Chapter 48. Cholecystitis and Cholelithiasis

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.

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 patients.15,16 Prophylactic cholecystectomy for asymptomatic cholelithiasis can be justified in certain circumstances, such as in patients with sickle cell disease, those undergoing open bariatric surgery, requiring long-term total parental nutrition, or patients who are therapeutically immunosuppressed after solid organ transplantation. Patients with sickle cell disease often have hepatic or vaso-occlusive crises that can be difficult to differentiate from acute cholecystitis.17 In patients following bariatric surgery, the development of gallstones is markedly increased during the period of rapid weight loss to an incidence of about 30%.18,19 Removing the gallbladder at the time of bariatric surgery can abolish gallstone-related morbidity relatively easily. This approach has been adopted by many bariatric surgeons during open bariatric procedures, but not during laparoscopic bariatric surgery, because the potential morbidity of an added laparoscopic cholecystectomy in the patient with morbid obesity appears greater than the potential later risk of cholelithiasis-related complications.20–22 In transplant patients, there is concern that immunosuppression may mask the signs and symptoms of inflammation until overwhelming infection has ocurred.23 Recommendations in the literature range from mandatory screening and treatment of biliary disease before transplantation, to prophylactic cholecystectomy 6 months post-transplantation, to expectant management of all asymptomatic patients.24–27 Other possible indications for prophylactic laparoscopic cholecystectomy include individuals who may not have access to modern health care facilities for an extended time period, such as missionaries and military personnel, and patients who are already undergoing an abdominal operation for other reasons. Prophylactic cholecystectomy has been occasionally advocated in diabetics. There is no evidence to support this policy, but good evidence to support a strategy of early cholecystectomy in the symptomatic patient. Diabetics tend to present with acute cholecystitis more frequently once they become symptomatic, and withstand complications less well.

Individuals without gallstones but with typical biliary symptoms, that is, acalculous cholecystitis or gallbladder dyskinesia (GBD), may also be considered for the procedure.10 GBD is often a diagnosis of exclusion. The Rome Committee, established in 1994, set three criteria to confirm GBD: (1) absence of gallbladder stones, sludge or microlithiasis, (2) abnormal ejection fraction (EF) less than 40% on hepatobiliary iminodiacetic acid (HIDA) scan after 30 minutes of continuous cholecystokinin (CCK) infusion, and (3) positive response without pain for 12 months after cholecystectomy.28

Other indications for cholecystectomy include gallbladder polyps and porcelain gallbladder. Gallbladder polyps are typically an incidental finding that affects approximately 5% of the population, with a higher percentage in Asian populations.29 Polyps that are smaller than 10 mm in diameter have a low likelihood of malignancy and can be followed radiologically. Polyps larger than 10 mm in diameter in patients over 50 years old have a higher likelihood of being malignant and are recommended for cholecystectomy.29,30 Porcelain gallbladder has an associated risk of gallbladder cancer. Earlier studies estimated the incidence of gallbladder cancer to be between 12 and 60%, but recent studies suggest that the overall risk is lower at 7%.31 Nevertheless, radiographic evidence of porcelain gallbladder warrants cholecystectomy.

Serum laboratory tests of patients with biliary disease include total bilirubin, alkaline phosphatase, transaminases, amylase, lipase, and complete blood count (CBC). Elevations in the liver function panel may suggest biliary obstruction. Elevations in amylase and lipase may suggest pancreatitis. With simultaneous elevation of both liver and pancreatic enzymes, gallstone pancreatitis must be ruled out.

In a patient with typical biliary colic, the only diagnostic imaging study necessary prior to laparoscopic cholecystectomy is an abdominal ultrasound revealing gallstones. Ultrasound demonstrates the size and number of stones, the thickness of the gallbladder wall, the presence or absence of pericholecystic fluid, the diameter of the common bile duct (CBD), and other components of the biliary ductal system. Other nonbiliary disorders such as hepatic lesions or steatosis, masses in the pancreas, or renal tumors may also be diagnosed. When ultrasound is negative despite typical biliary symptoms, CCK-stimulated HIDA scan demonstrating a low gallbladder EF with or without pain reproduction suggests gallbladder dyskinesia.28 If a patient with gallstones has atypical symptoms, however, a more extensive work-up including upper gastrointestinal contrast radiography or endoscopy, computerized tomography, or cardiac and pulmonary evaluation may be appropriate to rule out significant nonbiliary disease processes.

The number of absolute and relative contraindications to performing laparoscopic cholecystectomy has decreased over the past 20 years as minimally invasive surgical instrumentation and skills have improved (Table 48-2). Absolute contraindications include the inability to tolerate general anesthesia or laparotomy, refractory coagulopathy, diffuse peritonitis with hemodynamic compromise, cholangitis, and potentially curable gallbladder cancer. Diffuse peritonitis with hemodynamic compromise represents a surgical emergency in which attempted laparoscopic cholecystectomy is not prudent, because the etiology is not clear or secure, and the pneumoperitoneum may lead to vascular collapse. Standard open laparotomy allows rapid determination of the etiology and more expeditious management of the disorder. Suspicion of gallbladder malignancy mandates that standard open resection be undertaken. This is because of persistent concerns with adequacy of resection and the possibility of gallbladder perforation (occurring in 20–30% of laparoscopic cholecystectomies) with intraperitoneal dissemination of cancer.

Relative contraindications are dictated primarily by the surgeon's philosophy and experience. These include previous upper abdominal surgery with extensive adhesions, cirrhosis, portal hypertension, severe cardiopulmonary disease, morbid obesity, and pregnancy. In most patients, little is lost by initiating a laparoscopic cholecystectomy with conversion to laparotomy if the laparoscopic approach is deemed too risky.

