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Cholecystectomy

Cholecystectomy

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Cholecystectomy is the surgical removal of the gallbladder
Gallbladder
In vertebrates the gallbladder is a small organ that aids mainly in fat digestion and concentrates bile produced by the liver. In humans the loss of the gallbladder is usually easily tolerated....

. It is the most common method for treating symptomatic gallstone
Gallstone
A gallstone is a crystalline concretion formed within the gallbladder by accretion of bile components. These calculi are formed in the gallbladder, but may pass distally into other parts of the biliary tract such as the cystic duct, common bile duct, pancreatic duct, or the ampulla of...

s. Surgical options include the standard procedure, called laparoscopic
Laparoscopic surgery
Laparoscopic surgery, also called minimally invasive surgery , bandaid surgery, or keyhole surgery, is a modern surgical technique in which operations in the abdomen are performed through small incisions as opposed to the larger incisions needed in laparotomy.Keyhole surgery makes use of images...

 cholecystectomy, and an older more invasive procedure, called open cholecystectomy.

Open surgery


A traditional open cholecystectomy is a major abdominal surgery in which the surgeon removes the gallbladder through a 5- to 7-inch incision. Patients usually remain in the hospital at least 2 to 3 days and may require several additional weeks to recover at home. This procedure will therefore leave a right-sided subcostal scar.

Laparoscopic surgery


Laparoscopic
Laparoscopic surgery
Laparoscopic surgery, also called minimally invasive surgery , bandaid surgery, or keyhole surgery, is a modern surgical technique in which operations in the abdomen are performed through small incisions as opposed to the larger incisions needed in laparotomy.Keyhole surgery makes use of images...

 cholecystectomy has now replaced open cholecystectomy as the first-choice of treatment for gallstone
Gallstone
A gallstone is a crystalline concretion formed within the gallbladder by accretion of bile components. These calculi are formed in the gallbladder, but may pass distally into other parts of the biliary tract such as the cystic duct, common bile duct, pancreatic duct, or the ampulla of...

s and inflammation of the gallbladder unless there are contraindications to the laparoscopic approach. This is because open surgery leaves the patient more prone to infection. Sometimes, a laparoscopic cholecystectomy will be converted to an open cholecystectomy for technical reasons or safety.

Laparoscopic cholecystectomy requires several small incisions in the abdomen to allow the insertion of operating ports, small cylindrical tubes approximately 5 to 10 mm in diameter, through which surgical instruments and a video camera are placed into the abdominal cavity
Abdominal cavity
The abdominal cavity is the body cavity of the human body that holds the bulk of the viscera. It is located below the thoracic cavity, and above the pelvic cavity. Its dome-shaped roof is the thoracic diaphragm , and its oblique floor is the pelvic inlet...

. The camera illuminates the surgical field and sends a magnified image from inside the body to a video monitor, giving the surgeon a close-up view of the organs and tissues. The surgeon watches the monitor and performs the operation by manipulating the surgical instruments through the operating ports.

To begin the operation, the patient is placed in the supine position
Supine position
The supine position is a position of the body: lying down with the face up, as opposed to the prone position, which is face down, sometimes with the hands behind the head or neck. When used in surgical procedures, it allows access to the peritoneal, thoracic and pericardial regions; as well as the...

 on the operating table and anesthetized. A scalpel
Scalpel
A scalpel, or lancet, is a small and extremely sharp bladed instrument used for surgery, anatomical dissection, and various arts and crafts . Scalpels may be single-use disposable or re-usable. Re-usable scalpels can have attached, resharpenable blades or, more commonly, non-attached, replaceable...

 is used to make a small incision at the umbilicus
Navel
The navel is a scar on the abdomen caused when the umbilical cord is removed from a newborn baby...

. Using either a Veress needle
Veress needle
A Veress needle is a spring-loaded needle used to create pneumoperitoneum for laparoscopic surgery. Of the three general approaches to laparoscopic access, the Veress needle technique is the oldest and most traditional.-History:...

 or Hasson technique the abdominal cavity is entered. The surgeon inflates the abdominal cavity with carbon dioxide
Carbon dioxide
Carbon dioxide is a naturally occurring chemical compound composed of two oxygen atoms covalently bonded to a single carbon atom...

 to create a working space. The camera is placed through the umbilical port and the abdominal cavity is inspected. Additional ports are opened inferior to the ribs at the epigastric, midclavicular
Midclavicular line
A midclavicular line is a vertical line crossing through the left or right clavicle.-Clinical significance:It is useful for evaluating hepatomegaly and identifying heart sounds, as well as finding the gallbladder...

