Cholecystectomy is one of the most common surgical procedures performed in the United States with over 600,000 procedures performed each year. Open cholecystectomy, first performed by Carl Langenbuch in 1882, has been the primary treatment of gallbladder disease through the early 1990s.1 In 1985, the first endoscopic cholecystectomy was performed by Erich Mühe of Böblingen, Germany. Shortly thereafter, pioneers in France and the United States coupled a CCD video camera with a laparoscope to allow the entire surgical team to view the operative field and performed cholecystectomies with laparoscopic equipment. Since then, laparoscopic cholecystectomy has been adopted around the world, and subsequently been recognized as the gold standard for the treatment of gallstone disease.2–5 In 1992, the National Institutes of Health (NIH) Consensus Development Conference stated that laparoscopic cholecystectomy provides a safe and effective treatment for most patients with symptomatic gallstones.6 Currently it is estimated that over 80% of cholecystectomies are performed using the laparoscopic approach.
The advantages of laparoscopic over open cholecystectomy have been well documented. These advantages include earlier return of bowel function, less postoperative pain, improved cosmesis, shorter length of hospital stay, earlier return to full activity, and decreased overall cost.7–11 There has been an increase in the rate of cholecystectomies subsequent to the introduction of laparoscopic cholecystectomy accompanied by evidence of lower clinical thresholds for operative therapy of gallbladder disease.12–14
There are multiple indications for cholecystectomy with the most common being symptomatic cholelithiasis (Table 48-1). The diagnosis of symptomatic cholelithiasis is made by radiographic documentation of gallstones, usually using abdominal ultrasound, with the presence of symptoms attributable to a diseased gallbladder. Biliary colic is typically a severe and episodic right upper abdominal or epigastric pain that can radiate to the back. Attacks frequently occur postprandially or awaken the patient from sleep. Often times the postprandial pain will be associated with meals that are high in fat content. Once a patient begins to experience symptoms, there is a greater than 80% chance that he or she will continue to have symptoms in the future or develop a complication. These complications may result from obstruction of the gallbladder outlet, causing acute cholecystitis, or migration of a stone into the common bile duct, causing cholangitis or pancreatitis.
Table 48-1: Indications for Laparoscopic Cholecystectomy |Favorite Table|Download (.pdf)
Table 48-1: Indications for Laparoscopic Cholecystectomy
|Cholangitis or obstructive jaundice|
|Sickle cell disease|
|Total parenteral nutrition|
|No immediate access to health care facilities (eg, missionaries, military personnel, peace corps workers, relief workers)|
|Incidental cholecystectomy for patients undergoing procedure for other indications|
|Gallbladder polyps >10 mm in diameter|
Patients with asymptomatic gallstones have less than 20% chance of ever-developing symptoms, and the risks associated with prophylactic operation outweigh the potential benefit of surgery in most ...