Pregnancy is a controversial relative contraindication to laparoscopic cholecystectomy because of the unknown effects of prolonged CO2 pneumoperitoneum on the fetus. Laparoscopic cholecystectomy can be performed safely during pregnancy, but only with great care.29 We limit this intervention to the second trimester of gestation after organogenesis is complete and prior to the uterine fundus reaching a size and height that encroaches on the operative field. Open insertion of the initial port or alternative location of the initial port in the right upper quadrant should be used to avoid injury to the gravid uterus, and the insufflation pressure should be limited to less than 12 mm Hg to avoid respiratory embarrassment and decreased vena caval return. Also, maternal hyperventilation with close monitoring of end-tidal CO2 should be undertaken to prevent fetal acidosis. When visualization of the biliary tree is required, laparoscopic ultrasound is used in place of cholangiography in order to limit fetal radiation exposure. And finally, perioperative consultation with an experienced obstetrician is advisable, as is perioperative fetal heart monitoring.

Early experience suggested that acute cholecystitis was a relative contraindication to performing laparoscopic cholecystectomy. A number of recent reports indicate that laparoscopic cholecystectomy indeed can be done safely for patients with acute inflammation of the gallbladder, but should be performed in this setting only by experienced laparoscopic surgeons. There is clearly a higher rate of conversion in the setting of acute cholecystitis. In particular, after 72 hours the rate of conversion increases significantly. One should not hesitate to convert to an open cholecystectomy if significant adhesions or inflammation are identified during laparoscopy. The timing of cholecystectomy for acute cholecystitis has been a long-standing matter of debate. Based on several prospective studies, early surgical intervention has economic, social, and medical benefits and therefore is the preferred approach for experienced laparoscopic surgeons in the management of acute cholecystitis.32–36 Our practice is to proceed with laparoscopic cholecystectomy immediately after the diagnosis of acute cholecystitis has been made. In patients who present after 72 hours of symptoms, a laparoscopic cholecystectomy is attempted only if the patient has no pre-existing medical conditions which preclude an open cholecystectomy. If the patient does have significant comorbid illnesses, we continue with antibiotic therapy and possibly a percutaneous cholecystostomy tube and subsequent elective laparoscopic cholecystectomy 6–8 weeks later. Surgeons must be comfortable in their ability to safely perform the procedure laparoscopically; significant concerns based on laparoscopic findings should prompt conversion to open cholecystectomy. Despite the advent of minimally invasive technology, open cholecystectomy continues to be an acceptable method for removal of the gallbladder under any circumstances and should certainly be considered if proper facilities for performance of laparoscopic surgery are not available or if the surgeon is not adequately trained in this technology.

In addition to relative contraindications, there are situations when cholecystectomy, whether laparoscopic or open, should be avoided completely in favor of percutaneous cholecystostomy. Patients in which cholecystostomy should be used include patients who have absolute contraindications to surgery. These include patients with significant respiratory failure resulting in inability to tolerate general anesthesia and those who have had recent exacerbation of a significant comorbid illness such as myocardial infarction (MI).

Anatomy

The classic anatomy of the biliary tree is present in only 30% of individuals, so it may be said that anomalies are the rule, not the exception. As with any procedure, the knowledge of normal anatomy and common variants is critical to the success of surgical intervention. The cystic duct may join the CBD at an acute angle, travel parallel to the common duct for several centimeters prior to insertion, insert into the right hepatic duct, or be congenitally absent. The cystic artery usually arises from the right hepatic artery, but one must be absolutely sure that the cystic artery is visualized entering the gallbladder wall. Occasionally the right hepatic artery will loop up onto the surface of the gallbladder, and a very short cystic artery will arise. Furthermore, there can often be a posterior cystic artery, which can easily be injured if not recognized. The common bile duct begins at the junction of the cystic duct and the common hepatic duct and passes inferiorly to the ampulla of Vater. Its normal diameter is less than 6 mm, although it may be larger in elderly patients and those with biliary obstruction.

It is important to clearly identify the structures within the hepatocystic triangle, which is the ventral aspect of the area bounded by the gallbladder wall and cystic duct, the liver edge, and the common hepatic duct. Contained within the hepatocystic triangle is the eponymic Calot's triangle: The boundaries of Calot's triangle include the cystic duct, cystic artery, and the gallbladder wall. Aberrant anatomy is a well-recognized risk factor for biliary injury. An aberrant right hepatic duct (RHD) is the most common anomaly causing problems during laparoscopic cholecystectomies. The most dangerous variant is when the cystic duct joins a low-lying aberrant right sectoral duct. Injuries to these ducts are under-reported since occlusion of an aberrant duct may be asymptomatic and even unrecognized (Fig. 48-1).

Patient Preparation

As with any abdominal operation, patients are fasted for a minimum of 8 hours prior to the operation. Patients without major comorbidities are generally scheduled as outpatient procedures. Prophylactic antibiotics are up to the surgeon's discretion; evidence suggests that most patients have a very low risk of perioperative infection.37 Antiembolic stockings and sequential compression devices are placed on both legs to avoid pooling of blood in the lower extremities by the reverse Trendelenburg position generally used during this operation. Following induction of general endotracheal anesthesia, an orogastric tube may be placed to decompress the stomach. The abdomen is shaved and prepared in standard sterile fashion with particular care taken to rid the umbilicus of all debris.

Laparoscopic Cholecystectomy

Operating Room Setup

Most surgeons utilize two video monitors, one on each side of the operating table to facilitate visualization by both surgeon and assistant. Using the American technique, the surgeon stands to the left of the patient, the first assistant stands to the patient's right (Fig. 48-2). If a laparoscopic video camera operator is used, he stands to the left of the surgeon. In the French technique, the patient's legs are abducted and the surgeon stands between the legs.

