Cholecystectomy is indicated in symptomatic patients with proven disease of the gallbladder, and the indications for laparoscopic cholecystectomy are essentially those for open cholecystectomy. There are certain definitive contraindications, which at present include peritonitis, small bowel obstruction secondary to gallstone ileus, coagulopathy, and large diaphragmatic hernia. Relative contraindications are becoming fewer as the surgical experience of the individual surgeon increases. The factors for increased risk include cirrhosis with portal hypertension, previous intra-abdominal surgery with adhesions, and acute gangrenous cholecystitis.
Following a history and physical examination, the diagnosis of biliary disease is documented with ultrasound examination of the abdomen. The remainder of the gastrointestinal tract may require additional studies. A chest x-ray and electrocardiogram are usually performed and may indicate the need for further evaluation of the cardiopulmonary systems. Routine laboratory blood tests are obtained and should include a liver function panel as well as coagulation studies. The risks of laparoscopy, including trocar injuries to viscera or blood vessels and the increased risk of bile duct injuries during laparoscopic cholecystectomy, are discussed with the patient as well as the possibility of conversion to an open procedure. The management of patients with gallstones and common duct stones remains to be defined. An endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy are commonly tried first. If the common duct is successfully cleared of stones, then a staged laparoscopic cholecystectomy is performed. If the ERCP procedure is not successful, the patient should be prepared for an open cholecystectomy with common duct exploration.
General anesthesia with endotracheal intubation is recommended. Preoperative prophylactic antibiotics for anticipated bile pathogens are administered such that adequate tissue levels exist.
As laparoscopic cholecystectomy makes extensive use of supporting equipment, it is important to position this equipment such that it is easily visualized by all members of the surgical team (Figure 1).
The surgeon must have a clear line of sight to both the video monitor and the high flow CO2 insufflator such that he or she can monitor both the intra-abdominal pressure and gas flow rates. In general, all members of the team are looking across the operating table at video monitors and therefore the positions of the video monitors may require adjustment once all members step to their final positions at operation. The patient is placed supine with the arms either ...