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  • Biliary colic.
  • Chronic cholecystitis.
  • Acute cholecystitis.
  • Acalculous cholecystitis.
  • Gallstone pancreatitis.
  • Choledocholithiasis.

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Absolute

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  • 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.

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Relative

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  • Pregnancy (first or third trimester).
  • Previous abdominal operations precluding laparoscopic access.
  • Cirrhosis, portal hypertension, or bleeding disorders.

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Expected Benefits

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  • 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.

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Potential Risks

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  • 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.

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  • 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:
    • Suction-irrigator.
    • Disposable specimen retrieval bag.
    • Cholangiography equipment.

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  • 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.)

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  • 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.

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  • 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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