Pneumoperitoneum

A working space, provided by a pneumoperitoneum, is essential for the surgeon to see and to operate within the abdominal cavity. CO2 has the advantage of being noncombustible and rapidly absorbed from the peritoneal cavity. It may, however, lead to hypercarbia in patients with significant cardiopulmonary disease.38 The most common location for initial peritoneal entry is at the midline near the umbilicus. Supraumbilical or infraumbilical incisions may be made in vertical, horizontal, or curvilinear orientations based on surgeon's preference. Pneumoperitoneum can be established by either a closed or an open technique. In the closed technique, CO2 is insufflated into the peritoneal cavity through a Veress needle, which is subsequently replaced with a laparoscopic port, placed blindly into the abdominal cavity. In the open technique, a laparoscopic port is inserted under direct vision into the peritoneal cavity via a small incision; only after ensuring definitive and safe peritoneal entry is the pneumoperitoneum established. There are advantages and disadvantages to both techniques. Surgeons performing laparoscopic cholecystectomy should learn both and use them selectively based on the patient's body habitus and previous surgical history.

Port Placement and Exposure

Depending on the surgeon's preference, a 5- or 10-mm laparoscope is inserted into the abdomen through the periumbilical port and the abdominal cavity is visually explored. It is generally advantageous to use an angled (30- or 45-degree) laparoscope rather than a 0-degree scope, because the angled scopes enable obtaining multiple views of the same operative field. The patient is then placed in a reverse Trendelenburg position of 30 degrees while rotating the table to the left by 15 degrees. This maneuver allows the colon and duodenum to fall away from the liver edge. The falciform ligament and both lobes of the liver are examined closely for abnormalities. The gallbladder can usually be seen protruding beyond the edge of the liver.

Two small accessory subcostal ports are then placed under direct vision. The first 5-mm trocar is placed along the right anterior axillary line between the 12th rib and the iliac crest. A second 5-mm port is inserted in the right subcostal area in the midclavicular line. Grasping forceps are placed through these two ports to secure the gallbladder. The assistant manipulates the lateral grasping forceps, which are used to grasp the fundus and elevate the liver. The fourth working port is then inserted through an incision in the midline of the epigastrium (Fig. 48-3). This trocar is usually inserted approximately 5 cm below the xiphoid process, but the precise position and angle depends on the location of the gallbladder as well as the size of the medial segment of the left lobe of the liver. Dissecting forceps are then inserted and directed toward the gallbladder neck. One should note that the orientation of the laparoscope is generally parallel to that of the cystic duct when the fundus is elevated, whereas the instruments placed through the other three ports enter the abdomen at right angles to this plane. The surgeon uses a dissecting forceps to raise a serosal fold of the most dependent portion of the fundus. The assistant's heavy grasping forceps are then locked onto this fold using either a spring or ratchet device. With these axillary grasping forceps, the fundus of the gallbladder is then pushed in a lateral and cephalad direction, rolling the entire right lobe of the liver cranially.

This maneuver is complicated in patients with a fixed, cirrhotic liver or a heavy, friable liver because of fatty infiltration. In patients with few adhesions to the gallbladder, pushing the fundus cephalad exposes the entire gallbladder, cystic duct, and porta hepatis. Most patients, however, have adhesions between the gallbladder and the omentum, hepatic flexure and/or duodenum. These adhesions are generally avascular and may be lysed bluntly by grasping them with dissecting forceps at their site of attachment to the gallbladder wall and gently stripping them down toward the infundibulum. Extreme caution should be taken to avoid damage to surrounding structures. Use of electrocautery may accidentally damage the unvisualized CBD or proximally located duodenum. After exposing the infundibulum, blunt grasping forceps held in the surgeon's left hand and placed through the midclavicular trocar are used to grasp and place traction on the neck of the gallbladder.

Dissection

The infundibulum is grasped, placing traction on the gallbladder in a lateral direction to distract the cystic duct from the CBD (Fig. 48-4). Fine-tipped dissecting forceps (Maryland) are used to dissect away the overlying fibroareolar structures from the infundibulum of the gallbladder. The dissection should begin from a known structure, for example, the gallbladder, rather than in an unknown area, to avoid damage to the underlying structures such as a bile duct or hepatic artery. The dissection initially commences 4 or 5 cm proximal to the neck of the gallbladder and proceeds distally, such that a modified “top-down” technique is employed. The objective of the initial dissection is to free the gallbladder from its bed such that there is a window beneath it through which the liver substance can be seen. The hepatocystic triangle is maximally opened and converted into a trapezoid shape by retracting the infundibulum of the gallbladder inferiorly and laterally while maintaining the fundus under traction in a superior and medial direction. A lymph node usually lies on the surface of the cystic artery, and occasionally it is necessary to use a brief application of low-wattage electrosurgical coagulation to obtain hemostasis as the lymph node is bluntly swept away. To expose the reverse of Calot's triangle, the infundibulum of the gallbladder is pulled in a superior and medial direction. The use of an angled laparoscope facilitates viewing both sides of the hepatocystic triangle when used in combination with these retraction techniques. After clearing the structures from the apex of the triangle, the junction between the infundibulum and the origin of the proximal cystic duct can be tentatively identified. The strands of peritoneal, lymphatic, and neurovascular tissue are stripped away from the cystic duct to clear a segment from the surrounding tissue. Curved dissecting forceps are helpful in creating a window around the posterior aspect of the cystic duct to skeletonize the duct itself. Alternatively, the tip of the hook cautery can be used to encircle and expose the duct. It is generally unnecessary and potentially harmful to dissect the cystic duct down to its junction with the CBD. The cystic artery is separated from the surrounding tissue by similar blunt dissection at this time. If the cystic artery crosses anterior to the duct, the artery may require dissection and division prior to approaching the cystic duct. The neck of the gallbladder is thus dissected away from its liver bed, leaving a large window at its base through which the liver parenchyma is visualized. There should be two, and only two, structures (the cystic duct and artery) crossing this window—this is the “critical view of safety,” which should be demonstrated prior to clipping or cutting any tubular structures.38 To reiterate, no structure should be divided until the cystic duct and cystic artery are unequivocally identified. Developing this critical view of safety is an essential step to minimize the chance of bile duct injury during laparoscopic cholecystectomy (Fig. 48-5).38

