Cholecystectomy

Cholecystectomy is the surgical removal of the gallbladder. 

 

 

It is a common treatment of symptomatic ((gallstones)) and other gallbladder conditions.

 

 

Nearly 800,000 per year in the U.S. 

In the surgery, the gallbladder is removed from the neck to the fundus, and so bile will drain directly from the liver into the biliary tree. 

Up to 10% of people may continue to experience similar symptoms after cholecystectomy, a condition called postcholecystectomy syndrome.

Post cholecystectomy pain evaluation reveals that most have no significant abnormalities on imaging or laboratory testing and the cause remains obscure: a few have biliary causes such as ductal stones and some are diagnosed with our other abdominal pathology or functional bowel disease.

Many patients with post cholecystectomy pain undergo endoscopic retrograde cholangiopancreatography (ERCP) in the hopes of finding small stones or other pathology, or attempt to address the possibility of sphincter of Oddi dysfunction.

Complications of cholecystectomy: bile duct injury, wound infection, bleeding, retained gallstones, abscess formation and stenosis of the bile duct.

 

Gallstones are the most common reasons for removal of the gallbladder.

 

Biliary dyskinesia or gallbladder cancer are other reasons for a cholecystectomy.

 

Gallstones are asymptomatic in 80% of people and do not need surgery.

 

Of the more than 20 million people in the US with gallstones, only about 30% will eventually require cholecystectomy to relieve symptoms or treat complications.

 

Biliary colic, or pain is caused by gallstones, as a result of a temporarily blockage of the bile duct

 

Biliary colic pain is usually in the right upper part of the abdomen, of moderate to severe degree, and dissipates on its own after a few hours when the stone dislodges.

 

Biliary colic usually occurs following  meals when the gallbladder contracts to push bile out into the digestive tract. 

 

Following a first attack of biliary colic, more than 90% of people will have a repeat attack in the next 10 years.

 

It is the repeated attacks of biliary colic that lead to about 300,000 cholecystectomies in the US each year.

 

Acute cholecystitis, the inflammation of the gallbladder,  caused by interruption in the normal flow of bile, is another reason for cholecystectomy.

 

Acute cholecystitis is the most common complication of gallstones, as 90-95% of acute cholecystitis is caused by gallstones blocking drainage of the gallbladder.

 

An incomplete blockage by a stone of the bile duct that  passes quickly, results in biliary colic. 

 

If the gallbladder remains completely blocked for a prolonged period, the person develops acute cholecystitis.

 

Acute cholecystitis pain is similar to that of biliary colic, but lasts longer than six hours and occurs together with signs of infection such as fever, chills, or an elevated white blood cell count.

 

With cholecystitis there is usually have a positive Murphy sign on physical exam.

 

Five to ten percent of patients with acute cholecystitis do not have gallstones: acalculous cholecystitis. 

 

Acalculous cholecystitis is usually seen in people who have abnormal bile drainage secondary to a serious illness: multi-organ failure, serious trauma, recent major surgery, or following a long stay in the intensive care unit.

 

With repeat episodes of acute cholecystitis, chronic cholecystitis  can develop,and can be an indication for cholecystectomy.

 

Cholangitis and gallstone pancreatitis are more serious complications from gallstone disease, but uncommon.

 

Cholangitis and gallstone pancreatitis occur if gallstones leave the gallbladder, pass through the cystic duct, and get stuck in the common bile duct. 

 

The common bile duct drains the liver and pancreas, and a blockage at that site can lead to inflammation and infection in both the pancreas and biliary system. 

 

Cholecystectomy is often recommended to prevent repeat episodes from additional gallstones getting stuck.

 

Gallbladder carcinoma is a rare indication for cholecystectomy. \

 

For a living donor liver transplantation between adults, a cholecystectomy is performed in the donor because gallbladder interferes with removal of the right lobe of the liver and to prevent the formation of gallstones in the recipient.

 

The gallbladder is not removed in pediatric transplantations as the left lobe of the liver is used instead.

 

Cholecysteomy is considered a low risk surgical procedure. 

 

No specific contraindications exist for cholecystectomy.

 

Anesthesia risk as assessed by the ASA physical status classification of categories III, IV, and V are high risk categories for cholecystectomy.

 

Cholecystectomy risks include: damage to adjacent structures, hemorrhage, infection, and rarely death: death rate from cholecystectomy is about 0.1% in people under age 50 and about 0.5% in people over age 50.

 

Risk of death for cholecystectomy relates to co-existing illnesses.

 

Biliary injury, or damage to the bile ducts are serious complications of cholecystectomy

 

((Laparoscopic cholecystectomy)) has a higher risk of bile duct injury than the open approach, with injury to bile ducts occurring in 0.3% to 0.5% of laparoscopic cases and 0.1% to 0.2% of open cases.

