Laparoscopic Cholecystectomy

By David B. Adams

Laparoscopic cholecystectomy, commonly referred to as a lap chole, involves the removal of the gallbladder through a laparoscopic approach. The gallbladder normally stores bile produced in the liver until it is needed for digestion. Unfortunately, the gallbladder often forms gallstones.

Symptoms

Many patients have gallstones which do not cause symptoms and require no surgery. If, however, these stones attempt to pass out of the gallbladder and block the gallbladder outlet, severe upper abdominal pain can develop. This is known as colic.

Common symptoms may include:

• upper abdominal pain, occurring after meals rich in fat
• nausea and vomiting
• pain between the shoulder blades, and beneath the right shoulder
• chills and fever

Symptoms usually last for short periods of time and often occurs after fatty meals which stimulate the gallbladder to contract.

Causes

The formation of gallstones seems to be related to many factors, some of which are:

• body weight — over-weight people have a higher incidence of gallstones
• diet — a diet high in fat and cholesterol, and low in fiber
• gallbladder motility — if the gall bladder is slow to drain
• rapid weight loss — bariatric surgery patients experience higher incidences of gallstones

Acute Cholecystitis

Occasionally, these stones may become lodged within the neck of the gallbladder and result in prolonged episodes of pain associated with infection. This is known as acute cholecystitis and generally requires admission to hospital and cholecystectomy.

Obstructive Jaundice

Another complication of gallstones may be obstructive jaundice. In this situation, the gallstones pass out of the gallbladder and into the bile duct where they block the bile duct exit; that is, the gallstones prevent the flow of bile secretions into the duodenum. Jaundice is first recognized in the eyes, but acute jaundice results in a yellow tinge to the skin. This may result in cholangitis, a progressive form of jaundice and infections. This needs to be treated immediately. Once a person has had one attack of gallstones, they are likely to develop more. It is thus wise to remove the gallbladder between attacks, since surgery is simpler when there is no acute infection or obstruction.

Treatment

In the operating room under general anesthesia, a small needle is inserted into the umbilicus (belly button) to allow inflation of the abdomen with gas. Next, a small hole (port) is created, also in the bellow button, followed by the insertion of a thin scope with a camera at its end to allow visualization within the abdominal cavity. A second port is placed just under the breast bone in the midline of the abdomen, while third and fourth ports are placed in the right side of the abdomen. (These allow for removal of the gallbladder later in the procedure.)

The gallbladder is then freed of any scar tissue which may be present from previous episodes of acute cholecystitis. The cystic duct (the duct that joins the gallbladder to the bile duct) is then identified. Also identified is the cystic artery, a small blood vessel leading to the gallbladder.

A small incision is made either in the gallbladder itself or in the cystic duct to allow insertion of a small tube or catheter. Dye is injected through this catheter to allow visualization of the bile ducts and insure that no stones are present within the bile duct on an x-ray screen. If there are no stones present in the bile duct, the cystic duct is divided after sealing it with metallic clips. The cystic artery is then clipped and divided and the gallbladder is separated from the bed of the liver with a cautery device or laser. The gallbladder is then removed through one of the small incision ports. Finally, the ports are closed.

If a stone is found in the common bile duct, most may also be removed during the laparoscopy. These stones can be flushed through the bile duct and into the bowel where they will pass without further problems. If they are not flushed easily, access to the bile duct can be gained through the cystic duct by dilating it up to a size big enough to allow passage of a small scope known as a choledochoscope. The choledochoscope allows doctors to see within the bile duct and the stones can be grasped with small baskets and removed.

Rarely, if the stones are impacted a small drain is left in place, and the stones are removed later at another procedure called ERCP.

After waking up following a laparoscopic cholecystectomy, patients are usually able to eat right away. Also, patients are usually able to go home that very day or day following. Most patients return to normal activities within one to two weeks of their surgery.

Complications

Laparoscopic cholecystectomy has a complication rate of under two percent. It is a well-documented and frequently-performed procedure. Most patients recover and resume normal activities quickly. Rarely does the surgery impact adjacent organs in the body. When this occurs, a second procedure may be required.