Intraoperative Evaluation for Choledocholithiasis

After initially dissecting the proximal cystic duct, the CBD should be imaged if there is any concern for choledocholithiasis or questions regarding the biliary anatomy. This can be achieved by intraoperative cholangiography (IOC) or intracorporeal laparoscopic ultrasonography (LUS). Prior to either procedure, a clip is applied high on the cystic duct at its junction with the gallbladder to prevent stones migrating down the duct during subsequent manipulation. To perform IOC, the anterolateral wall of the cystic duct is incised and dissecting forceps are used to gently compress the cystic duct systematically back toward the gallbladder, thereby milking stones away from the CBD and out of the ductotomy. A 4F or 5F catheter is inserted into the duct through a hollow, 5-mm metal tube that has an appropriate gasket to prevent carbon dioxide leakage around the catheter itself. The cholangiography catheter is inserted into the cystic duct and a clip is applied loosely to secure the catheter in place. If the introducer has grasping jaws, it can be used to secure the catheter into the duct. Alternatively, catheters equipped with balloons proximal to the tip may be used for fixation. Cholangiography can be performed by either real-time fluoroscopy (dynamic) or by obtaining two standard radiographs (static) after injecting 5 and 10 mL of water-soluble contrast medium. The films should be inspected for the following: (1) the length of cystic duct and location of its junction with the CBD, (2) the diameter of the CBD, (3) the presence of luminal filling defects within the CBD, (4) free flow of contrast into the duodenum, and (5) anatomy of the extrahepatic and intrahepatic biliary tree. After the cholangiocatheter is removed, the cystic duct is doubly clipped below the ductotomy with care to avoid the wall of the CBD, and then divided. The posterior jaw of the clip applier must be visualized prior to applying each clip in order to avoid injuring the surrounding structures. Great care should be taken so that the CBD is not tented up into the clip. If the cystic duct is particularly large or friable, it may be preferable to replace one of the clips with a suture, either hand-tied or a preformed loop with slip knot.

Evaluation of the CBD by LUS is an alternative to cholangiography. Several studies39,40 performed at open cholecystectomy reported intracorporeal ultrasonography to be more accurate than operative cholangiography in assessing the CBD for stones (97–99% vs 89–94%).41–43 However, few surgeons adopted ultrasound for this purpose. Recently, LUS has been used in several centers during laparoscopic cholecystectomy and is gaining popularity.43–47 With LUS, the transducer has a higher frequency with improved resolution compared to those used with transabdominal ultrasonography. In experienced hands, LUS appears to be as accurate as cholangiography for demonstrating choledocholithiasis but can be performed more rapidly.48 In a recent prospective multicenter trial with 209 laparoscopic cholecystectomy patients, the time to perform LUS (7 ± 3 minutes) was significantly less than that of IOC (13 ± 6 minutes).48 The study showed that LUS was more sensitive for detecting stones but that IOC was better in delineating intrahepatic anatomy and defining anatomical anomalies of the ductal system. The authors concluded that the two methods of duct imaging were complementary. Despite these promising data, more clinical experience will be necessary to establish the appropriate role of LUS for the detection of choledocholithiasis during laparoscopic cholecystectomy.49,50

Completion of Cholecystectomy

The cystic duct is clipped using an endoscopic clip applier and divided using scissors. Two clips are placed proximally on the cystic duct and one clip is placed toward the gallbladder (Fig. 48-6). For cystic ducts that are large or friable, a preformed endoloop is preferable for ligating the distal cystic duct. After the duct is divided, the cystic artery is dissected from the surrounding tissue for an adequate distance to permit placement of three clips. The surgeon must determine that the structure is indeed the cystic artery and not the right hepatic artery looping up onto the neck of the gallbladder or an accessory or replaced right hepatic artery. After an appropriate length of cystic artery has been dissected free, it is clipped proximally and distally prior to transection (Fig. 48-7). Electrocautery should not be used for this division, as the current may be transmitted to the proximal clips leading to subsequent necrosis and hemorrhage.

The ligated stumps of the cystic duct and the artery are then examined to ensure that there is no leakage of either bile or blood and that the clips are placed securely and compress the entire lumen of the structures without impinging on adjacent tissues. A suction-irrigation catheter is used to remove any debris or blood that has accumulated during the dissection. Separation of the gallbladder away from its hepatic bed is then initiated using an electrosurgical probe to coagulate small vessels and lymphatics. While maintaining cephalad traction on the fundus of the gallbladder with the axillary forceps, the midclavicular forceps pulls the neck of the gallbladder anterosuperiorly and then alternatively medially and laterally to expose and place the tissue connecting the gallbladder to its fossa under tension. An electrocautery spatula or hook is used to coagulate and divide the tissue. Intermittent blunt dissection will facilitate exposure of the proper plane (Fig. 48-8).