 

In laparoscopic cholecystectomy, approximately only 25-30% of biliary injuries are identified during the operation, the rest are apparent in the early post-operative period.

 

When bile ducts are damaged it causes leakage of bile into the abdomen, with signs and symptoms including  abdominal pain, tenderness, fever and signs of sepsis several days following surgery.

 

Bile leakage is associated with rising total bilirubin and alkaline phosphatase.

 

Complications from a bile leak can persist for years and can lead to death. 

 

Most bile injuries require surgical repair, and biliary injuries are properly treated and repaired, more than 90% of patients can have a long-term successful recovery.

Injury of the bile ducts can be prevented and treated by routinely using intraoperative cholangiography.

 

Leakage from the stump of the cystic duct is a complication that is more common with the laparoscopic approach than the open approach but is rare, occurring in less than 1% of procedures.

 

Leakage from the stump of the cystic duct  is treated by drainage followed by insertion of a bile duct stent.

 

If the surgeon has problems identifying anatomical structures laparoscopically , conversion  from laparoscopic to open cholecystectomy may be necessary.

 

Common bile duct stones are found in 10-15% of patients during cholecystectomy when intraoperative cholangiography (IOC) is performed.

 

Laparoscopic cholecystectomy uses several (usually 4) 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 are placed into the abdominal cavity. 

 

The laparoscope, has a  video camera and light source at the end, illuminates the abdominal cavity and sends a magnified image from inside the abdomen to a video screen, giving the surgeon a clear view of the organs and tissues. 

 

The cystic duct and cystic artery are identified and dissected, then ligated with clips and cut in order to remove the gallbladder. 

 

Laparoscopic surgery is the primary type of cholecystectomy performed.

 

With an open cholecystectomy, a surgical incision of around 8 to 12 cm is made below the edge of the right rib cage.

 

The gallbladder is removed through this large opening, typically using electrocautery.

 

Open cholecystectomy is often done if difficulties arise during a laparascopic cholecystecomy.

 

Difficulties include: unusual anatomy, poor visualization of structures, the presence of malignancy, severe cholecystitis, emphysematous gallbladder, fistulization of gallbladder and gallstone ileus, cholangitis, cirrhosis/ portal hypertension, and blood dyscrasias.

 

Incidental cancer  of the gallbladder is found in approximately 1% of cholecystectomies.

 

95% of people undergoing cholecystectomy as treatment for simple biliary colic, removing the gallbladder completely resolves their symptoms.

 

Up to 10% of people who undergo cholecystectomy develop a condition called postcholecystectomy syndrome.

 

Postcholecystectomy syndrome symptoms are typically similar to the pain and discomfort of biliary colic with persistent pain in the upper right abdomen and commonly include gastrointestinal distress.

 

Following cholecystectomy some may develop diarrhea, presumed to be due to disturbances in the biliary system that speed up enterohepatic recycling of bile salts, overwhelming the terminal ileum, the portion of the intestine where these salts are normally reabsorbed, and  developing  diarrhea.

 

Postcholecystectomy syndrome diarrhea in most cases resolves within weeks or a few months, though in rare cases the condition can last for years. 

 

It is generally safe for pregnant women to undergo laparoscopic cholecystectomy during any trimester of pregnancy.

 

Surgery is recommended for women with symptomatic gallstones to decrease the risk of spontaneous abortion and pre-term delivery, because 

acute cholecystitis is the second most common cause of acute abdomen in pregnant women after appendectomy.

 

Porcelain gallbladder is a condition where the gallbladder wall shows calcification on imaging tests.

 

It is not an indication for cholecystectomy.

 

Conservative management for biliary colic involves a watchful approach, by treating symptoms as-needed with oral medications: the preferred treatment for people with gallstones but no symptoms, or mild symptoms.

 

Conservative management for acute cholecystitis involves treating the infection without surgery: It consists of treatment with intravenous antibiotics and fluids.

 

Cholecystostomy refers to the drainage of the gallbladder via insertion of a small tube through the abdominal wall. 

 

Cholecystostomy can be used for people immediate drainage of the gallbladder but have a high risk of complications from surgery under general anaesthesia.

 

With  cholecystostomy draining of pus and infected material through the tube reduces inflammation in and around the gallbladder:  It can be a lifesaving procedure, without emergency surgery.

 

For some people, drainage with cholecystostomy is sufficient and they don’t need subsequent cholecystectomy.

 

For others, percutaneous cholecystostomy allows them to improve enough in the short term that they can get surgery at a later time.

It is not clear that cholecystectomy is best for high-risk surgical patients with acute cholecystitis.