c

c



   

 

  

c     

 

! ! 
" 


"#  



"
$%&'%'()'

'%*+%*$'$'',($' 




"
- -

"# 
" 



.
c
 /" "
"  
"  "  0 # 
"

##

1"
 
 
# "  
" -.
1 
2 1   
1" 

-




" 



Is the surgical removal of the gallbladder. It is the most common method for treating
symptomatic gallstones. Surgical options include the standard procedure,
calledlaparoscopic cholecystectomy, and an older more invasive procedure,
called opencholecystectomy. 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. A traditional open cholecystectomy is a
major abdominal surgery in which the surgeon removes the gallbladder through a 10-18
cm (4-7 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 although in some cases, the patient can take as long as 30 days
to fully complete treatment. Laparoscopic cholecystectomy has now replaced open
cholecystectomy as the first-choice of treatment for gallstones and inflammation of the
gallbladder unless there are contraindications to the laparoscopic approach.
Sometimes, a laparoscopiccholecystectomy 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 5-10 mm in diameter, through which surgical
instruments and a video camera are placed into the abdominal cavity. 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 anesthetized and placed in the supine position on
the operating table. A scalpel is used to make a small incision at the umbilicus. Using
either a Veress needle or Hasson technique the abdominal cavity is entered. The
surgeon inflates the abdominal cavity with carbon dioxide to create a working space.
The camera is placed through the umbilical port and the abdominal cavity is inspected.
Additional ports are placed inferior to the ribs at the epigastric, midclavicular,
and anterior axillary 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
duct, and common hepatic duct). The triangle is gently dissected to clear the peritoneal
covering and obtain a view of the underlying structures. The cystic duct and the cystic
artery 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 Single Incision laparoscopic Surgery.

c
 
 




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.

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% oflaparoscopic 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 laparoscopiccholecystectomy 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.