Dissection of the gallbladder fossa continues from the infundibulum to the fundus, progressively moving the midclavicular grasping forceps cephalad to allow maximal countertraction. The dissection proceeds until the gallbladder is attached by only a thin bridge of tissue. At this point, prior to completely detaching the gallbladder, the hepatic fossa and porta hepatis are once again inspected for hemostasis and bile leakage. Small bleeding points are coagulated and the right upper quadrant is liberally irrigated and then aspirated dry while checking for any residual bleeding or bile leakage. The final attachments of the gallbladder are divided, and the liver edge is again examined for hemostasis.

After the cholecystectomy has been performed, the gallbladder must be removed from the abdominal cavity. The gallbladder may be placed within an entrapment sac prior to extracting it through the abdominal wall (Fig. 48-9). This is recommended particularly if the gallbladder has been perforated intraoperatively or if the specimen is large. If the stone burden is small, the gallbladder can be extracted at the subxiphoid port site. Usually, the gallbladder is most easily removed at the umbilical port site where there are no muscle layers anterior to the fascial plane. Also, if the fascial opening needs to be enlarged because of large or numerous stones, extension of the umbilical incision causes less postoperative pain and has better cosmesis than does enlarging the subxiphoid incision. The laparoscope is removed from the umbilical port and placed through the epigastric port. Large “claw” grasping forceps are introduced through the umbilical port to grasp the infundibulum of the gallbladder. The forceps, trocar, and gallbladder neck are then retracted as a unit through the umbilical incision. The neck of the gallbladder is thus exteriorized through the anterior abdominal wall with the fundus remaining within the abdominal cavity. If the gallbladder is not distended with bile or stones, it can be simply withdrawn with gentle traction. In many cases, a suction catheter introduced through an incision in the gallbladder neck is used to aspirate bile and small stones. Stone forceps can also be placed into the gallbladder to extract or crush calculi if necessary. Occasionally, the fascial incision must be extended to extract larger stones or thick-walled gallbladders.

Each incision is infiltrated with bupivacaine for postoperative analgesia. The fascia of the umbilical incision is closed with one or two large absorbable sutures in an interrupted or figure-of-eight fashion. Closure of the subxiphoid fascia is optional, as visceral herniation is unlikely to occur because of the oblique entry angle of the trocar into the abdominal cavity and its location anterior to the falciform ligament. The skin of the subxiphoid and umbilical incisions is closed with subcuticular absorbable sutures. The skin incisions at both 5-mm port sites can be closed with absorbable sutures, adhesive strips, or skin closure adhesives. The orogastric tube is removed in the operating room, and the patient is transferred to the postanesthesia care unit. Patients are allowed out of bed as soon as they are fit enough to walk, and more than 90% of patients are discharged from the hospital within 24 hours. Fit patients who have been preoperatively selected may be safely discharged within 6 hours following surgery.45 Patients are evaluated 1 week following surgery and if sutures are present, they are removed. At this time, more than 95% of patients are back to a normal routine and most return to work immediately following their clinic visit.

The advantages of laparoscopic cholecystectomy over other therapies for gallstone disease are multiple (Table 48-3). Unlike nonresective techniques for gallstone ablation, laparoscopic cholecystectomy removes the diseased gallbladder along with its stones. Relative to traditional open cholecystectomy, postoperative pain and intestinal ileus are diminished with laparoscopic cholecystectomy. The small size of the fascial incisions allows rapid return to heavy physical activities. The small incisions are also cosmetically more appealing than is the large incision used during traditional cholecystectomy. The patient can usually be discharged from the hospital either on the same day or the day following operation, and can return to full activity within a few days.7,11 These factors lead to overall decreased cost of laparoscopic cholecystectomy compared to its traditional open counterpart.8

There are, however, several potential disadvantages of laparoscopic cholecystectomy. As opposed to nonresective treatments for gallstones, patients must be acceptable candidates for general anesthesia and possible laparotomy. Three-dimensional depth perception is limited by the two-dimensional monocular image of the videoscope. It is more difficult to control significant hemorrhage using laparoscopic technology than in an open surgical field. There is also less haptic discrimination of structures using laparoscopic instruments as opposed to direct digital palpation during open cholecystectomy. CO2 insufflation to create the pneumoperitoneum is associated with a number of potential risks, including reduction of vena caval flow and systemic hypercarbia with acidosis.

Conversion to Open Operation

Surgeons performing laparoscopic cholecystectomy should not think of conversion to open operation as a complication, but rather a sound clinical judgment, and hence not hesitate to convert to a traditional open cholecystectomy if the anatomy is unclear, if complications arise, or there is failure to make reasonable progress in a timely manner. Some complications requiring laparotomy are obvious, such as massive hemorrhage or major injury to the bile duct. Open laparotomy allows the additional tool of manual palpation and haptic sensation and should be performed when the anatomy cannot be delineated because of inflammation, adhesions, or anomalies. Fistulae between the biliary system and bowel are rare, but may require laparotomy for optimal management. The demonstration of potentially resectable gallbladder carcinoma also dictates an open exploration. Finally, CBD stones that cannot be removed laparoscopically and are unlikely to be extracted endoscopically (because of Billroth II anastomosis, previously failed endoscopic retrograde cholangiopancreatography [ERCP], or an inexperienced endoscopist) should be converted to open operation without hesitation.

