PROCEDURE OF THE DAY
Cholecystectomy (pronounced /ˌkɔləsɪsˈtɛktəmi/, plural: cholecystectomies) is the surgical removal of the gallbladder. Despite the development of non-surgical techniques, it is the most common method for treating symptomatic gallstones, although there are other indications for the procedure, including carcinoma. Each year more than 500,000 Americans have gallbladder surgery. Surgery options include the standard procedure, called laparoscopic cholecystectomy, and an older more invasive procedure, called open cholecystectomy. A cholecystectomy is performed when attempts to treat gallstones with ultrasound to shatter the stones (lithotripsy) or medications to dissolve them have not proved feasible.
Traditional open cholecystectomy is a major abdominal surgery in which the surgeon removes the gallbladder through a 10 to 18 cm (4- to 7-inch) incision. Patients usually remain in the hospital overnight and may require several additional weeks to recover at home. It takes a minimum of 7 to 15 days to complete the treatment.
Laparoscopic cholecystectomy has now replaced open cholecystectomy as the first-choice of treatment for gallstones unless there are contraindications to the laparoscopic approach. Sometimes, a laparoscopic cholecystectomy will be converted to an open cholecystectomy for technical reasons or safety.
A US Navy general surgeon and an operating room nurse discuss proper procedures while performing a laparoscopic cholecystectomy surgery.
Laparoscopic cholecystectomy requires several small incisions in the abdomen to allow the insertion of surgical instruments and a small video camera. After the initial incisions, the surgeon will inflate the abdominal cavity with carbon dioxide. The camera 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 separate small incisions. The gallbladder is identified and carefully Calot's Triangle (the area bound by the liver, cystic duct, and common hepatic duct) is cleared. The cystic duct and the cystic artery are identified, clipped with tiny titanium clips and cut.Then the gallbladder is separated from the liver bed and removed through one of the small incisions. 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 belly-button. This advanced technique is called Single Incision laparoscopic Surgery or "SILS".
Risks and Complications
Laparoscopic cholecystectomy does not require the abdominal muscles to be cut, resulting in less pain, quicker healing, improved cosmetic results, and fewer complications such as infection and adhesions. Most patients can be discharged on the same or following day as the surgery, and most patients can return to any type of occupation in about a week.
A significant proportion of the population, between 5-40%, develop a condition called postcholecystectomy syndrome, or PCS. Symptoms include gastrointestinal distress and persistent pain in the upper right abdomen.
As many as twenty percent of patients develop chronic diarrhea, which may last for many years, but often improves over time.
An uncommon but potentially serious complication is injury to the common bile duct, which connects the gallbladder and liver. An injured bile duct can leak bile 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, gangrenous gallbladders, and other problems that obscure vision are discovered during about 5% of laparoscopic 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 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 an anomalous bile duct known as Ducts 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.
After removal of a gallbladder, fat metabolism can be inhibited and bile salts should be taken. After the gallbladder is removed, bile is still produced by the liver, but is released in a continuous, slow trickle into the intestine. Thus, when eating a meal that is high in fat content, there may not be an adequate amount of bile in the intestine to properly handle the normal absorption process.
The change in intestinal bile concentration during high-fat intake may cause diarrhea or bloating, because excess fat in the intestine will draw more water into the intestine, and because bacteria then digests the fat which produces gas.
The treatment for digestive problems after removal will follow the reason for the problem. Once a gallbladder is removed it is important to be on bile acid supplements. They need to be taken with every meal in which fat is consumed otherwise your fats will not be properly emulsified and absorbed.
After removal, the gall bladder should be sent for biopsy (pathological examination) to look for an incidental cancer - if it is found, a reoperation to remove part of liver and lymph nodes will be required in most cases - this should be done as soon as possible.
A difficult lap cholecystectomy, performed in a patient with intraabdominal adhesions.