa during an episode of acute cholecystitis, surgeons have historically advocated for a “cool down” period prior to cholecystectomy. The results of randomized controlled trials evaluating early (within 24-72 hours of the diagnosis) and late cholecystectomy, however, have established that early cholecystectomy is technically feasible and leads to a shorter total hospital stay. A recent meta-analysis further noted no significant differences in conversion rates or complications in those receiving an early operation.[6]

Gallstone pancreatitis

The current American Gastroenterological Association guidelines for the management of acute pancreatitis lists several pre-operative considerations in cases of gallstone pancreatitis. Management includes vigorous fluid replacement, pain control, and correction of metabolic abnormalities. Urgent ERCP (within 24 hours) should be performed in patients who have concomitant cholangitis. Early ERCP (within 72 hours) should be performed in those with a high suspicion of persistent common bile duct (CBD) stones (e.g. visible CBD stone on imaging, jaundice, persistent dilated CBD). Early ERCP in cases without cholangitis or suspicion of persistent CBD stones remains controversial with practice patterns that vary between institutions. Definitive surgical management should be performed during the same hospital admission if possible. Otherwise, intervention should occur no later than 2 to 4 weeks after discharge. [7] In cases where it is unclear whether gallstones are still present in the common bile duct, intra-operative cholangiography and possible common bile duct exploration has been advocated.[3]

Choledocholithiasis

Only elevated bilirubin and alkaline phosphatase have sensitivities greater than 50% in aiding in the diagnosis of choledocholithiasis.[3] The indications for preoperative ERCP are similar to those found in Gallstone pancreatitis. Aside from those cases where ERCP is unsuccessful, the indications for intra-operative cholangiography in cases where ERCP is not performed include: a persistently dilated common bile duct on imaging, elevated liver function tests, and a recent history of jaundice.

Suspected Gallbladder Carcinoma

Only 8 – 10% of these cases are diagnosed preoperatively. Several ultrasonographic findings are suggestive of carcinoma. These include: a complex mass filling the gallbladder lumen, marked thickening of the gallbladder wall, and any the identification of polypoid or fungating structures associated with the gallbladder. Further considerations include gallstone size (with an increased risk associated with increased size) and gallbladder wall calcification (with an incidence of 12.5 – 61% associated with porcelain gallbladder).[3] Most gallbladder cancers are discovered in the operating room, necessitating the examination of the gallbladder after removal – particularly in patients aged 50 or older (4% incidence that increases with age). Many surgeons advocate the use of frozen section analysis in suspected cases. If the depth of invasion can be established, simple cholecystectomy is adequate in tumors do not extend beyond the gallbladder lamina propria (Tis and T1a tumors). The management of T1b disease remains controversial, although hepatoduodenal lymph node dissection with or without combined resection of the gallbladder fossa has been recommended.[8]

Techniques

Laparoscopic Cholecystectomy Technique
Single Incision Cholecystectomy Technique
NOTES Cholecystectomy Technique

Outcomes

Based on a review of 80,000 cases worldwide between 1990 and 1998, the overall mortality rate for laparoscopic cholecystectomy is 1.2%, with morbidity rates ranging around 7%. Approximately 5% of cases were converted to open based on the 14 studies reviewed. Mean length of stay is 1.8 days with a mean return to work time of 6 days. [3]

Specific Complications

Common Bile Duct Injury

After the introduction of laparoscopic cholecystectomy, several investigators noted that the incidence of common bile duct injury had increased in comparison to open cholecystectomy (0.5% vs. 0.1%).[9,10] In North Carolina, for example, a statewide audit between 1988 and 1992 found that the number of bile duct injuries nearly tripled.[11] This led to an increased effort to identify the etiology of common bile duct injury after laparoscopic cholecystectomy. Work by the United States’ based Southern Surgeons Club published in 1991 noted that the increased incidence may be related to experience, with the incidence of bile-duct injury as high as 2.2% within the a surgeon’s first 13 cases.[12] Further work published in 1995 by the same group further delineated the effect of the “learning curve” in the evaluation of 8,839 procedures performed by 55 surgeons. From this experience they developed a regression model that predicted that a surgeon had a 1.7% chance of injuring the bile duct during their first procedure, and a 0.17% chance by the 50th.[13] As more surgeons have gained experience with the procedure, common bile duct injury rates have reached a plateau of around 0.2% (ranging from 0.1 – 0.8%).[3] This has led to the suggestion that the current rate of injury may not be completely related to the “learning curve” effect. Continued efforts to prevent this complication focus on proper identification of key structures in the triangle of Calot (via the “Critical View”)[14,15] along with continued investigations into the cognitive psychology and other human factors associated with common bile duct injury during minimally invasive cholecystectomy.[16]