Open Cholecystectomy

The technical aspects of performing an open cholecystectomy have not changed significantly since Langenbuch's description of this procedure more than 100 years ago. Although this operation can be performed safely through a midline, paramedian, or right subcostal incision, most surgeons prefer the right subcostal (Kocher) incision. Adequate exposure of the gallbladder and the hepatoduodenal ligament is the key to performing a safe cholecystectomy. Laparotomy sponges may be packed temporarily between the dome of the liver and the diaphragm, and appropriate retractors should be inserted to optimize visualization of the hepatoduodenal ligament and its structures. The hepatic flexure of the colon is packed or retracted inferiorly and the medial segment of the left liver lobe is retracted superiorly. When a large distended gallbladder is encountered, removal can be facilitated by decompressing the gallbladder. Adhesions of omentum or viscera adjacent to the gallbladder are divided with sharp dissection or electrocautery.

Meticulous dissection and positive identification of the cystic duct, its entry into the CBD, and the cystic artery are mandatory and significantly reduce the likelihood of bile duct injury. Most experienced surgeons prefer to identify these important structures before beginning dissection of the gallbladder from the hepatic bed. The fundus and infundibulum of the gallbladder are grasped with curved clamps. The fundus is retracted anteriorly and superiorly and the infundibulum inferiorly and laterally, exposing the structures of Calot's triangle. Caudal counter-retraction of the hepatoduodenal ligament stretches and exposes the porta hepatis, placing the peritoneum overlying the cystic duct and artery on tension. This maneuver may be accomplished with a retractor, although the left hand of the first assistant effectively retracts the duodenum. The surgeon introduces the left index finger into the foramen of Winslow and palpates for calculi in the CBD. Acute inflammation or chronic scarring may preclude approaching the infundibulum first; many surgeons prefer to dissect the fundus initially (fundus first or top-down technique), and the ductal and vascular structures subsequently, only after the organ has been separated from the liver. Careful ligation of the cystic duct is essential in preventing not only a biliary leak, but also in reducing the possibility of bile duct injury and stricture. Ligation of the cystic duct in close proximity to its junction with the CBD has long been considered an essential component of open cholecystectomy. Experience with laparoscopic cholecystectomy suggests that the length of the cystic duct stump is not a critical factor and probably does not significantly contribute to postcholecystectomy syndrome, a poorly defined clinical entity characterized by pain following gallbladder removal. The cystic artery should be dissected, secured, and divided near the surface of the gallbladder. This will reduce bleeding associated with division of the peritoneum investing the gallbladder and separation of areolar tissue between the gallbladder and the liver. Intraoperative cholangiography can be performed at the discretion of the surgeon.

Throughout the procedure, care should be exercised to minimize spillage of bile into the peritoneal cavity. Drains are not mandatory and are indicated only if the surgeon is concerned about identifying or controlling a possible bile leak. Common pitfalls are usually related to inadequate exposure, severe inflammation, bleeding, and anatomic variants, which can lead to injury of portal structures, including the common bile duct and the hepatic artery or its branches. With a short cystic artery, the right hepatic artery must be carefully identified. Similarly with a short cystic duct, careful dissection and high ligation of the cystic duct near the gallbladder should be employed to avoid injury to the common bile duct. In fact, in the face of severe inflammation with obliteration of normal tissue planes it may be safest to perform a subtotal cholecystectomy, leaving a portion of the infundibulum in situ (after removing all stones) and suture ligating the mucosal side of the cystic duct origin. If there is unintentional gallbladder puncture, a second clamp or purse-string suture can be applied to prevent gallbladder bile and stone spillage. Before closing the abdominal incision, bleeding and bilious drainage must be controlled. Structures in the porta hepatis are re-examined, with special attention to the cystic duct stump. The subhepatic space is irrigated with warm saline and all irrigants are evacuated. The incision is usually closed in one or two layers. The skin can be closed with sutures or staples.

Acute Cholecystitis

Acute cholecystitis may be treated successfully by laparoscopic cholecystectomy. Intervention during the early phase often reveals an inflamed, edematous, thick-walled, and tensely distended organ. To gain adequate traction on the gallbladder with the grasping forceps, it may be necessary to decompress the gallbladder by aspirating its contents with a large-gauge needle or suction irrigator. As long as the inflammation is limited to the gallbladder, laparoscopic cholecystectomy is usually technically feasible. However, if inflammation extends to the porta hepatis, great care must be taken in proceeding with the operation. The normally thin, minimally adherent tissue that invests the cystic duct and artery is markedly thickened and edematous and may not readily separate from these structures with the usual blunt dissection techniques. The duct wall also may be edematous, thus making its external diameter similar to the gallbladder neck and CBD. If the anatomy is unclear, cholangiography must be performed before clipping or dividing tissue. When acute inflammation has been present for several days or weeks before operation, the pericholecystic tissue planes may be obliterated by thick, woody tissue that is difficult to dissect bluntly. The surgeon may therefore need to convert to open cholecystectomy if the minimal access approach is initially attempted during this subacute phase. There is no harm in inserting the laparoscope and assessing the right upper quadrant. The decision to convert to an open operation is a matter of judgment, based on the existing anatomy, local conditions, and the surgeon's experience and confidence in his or her ability to complete the procedure using minimal access techniques.