, and anterior axillary
Anterior axillary line
The anterior axillary line is a coronal line on the anterior torso marked by the anterior axillary fold.-External links:* http://www.meddean.luc.edu/Lumen/MedEd/MEDICINE/PULMONAR/apd/lines.htm...

 positions. The gallbladder fundus is identified, grasped, and retracted superiorly. With a second grasper, the gallbladder infundibulum is retracted laterally to expose and open Calot's Triangle (the area bound by the cystic artery
Cystic artery
-Most common arrangement:In the classic arrangement, occurring with a frequency of approximately 70%, a singular cystic artery originates from the geniculate flexure of the right hepatic artery in the upper portion of the hepatobiliary triangle...

, cystic duct
Cystic duct
The cystic duct is the short duct that joins the gall bladder to the common bile duct. It usually lies next to the cystic artery. It is of variable length...

, and common hepatic duct
Common hepatic duct
The common hepatic duct is the duct formed by the convergence of the right hepatic duct and the left hepatic duct . The common hepatic duct then joins the cystic duct coming from the gallbladder to form the common bile duct...

). The triangle is gently dissected to clear the peritoneal covering and obtain a view of the underlying structures. The cystic duct
Cystic duct
The cystic duct is the short duct that joins the gall bladder to the common bile duct. It usually lies next to the cystic artery. It is of variable length...

 and the cystic artery
Cystic artery
-Most common arrangement:In the classic arrangement, occurring with a frequency of approximately 70%, a singular cystic artery originates from the geniculate flexure of the right hepatic artery in the upper portion of the hepatobiliary triangle...

 are identified, clipped with tiny titanium clips and cut. Then the gallbladder is dissected away from the liver bed and removed through one of the ports. This type of surgery requires meticulous surgical skill, but in straightforward cases can be done in about an hour.

Recently, this procedure is performed through a single incision in the patient's umbilicus. This advanced technique is called Laparoendoscopic Single Site Surgery or "LESS".

Procedural risks and complications


Laparoscopic
Laparoscopic surgery
Laparoscopic surgery, also called minimally invasive surgery , bandaid surgery, or keyhole surgery, is a modern surgical technique in which operations in the abdomen are performed through small incisions as opposed to the larger incisions needed in laparotomy.Keyhole surgery makes use of images...

 cholecystectomy does not require the abdominal muscle
Muscle
Muscle is a contractile tissue of animals and is derived from the mesodermal layer of embryonic germ cells. Muscle cells contain contractile filaments that move past each other and change the size of the cell. They are classified as skeletal, cardiac, or smooth muscles. Their function is to...

s to be cut, resulting in less pain, quicker healing, improved cosmetic results, and fewer complications such as infection
Infection
An infection is the colonization of a host organism by parasite species. Infecting parasites seek to use the host's resources to reproduce, often resulting in disease...

 and adhesions
Adhesion (medicine)
Adhesions are fibrous bands that form between tissues and organs, often as a result of injury during surgery. They may be thought of as internal scar tissue that connect tissues not normally connected.-Pathophysiology:...

. Most patients can be discharged on the same or following day as the surgery, and can return to any type of occupation in about a week. Furthermore, flexible instruments are being used in laparoscopic surgery by some surgeons. Using the SPIDER surgical system, they can perform the cholestectomy through a single incision through the navel. These patients often recover faster than traditional methods, and have an almost invisible scar.

An uncommon but potentially serious complication is injury to the common bile duct
Common bile duct
The common bile duct is a tube-like anatomic structure in the human gastrointestinal tract. It is formed by the union of the common hepatic duct and the cystic duct . It is later joined by the pancreatic duct to form the ampulla of Vater...

