CHAPTER 12 Laparoscopic Cholecystectomy
Case Study
A right upper quadrant ultrasound is obtained, which shows gallstones and gallbladder wall thickening (Fig. 12-1). The common bile duct (CBD) is visualized and is of normal caliber.
INDICATIONS FOR CHOLECYSTECTOMY
I. Biliary colic (pain associated with transient obstruction of the cystic duct) is the most common indication for cholecystectomy. Episodes of biliary colic typically persist for 1 or more hours and may last as long as 24 hours. These episodes are characteristically precipitated by ingestion of fatty meals, although this is not always the case. Patients with symptomatic cholelithiasis are believed to be at higher risk for gallstone-related complications than are patients without symptoms. In addition to bringing about the resolution of symptoms, cholecystectomy in these patients serves to prevent the potential complications that comprise the other indications for this operation. Cholecystectomy is performed electively in patients with biliary colic, although severe or frequent symptoms may necessitate prompt intervention.
II. Acute Calculous Cholecystitis: More than 90% of cases of acute cholecystitis are related to gallstones. Persistent cystic duct obstruction leads to gallbladder distention and inflammation. Gallbladder ischemia and necrosis represent an endpoint of this process in severe cases. Patients typically present with persistent right upper quadrant pain, with or without nausea and vomiting. Murphy’s sign, which is positive when a patient halts inspiration when the right upper quadrant of the abdomen is palpated, is characteristic. In rare instances, cholecystitis may present with systemic signs of sepsis. Cholecystectomy is the first-line treatment for acute cholecystitis and should be performed promptly after the diagnosis is confirmed. In selected cases, such as in the unstable or high-risk patient, cholecystostomy (drainage of the gallbladder) may be used as a temporizing measure. This procedure is commonly performed by interventional radiologists under fluoroscopic guidance, thus avoiding some of the risks associated with general anesthesia and conventional surgical management.
III. Choledocholithiasis: The preoperative evaluation of patients with calculous gallbladder disease should identify patients at risk for CBD stones. Signs and symptoms of choledocholithiasis may include jaundice, light-colored stools, dark-colored urine, elevated liver function test, and a dilated CBD on ultrasound (US) (>5 mm). Options for the evaluation and management of suspected choledocholithiasis include endoscopic retrograde cholangiopancreatography (ERCP), magnetic resonance cholangiopancreatography (MRCP), and intraoperative cholangiography at the time of cholecystectomy. Patients with choledocholithiasis may also present with cholangitis, a bacterial infection of the biliary ducts. The signs and symptoms of cholangitis include Charcot’s triad (fever, jaundice, and abdominal pain) and Reynold’s pentad (fever, jaundice, abdominal pain, hypotension, and mental status changes). The primary management of cholangitis is nonsurgical. Most cases resolve with antibiotics and supportive care. Gallstone-associated cholangitis that does not resolve after the initiation of medical management warrants endoscopic or percutaneous cholangiography, with biliary drainage and stone clearance, if possible. In rare circumstances, CBD exploration and T-tube (drain) placement may be lifesaving when other options are not feasible or have been unsuccessful.
IV. Gallstone Pancreatitis: Gallstones are responsible for the majority of cases of acute pancreatitis. Obstruction of the pancreatic duct by a CBD stone may resolve spontaneously after the passage of the stone into the duodenum. Worsening pancreatitis, however, sometimes reflects impaction of a common duct stone and persistent pancreatic duct obstruction. ERCP with stone extraction and sphincterotomy is the diagnostic and treatment modality of choice in patients with suspected gallstone pancreatitis, particularly when clinical indicators, including elevated levels of pancreatic enzymes, do not improve. Cholecystectomy should be performed after resolution of the symptoms of pancreatitis and normalization of pancreatic enzyme levels, but before hospital discharge. This recommendation is predicated on a high reported incidence of recurrent pancreatitis during the initial months after a first attack of gallstone pancreatitis.
V. Biliary dyskinesia resembles biliary colic in symptoms. The diagnosis is made when gallbladder imaging (US, CT scan) does not show gallstones. Cholescintigraphy (HIDA) demonstrating a decreased gallbladder ejection fraction confirms the diagnosis. Between 85% and 95% of patients with a low gallbladder ejection fraction and characteristic symptoms report improvement after cholecystectomy.
VI. Acute acalculous cholecystitis clinically resembles acute calculous cholecystitis. The pathogenesis of cholecystitis in the absence of stone disease is poorly understood, but acalculous cholecystitis most often afflicts the critically ill. Cholecystectomy is curative. Cholecystotomy, however, is frequently an appropriate management strategy in these patients, given their frequent high degree of acuity and the efficacy and potentially definitive nature of simple drainage of the gallbladder in the absence of gallstones.
VII. Gallstone ileus is a mechanical obstruction of the gastrointestinal tract. It is caused by the passage of a large-diameter gallstone through a spontaneous biliary–enteric fistula (most often between the gallbladder and the duodenum). Gallstone ileus most commonly affects elderly patients and mandates a laparotomy to relieve the bowel obstruction (usually with enterolithotomy). Cholecystectomy and biliary–enteric fistula take-down may be performed at the time of laparotomy or, if inflammation precludes safe dissection during the initial operation or the patient is unstable, at a subsequent time.
VIII. Gallbladder cancer is an aggressive malignancy that largely afflicts the elderly and is more common in women than in men. Unfortunately, most patients with gallbladder cancer have unresectable disease at the time of presentation, and the estimated 5-year survival rate among all patients with this malignancy is less than 15%. In the setting of suspected carcinoma of the gallbladder, open abdominal exploration should be undertaken. This approach facilitates an evaluation for metastatic disease and facilitates radical cholecystectomy (en bloc resection of the gallbladder and adjacent liver as well as regional lymphadenectomy), in the event that no metastases are identified. Importantly, suspicion of gallbladder cancer during laparoscopic cholecystectomy should prompt conversion to an open operation.
PREOPERATIVE EVALUATION
In addition to a review of standard preoperative studies, reassessment of all studies obtained in evaluating a patient with gallbladder pathology is essential because laboratory data and study results significantly influence management (Fig. 12-2). Of particular importance are:
I. Liver function tests (LFTs), which include alanine aminotransferase, aspartate aminotransferase, bilirubin, alkaline phosphatase, and pancreatic enzymes (amylase and lipase), are essential to the evaluation of biliary pathology. Elevation of LFTs, particularly serum bilirubin, are predictive of CBD stones. Decisions to obtain a preoperative MRCP or ERCP or to perform an intraoperative cholangiogram at the time of cholecystectomy are sometimes predicated on these values. Elevated pancreatic enzymes are indicative of pancreatitis. These levels should be allowed to normalize before cholecystectomy, and interrogation of the CBD, whether by MRCP, ERCP, or intraoperative cholangiogram, is performed in conjunction with cholecystectomy after gallstone pancreatitis.
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