Laparoscopic 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 25-30% of biliary injuries are identified during the operation; the rest become apparent in the early post-operative period.

Cholangiography performed during surgery increases the likelihood of intraoperative detection of bile duct injuries.

Common bile duct injuries relative infrequent during cholecystectomy:1:200-1:400.

Repair of common bile duct injuries is complex and may require muliple surgical procedures.

Nearly a 3 fold increased risk of death among individuals that experience common bile duct injuries compared to those without such injury.

It is safe to do elective procedures as same-day surgery.

Optimal outcomes and costs associated with performance of the procedure within 2 days of acute cholecystitis (Zafar SN et al).

Traditionally performed with two 10 mm and two 5 mm trocars.

Use of minilaproscopic surgery with 2 mm instruments has no significant advantages and perhaps the disadvantage of longer operative time and need to convert the procedure to use conventional sized instruments.

Preliminary results of a large trial have shown that single-incision laparoscopic cholecystectomy (SILC) is safe, and, although it requires more operating time, cosmetic satisfaction was higher among patients who had SILC compared to those who underwent traditional (4-port) laparoscopic surgery.

At least 10% of patients undergoing cholecystectomy have pain afterwards.

Of patients who have pain postoperatively a few have a biliary cause such as a ductal stone, and some have other gastrointestinal pathology or functional bowel disease, but most have no significant abnormalities on imaging the laboratory testing.

Bile duct injury occurs more frequently during a laparoscopic cholecystectomy than during open cholecystectomy.

Rates of complications other than bile duct injury after laparoscopic cholecystectomy:

 

Wound infection 1.25%

 

 

Urinary retention 0.90%

 

 

Bleeding 0.79%

 

 

Retained stone in the common bile duct 0.50%

 

 

Respiratory 0.48%

 

 

Cardiac 0.36%

 

 

Intra-abdominal abscess 0.34%

 

 

Hernia 0.21%

 

Bowel injury, sepsis, pancreatitis, and deep vein thrombosis/pulmonary embolism to be around 0.15% each.

 

Leakage from the stump of the cystic duct is a complication is more common with the laparoscopic approach than the open approach but is still 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.

In the presence of inflammation, dissection may be technically more difficult and can distort local anatomy increasing the risk of bile duct injury.

If dissection is difficult a low threshold to conversion to open cholecystectomy should be present and avoiding dissection when there is poorly defined anatomy, and the surgeon should be willing to abandon total cholecystectomy in favor of subtotal cholecystectomy or cholecystostomy to prevent bile duct injury.

To limit surgical trauma to the abdominal wall, presently there is use of smaller and fewer laparoscopic ports.

Single incision laparoscopic procedures and minilaparoscopic cholecystectomy are more challenging to perform and prolong operating time and increased costs, as does robotic assisted laparoscopic cholecystectomy.

Postoperative complications after laparoscopic cholecystectomy is reported in about 6% of patients.

The most common complications are abdominal wall or intra-abdominal wall bleeding at 1.8%, and superficial wound infection at 1%.

Extrahepatic bile duct injury occurs in 0.4%.