Several authors have reported performing laparoscopic cholecystectomy51 in the face of acute inflammation with success but with a higher conversion rate than for elective laparoscopic cholecystectomy.52–57 Lo and associates reported in their prospective study that despite longer operative times and postoperative stays for early laparoscopic cholecystectomy in patients with acute cholecystitis (treatment within 5 days) versus delayed laparoscopic cholecystectomy (initial conservative treatment followed by laparoscopic cholecystectomy 3–4 months later), the advantage of early laparoscopic cholecystectomy was the reduction in the total hospital stay, from 15 to 7 days. In a second prospective study of 105 patients randomized to early laparoscopic cholecystectomy (within 24 hours of diagnosis of acute cholecystitis) versus delayed laparoscopic cholecystectomy (6–8 weeks later), there was no significant difference in conversion rate (early 21% vs delayed 24%), postoperative analgesic requirement, or number of postoperative complications. The early group did have a longer operative time (123 vs 107 minutes; p = .04), but total hospitalization was shorter (8 vs 12 days; p = .001).57 Rattner and associates retrospectively reviewed 20 patients who underwent attempted laparoscopic cholecystectomy for acute cholecystitis and examined factors that were predictive of a successful procedure.54 Seven of the 20 patients (35%) required conversion to open cholecystectomy. The interval from admission to cholecystectomy in the successful cases was 0.6 days versus 5 days in the cases requiring conversion to open cholecystectomy. Converted cases also had a significantly higher white blood cell (WBC) count, alkaline phosphatase levels, and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores compared to those undergoing successful laparoscopic cholecystectomy. Ultrasonographic findings such as gallbladder distention, wall thickness, and pericholecystic fluid did not correlate with the success of laparoscopic cholecystectomy.

More recent studies have confirmed that laparoscopic cholecystectomy is an equivalent or better option than open surgery for treating acute cholecystitis.58,59 In a study of two prospectively randomized groups, Johansson and associates reported that there were no differences in post-operative complications or pain when comparing laparoscopic to open cholecystectomy.55 Using a cohort of almost 1 million patients from the National Hospital Discharge Surveys from 2000 to 2005, Csikescz and associates reported recently that patients undergoing laparoscopic cholecystectomy for acute cholecystitis have low conversion rates (9.5%), lower morbidity (16 vs 36%), and lower unadjusted mortality (0.4 vs 3%) compared to open cholecystectomy.56

It can be concluded that laparoscopic cholecystectomy should be performed immediately after the diagnosis of acute cholecystitis. Delaying surgery allows inflammation to become more intense and neovascularized, thus increasing the technical difficulty of laparoscopic cholecystectomy.

Intraoperative Gallbladder Perforation

Perforation of the gallbladder with bile or stone leakage can be a nuisance but should not ordinarily require conversion to open cholecystectomy. Perforation may occur secondary to traction applied by the grasping forceps or because of electrosurgical thermal injury during removal of the gallbladder from its bed. In our experience, almost one-third of the patients have had intraoperative spillage of bile or stones.5 Patients with a bile leak have not experienced an increased incidence of infection, prolongation of hospitalization, or postoperative disability, nor adverse long-term complications60 (mean follow-up of 41 months in 250 consecutive laparoscopic cholecystectomy patients). The only difference between those with and without bile leakage was that the operating time of patients with a gallbladder perforation was approximately 10 minutes longer, presumably because of the time spent in cleaning up the operative field. When perforation does occur, the bile should be aspirated completely and irrigation used liberally. The hole in the gallbladder is best secured with a grasping instrument and then sutured or tied with an endoloop. The stones should be retrieved and removed. Gallbladder spillage, when treated in this manner, results in no adverse short- or long-term complications. Escaped stones composed primarily of cholesterol pose little threat of infection. However, pigment stones frequently harbor viable bacteria and may potentially lead to subsequent infectious complications if allowed to remain in the peritoneal cavity.61,62 The long-term complications of retained stones, either intra-abdominally with resultant abscess formation or intramurally with resultant port site abscess, have not been prospectively studied, but recent case reports and case series in the surgical literature document a clear potential for long-term infectious complications.63–66 The relative infrequency of these complications probably does not justify conversion to open operation in the face of spilled stones, but vigilance in avoidance of perforation, a careful search for escaped stones, the aggressive use of irrigation, and liberal use of a plastic retrieval bag for large and friable gallbladders are recommended.67

Laparoscopic Cholecystectomy

Most complications related to laparoscopic removal of the gallbladder are similar to those occurring during traditional open cholecystectomy (Table 48-4). These complications include hemorrhage, bile duct injuries, bile leaks, retained stones, pancreatitis, wound infections, and incisional hernias. Other potential complications are pneumoperitoneum related (gas embolism, vagal reaction, ventricular arrhythmias, or hypercarbia with acidosis) and trocar related (injuries to the abdominal wall, intra-abdominal organ, or major blood vessels). The protective shield on disposable trocars is not an insurance against perforation of intestine or major vessels, especially after previous abdominal operations. Regardless of the make of trocar, during its insertion one should never aim toward the spine or the location of the great vessels, and a hand is used as a brake to prevent inadvertently introducing the trocar too far. Insertion of the initial trocar, especially when performed in a closed fashion, can cause iatrogenic injury to the bowel, bladder, aorta, iliac artery, or vena cava.68,69 When a trocar injury to a major blood vessel is suspected, the patient must be opened immediately without removing the trocar until the involved blood vessel is isolated. In contrast, if the small-bore Veress needle enters a viscus or blood vessel, the operation can generally be completed and the patient monitored closely for signs of complications in the postoperative period.

The laparoscopic trocars may also lacerate blood vessels in the abdominal wall. Prior to removal, each trocar should be visualized from the peritoneal aspect using the laparoscope. If significant hemorrhage is seen, it can generally be controlled with cautery, intraoperative tamponade with a Foley catheter, or a through-and-through suture on each side of the trocar insertion site.

Most serious complications occur early in the surgeon's experience. For instance, in a multivariate regression analysis of 8839 laparoscopic cholecystectomies in which there were 15 bile duct injuries, the only significant factor associated with an adverse outcome was the surgeon's experience with the procedure.70 The regression model predicted that a surgeon had a 1.7% chance of a bile duct injury occurring in the first case and 0.17% chance of a bile duct injury in the 50th case.