Other Complications

In their 2005 review of 1,674 consecutive laparoscopic cholecystectomies, Misra and colleagues at Tufts-New England Medical Center found the following complication rates:[17]

• Cystic duct leaks – 0.63%
• Duct of Luschka leaks – 0.52%
• Postoperative hemorrhage – 0.42%
• Wound Infection – 0.94%
• Wound herniation – 1.4%
• Deep Vein Thrombosis – 0.31%

See Also

Avoiding Pitfalls in Cholecystectomy

References

1. Reynolds W Jr. The first laparoscopic cholecystectomy. JSLS. 5:89-94, 2001.
2. Deveney K. Laparocopic Cholecystectomy. In The SAGES Manual: Fundamentals of Laproscopy, Thoracoscopy, and GI Endoscopy, 2nd ed. C.E.H. Scott-Connor (ed). Springer Science+Business Media:New York, 2006. pp. 131-139.
3. Harris HW. Chapter 47: Biliary System. In Surgery: Basic Science and Clinical Evidence, 2nd ed. JA Norton, PS Barie et al (eds.). Springer Science+Business Media:New York, 2008. pp. 911-942.
4. Zhou H, Zhang J, Wang Q, Hu Z. Meta-analysis: Antibiotic prophylaxis in elective laparoscopic cholecystectomy. Aliment Pharmacol Ther. 15:1086-1095, 2009.
5. Jelin EB, Smink DS, Vernon AH, Brooks CD. Management of biliary tract disease during pregnancy: a decision analysis. Surg Endosc. 22:54-60, 2008.
6. Gurusamy KS, Samraj K. Early versus delayed laparoscopic cholecystectomy for acute cholecystectomy. Cochrane Database Syst Rev. 4:CD005440, 2006
7. AGA Institute on “Management of Acute Pancreatitis” Clinical Practice and Economics Committee, AGA Institute Governing Board. AGA Institute medical position statement on acute pancreatitis. Gastroenterology. 132:2019-2021, 2007.
8. You DD, Lee HG, Paik KY, et al. What is an adequate extent of resection for T1 gallbladder cancer? Ann Surg. 247:835-838, 2008.
9. Adamsen S, Hansen OH, Funch-Jensen P, et al. Bile duct injury during laparoscopic cholecystectomy: a prospective nationwide series. J Am Coll Surg. 184:571-578, 1997.
10. MacFadyen BV, Vecchio R, Ricardo AE, Mathis CR. Bile duct injury after laparoscopic cholecystectomy. Surg Endosc. 12:315-321, 1998.
11. Rutledge R, Fakhry SM, Baker CC, et al. The impact of laparoscopic cholecystectomy on the management and outcome of biliary tract disease in North Carolina: a statewide, population-based, time-series analysis. J Am Coll Surg. 183:31-45, 1996.
12. Southern Surgeon’s Club. A prospective analysis of 1518 laparoscopic cholecystectomies. The Southern Surgeon’s Club. NEJM. 18:1073-1078, 1991.
13. The Souther Surgeon’s Club, MJ Moore, CL Bennett. The Learning Curve for Laparoscopic Cholecystectomy. Am J Surg. 170:55-59, 1995.
14. Stratsberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg. 180:101-125, 1995.
15. Hunter JG. Avoidance of bile duct injury during laparoscopic cholecystectomy. Am J Surg. 162:71-76, 1991.
16. Way LW, Stewart L, Gantert W, et al. Causes and prevention of laparoscopic bile duct injuries: analysis of 252 cases from a human factors and cognitive psychology perspective. Ann Surg. 237:460-469, 2003.
17. Misra M, Schiff J, Rendon G, Rothschild J, Schwaitzberg S. Laparoscopic cholecystectomy after the learning curve: What should we expect?. Surg Endosc. 19:1266-1271, 2005.