Chapter 62: Cholelithiasis and Cholecystitis

HISTORY AND BACKGROUND

Cholecystectomy is one of the most common surgical procedures performed in the United States, with over 700,000 procedures performed each year.¹ Open cholecystectomy, first performed by Carl Langenbuch in 1882, had been the primary treatment of gallbladder disease through the early 1990s.² 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 video camera with a laparoscope to allow the surgeon and the entire surgical team to more easily 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.^3,4 The first laparoscopic cholecystectomy in the United States was performed in 1988, and by 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.⁵ Currently, it is estimated that approximately 90% of cholecystectomies in the United States are performed using a laparoscopic approach.⁶

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, decreased wound infections and incision hernia formation, and decreased overall cost.^4,5,7,8 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.^9,10

INDICATIONS FOR CHOLECYSTECTOMY

Symptomatic Cholelithiasis

There are multiple indications for cholecystectomy, with the most common being symptomatic cholelithiasis, also termed “biliary colic” (Table 62-1). Biliary colic typically presents as a severe and episodic right upper abdominal or epigastric pain that can radiate to the back. Attacks frequently occur within 1 to 2 hours postprandially or awaken the patient from sleep. Most often, the postprandial pain will be associated with meals that are high in fat content. These episodes typically last between 30 minutes and 6 hours and can be associated with nausea and vomiting.

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 ...