Of all the potential complications, biliary injuries have received the most attention and are discussed at length elsewhere in this text. Most series quote a major bile duct injury rate of around 0.2% during open cholecystectomy, whereas the incidence of bile duct injuries during laparoscopic cholecystectomy is 0.40% or higher.34 These injuries can cause major morbidity, prolonged hospitalization, high cost, and litigation.70,71 In addition to the surgeon's experience and aberrant anatomy, a number of reports mention chronic inflammation with dense scarring, operative bleeding obscuring the field, or fat in the portal area contributing to the biliary injuries.38,70–72 The classic biliary injury, however, occurs when the CBD or a RHD is mistaken for the cystic duct and is divided between clips. Many surgeons attribute this misidentification to the direction of traction of the gallbladder, that is, pulling the CBD and the cystic duct into alignment, thus making them appear to be one. Other contributing factors to misidentification are a short cystic duct, a large stone in Hartmann's pouch (making retraction and display of the cystic duct difficult), or tethering of the infundibulum to the CBD by acute or chronic inflammation. Constant awareness of these potential misidentifications and technical causes of biliary injuries is the best method of prevention. If a partial bile duct injury occurs and is recognized intra-operatively, an immediate primary repair, possibly in conjunction with a T-tube should be performed. A complete transection of the bile duct is a rare injury and an end-to-end repair is a technically challenging procedure that may require assistance from an experienced hepatobiliary surgeon. When a bile duct injury is discovered in the postoperative period, a coordinated effort by radiologists, endoscopists, and surgeons is necessary to optimize management.40 There should be no hesitation in asking for the help of a surgeon experienced in biliary repair.

Open Cholecystectomy

Experience with open cholecystectomy is vast, spanning generations of surgeons and having been practiced in virtually every country throughout the world. Over time, this operation has proved to be safe and effective. In a collected series of about 20,000 patients who underwent cholecystectomy between l946 and 1973 at 10 different institutions, from the United States and throughout the world, the overall mortality rate was l.6%. This figure is comparable to a l.7% mortality rate reported for more than 12,000 patients operated on for calculous biliary tract disease between 1932 and 1979 at a single US university center. In this latter group, the operative mortality rate for patients who underwent elective cholecystectomy was 0.1%. More recently, a US population-based study examining the outcome of all open cholecystectomies performed in a 12-month period in two states reported an overall mortality rate of 0.17%.73 The morbidity rate was 14.7%, which includes all reported complications, including minor problems such as electrolyte imbalances, atelectasis, urinary retention, and other assorted difficulties that can occur following any surgical procedure. In this study, morbidity and mortality were dependent on age as well as disease status. Perhaps the most significant complication that can arise during open or laparoscopic cholecystectomy is bile duct injury. Numerous reports in the literature, including this large population-based study indicate that the risk of bile duct injury during open cholecystectomy is between 0.1 and 0.2%. Similar morbidity and mortality data have been reported by other large series. These data confirm that open cholecystectomy continues to be a very safe operation that can be performed with a very low morbidity and mortality. In elective situations, open cholecystectomy is being performed in many hospitals throughout the world on patients who are admitted the day of surgery, with an overall stay of 2–4 days.

The advent of laparoscopic cholecystectomy provided a dramatic benefit to patients who previously underwent laparotomy for gallbladder disease. While laparoscopy has already set a high bar for cholecystectomy with regards to perioperative and intraoperative outcomes, there are areas of surgical research examining ways that could potentially make the procedure even less invasive.

Single-Port Laparoscopic Surgery

Single-port laparoscopy is a recent development in laparoscopic surgery that involves introducing all operative instruments and devices through a single skin incision, usually at the umbilicus.74–76 The proposed benefit of single-port laparoscopic cholecystectomy over traditional laparoscopic cholecystectomy is by reducing the overall number of abdominal incisions from three or four to one, there will be less perioperative pain and fewer resulting incisional complications. From a technical standpoint, single-port surgery leads to all of the instruments entering the operative field in line with the optics. Triangulation and traction or countertraction are made more difficult, but new instrumentation is being developed to overcome these limitations. There are currently no established standard techniques for performing this procedure and postoperative results are just emerging.

Natural Orifice Translumenal Endoscopic Surgery

Natural orifice translumenal endoscopic surgery (NOTES) is an investigational procedure that aims to reduce and eventually eliminate all abdominal incisions by accessing the peritoneum through natural orifice routes including transoral or transgastric, transvaginal, and transanal or transcolonic. By eliminating abdominal incisions, the hypothesis is that there will be less pain, fewer complications and decreased morbidity associated with abdominal incisions.77–81 These benefits are proposed to include decreased incisional hernias, wound infections, and post-operative pain, while improving cosmesis. Given the current state of technology and lack of appropriate instrumentation, few pure NOTES cholecystectomies have been performed worldwide.82–84 NOTES hybrid procedures, where a laparoscopic instrument is used in conjunction with the natural orifice devices, have been performed in greater numbers, though only in a relatively few specialized centers. Results from these procedures are also just being reported and large sets of data are not yet available to evaluate the proposed benefits of NOTES.

Cholecystectomy remains one of the most common operations performed in the United States and worldwide. Laparoscopic cholecystectomy is the standard for treatment of gallstone and gallbladder disease. There are numerous advantages of laparoscopic cholecystectomy over open cholecystectomy, including decreased pain, length of stay, recovery time, incisional complications, and improved cosmesis. However, occasionally anatomical or physiological considerations will hinder or preclude the minimal access approach, and conversion to an open operation in such cases reflects sound clinical judgment and should not be considered a complication. Additionally, there are current studies underway to investigate new ways to perform cholecystectomies that may result in additional benefits over traditional laparoscopic cholecystectomy.