Chapter 11. Laparoscopic Cholecystectomy

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

Absolute

• 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.

Relative

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

Expected Benefits

• 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.

Potential Risks

• 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.

• 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.

• 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.)

• 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.

• 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 ...