- Biliary colic.
- Chronic cholecystitis.
- Acute cholecystitis.
- Acalculous cholecystitis.
- Gallstone pancreatitis.
- Inability to tolerate an operation under general anesthesia (eg, patients with end-stage cardiopulmonary disease or hemodynamic instability).
- Suspicion of gallbladder cancer based on preoperative imaging.
- Pregnancy (first or third trimester).
- Previous abdominal operations precluding laparoscopic access.
- Cirrhosis, portal hypertension, or bleeding disorders.
- Patients with gallstone pancreatitis or biliary obstruction from choledocholithiasis risk recurrent complications if the gallbladder is not removed.
- Biliary colic will most likely recur unless the gallbladder is removed.
- Acute cholecystitis may progress to gallbladder necrosis and possibly sepsis unless cholecystectomy is performed.
- Possible complications include:
- Bleeding (from the cystic artery stump, gallbladder fossa, abdominal wall, omental or mesenteric adhesions).
- Surgical site infection (either superficial or deep).
- Bile leak (most likely from the cystic duct stump), biliary tract injury, or both.
- Bowel injury.
- Systemic complications of abdominal surgery (pneumonia, venous thromboembolism, and cardiovascular events).
- Postoperative choledocholithiasis.
- Standard laparoscopic equipment:
- 5-mm and 10-mm trocars, 5-mm or 10-mm 30-degree laparoscope.
- Atraumatic graspers.
- Electrocautery instrument (hook or spatula).
- Maryland dissector.
- Clip applier.
- Laparoscopic scissors.
- Other equipment available as necessary:
- Disposable specimen retrieval bag.
- Cholangiography equipment.
- Abdominal ultrasound and liver function tests.
- Preoperative endoscopic retrograde cholangiopancreatography (ERCP) for patients with clinical, laboratory, or radiographic evidence of choledocholithiasis. (Some surgeons with advanced laparoscopy experience may prefer laparoscopic common duct exploration.)
- Cardiopulmonary evaluation as needed.
- Anesthesiology consultation as needed.
- Nothing by mouth for 6 hours before surgery.
- Prophylactic antibiotics for patients with acute cholecystitis. (Although preoperative antibiotics are recommended by many surgeons, their benefit in patients with uncomplicated biliary colic or chronic cholecystitis has not been established.)
- The patient should be supine with the arms perpendicular to the body or tucked to the side.
- After general anesthesia, the abdomen is prepped from nipple to pubis and sterilely draped.
- The primary surgeon stands on the patient's left side, while the assistant stands on the patient's right.
- General anesthesia is used.
- A small periumbilical incision is made, with the location and orientation depending on the patient's body habitus and cosmetic considerations. Although most surgeons employ a closed technique to establish pneumoperitoneum and initial access (usually with a Veress needle), an open technique is also appropriate.
- Figure 11–1: Port positions:
- 5-mm (preferred) or 10-mm port in the periumbilical position for a 5-mm or 10-mm laparoscopic scope.
- 10-mm port in the subxiphoid position with the intra-abdominal portion located to the right of the falciform ligament.
- 5-mm port 2 fingerbreadths below the costal margin and close to the midclavicular line, to position the port over the gallbladder intra-abdominally.
- 5-mm port laterally along the anterior axillary line for gallbladder fundus retraction.
- The laparoscope is used to explore the abdomen for adhesions and potential injuries that may have occurred during ...
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