, which connects the gallbladder and liver. An injured bile duct can leak bile
Bile
Bile or gall is a bitter-tasting, dark green to yellowish brown fluid, produced by the liver of most vertebrates, that aids the process of digestion of lipids in the small intestine. In many species, bile is stored in the gallbladder and upon eating is discharged into the duodenum...

 and cause a painful and potentially dangerous infection. Many cases of minor injury to the common bile duct can be managed non-surgically. Major injury to the bile duct, however, is a very serious problem and may require corrective surgery. This surgery should be performed by an experienced biliary surgeon.

Abdominal peritoneal adhesions
Adhesion (medicine)
Adhesions are fibrous bands that form between tissues and organs, often as a result of injury during surgery. They may be thought of as internal scar tissue that connect tissues not normally connected.-Pathophysiology:...

, gangrenous
Gangrene
Gangrene is a serious and potentially life-threatening condition that arises when a considerable mass of body tissue dies . This may occur after an injury or infection, or in people suffering from any chronic health problem affecting blood circulation. The primary cause of gangrene is reduced blood...

 gallbladders, and other problems that obscure vision are discovered during about 5% of laparoscopic
Laparoscopic surgery
Laparoscopic surgery, also called minimally invasive surgery , bandaid surgery, or keyhole surgery, is a modern surgical technique in which operations in the abdomen are performed through small incisions as opposed to the larger incisions needed in laparotomy.Keyhole surgery makes use of images...

 surgeries, forcing surgeons to switch to the standard cholecystectomy for safe removal of the gallbladder. Adhesions and gangrene, of course, can be quite serious, but converting to open surgery does not equate to a complication.

A Consensus Development Conference panel, convened by the National Institutes of Health
National Institutes of Health
The National Institutes of Health are an agency of the United States Department of Health and Human Services and are the primary agency of the United States government responsible for biomedical and health-related research. Its science and engineering counterpart is the National Science Foundation...

 in September 1992, endorsed laparoscopic cholecystectomy as a safe and effective surgical treatment for gallbladder removal, equal in efficacy to the traditional open surgery. The panel noted, however, that laparoscopic cholecystectomy should be performed only by experienced surgeons and only on patients who have symptoms of gallstones.

In addition, the panel noted that the outcome of laparoscopic cholecystectomy is greatly influenced by the training, experience, skill, and judgment of the surgeon performing the procedure. Therefore, the panel recommended that strict guidelines be developed for training and granting credentials in laparoscopic surgery, determining competence, and monitoring quality. According to the panel, efforts should continue toward developing a noninvasive approach to gallstone treatment that will not only eliminate existing stones, but also prevent their formation or recurrence.

One common complication of cholecystectomy is inadvertent injury to analogous bile ducts known as Ducts of Luschka
Ducts of Luschka
An accessory bile duct is a conduit that transports bile and is considered to be supernumerary or auxiliary to the biliary tree.It may be described by its location relative to the gallbladder as supravescicular or subvesicular .-Duct of Luschka:In the surgical literature, the term duct of Luschka...

, occurring in 33% of the population. It is non-problematic until the gall bladder is removed, and the tiny supravesicular ducts may be incompletely cauterized or remain unobserved, leading to biliary leak post-operatively. The patient will develop biliary peritonitis within 5 to 7 days following surgery, and will require a temporary biliary stent. It is important that the clinician recognize the possibility of bile peritonitis early and confirm diagnosis via HIDA scan to lower morbidity rate. Aggressive pain management and antibiotic therapy should be initiated as soon as diagnosed.

Biopsy


After removal, the gallbladder should be sent for pathological examination to confirm the diagnosis and look for an incidental cancer. If cancer is present, a reoperation to remove part of the liver and lymph nodes will be required in most cases.

Long-term prognosis


A minority of the population, from 5% to 40%, develop a condition called postcholecystectomy syndrome
Postcholecystectomy syndrome
Postcholecystectomy syndrome describes the presence of abdominal symptoms after surgical removal of the gallbladder .Symptoms of postcholecystectomy syndrome may include:* Upset stomach, nausea, and vomiting....

, or PCS. Symptoms can include gastrointestinal distress and persistent pain in the upper right abdomen.

As many as twenty percent of patients develop chronic diarrhea. The cause is unclear, but is presumed to involve the disturbance to the bile system. Most cases clear up within weeks, though in rare cases the condition may last for many years. It can be controlled with drugs.

External links