The indications for laparoscopic cholecystectomy are similar to those for open cholecystectomy. These include, but are not limited to, symptomatic cholelithiasis, acute calculus and acalculous cholecystitis, gallstone pancreatitis, biliary dyskinesia, and gallbladder masses and polyps that are concerning for malignancies. Cholecystectomy for mild gallstone pancreatitis should be performed during the initial admission for pancreatitis and deferred for several weeks in patients with severe pancreatitis. Contraindications to laparoscopic cholecystectomy include small bowel obstruction secondary to gallstone ileus (which would mandate an open surgical approach), coagulopathy, and medical comorbidities prohibiting surgery. Relative contraindications to a laparoscopic approach, primarily previous intra-abdominal surgery resulting in adhesions and severe cholecystitis, are decreasing as surgeon experience with minimally invasive surgery increases. Factors associated with increased surgical risk include older age, specific medical comorbidities such as diabetes mellitus, male sex, cirrhosis with or without portal hypertension, and acute gangrenous cholecystitis.
Following a history and physical examination, the diagnosis of biliary disease is typically documented with ultrasound examination of the right upper quadrant. The remainder of the gastrointestinal tract may require additional studies. A chest x-ray and electrocardiogram may be performed as indicated. Routine laboratory blood tests are obtained and should include a liver function panel. Coagulation studies should be ordered if there is a concern for hepatic insufficiency or other causes of coagulopathy. The risks of laparoscopic cholecystectomy include bleeding, infection, trocar injuries to viscera or blood vessels, and bile duct injury. These should be discussed with the patient as well as the possibility of conversion to an open procedure. Management of patients with gallstones and suspected common duct stones is based on risk stratification. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stone extraction, if necessary, is indicated in patients with jaundice. Preoperative ERCP or magnetic resonance cholangiopancreatography should be considered for patients with dilated bile ducts on imaging and/or elevated liver function tests.
General anesthesia with endotracheal intubation is mandatory. Preoperative prophylactic antibiotics for anticipated bile pathogens can be administered, although there is evidence that the routine use of preoperative antibiotics for elective laparoscopic cholecystectomy is unnecessary for low-risk patients.
Because 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 carbon dioxide 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. The positions of the video monitors may require adjustment once all members step up to their final positions at operation. The patient is placed supine with the arms either secured at the sides or ...