Overview
Definition:
Laparoscopic cholecystectomy is the surgical removal of the gallbladder using minimally invasive techniques, employing a laparoscope and specialized instruments inserted through small abdominal incisions.
Epidemiology:
Gallbladder disease, particularly cholelithiasis, is highly prevalent, affecting approximately 10-20% of the adult population globally
Women, individuals over 40, those with obesity, and certain ethnicities have higher risks
It is the most common indication for abdominal surgery in many regions.
Clinical Significance:
Laparoscopic cholecystectomy is the gold standard treatment for symptomatic gallstones and acute cholecystitis, significantly reducing postoperative pain, hospital stay, and recovery time compared to open surgery
Understanding its nuances is crucial for surgical trainees preparing for DNB and NEET SS examinations.
Indications
Symptomatic Cholelithiasis:
Recurrent biliary colic, confirmed by characteristic pain and ultrasonographic evidence of gallstones.
Acute Cholecystitis:
Inflammation of the gallbladder, typically due to cystic duct obstruction by gallstones, presenting with persistent pain, fever, and leukocytosis.
Biliary Dyskinesia:
Functional gallbladder disorder characterized by abnormal gallbladder contraction and impaired bile emptying, diagnosed by HIDA scan with low ejection fraction.
Gallbladder Polyps:
Polyps larger than 1 cm or rapidly growing polyps, considered precancerous, warrant cholecystectomy.
Acute Cholangitis And Pancreatitis:
As a source of recurrent episodes or in specific clinical scenarios, after initial management of the acute event.
Preoperative Preparation
Patient Assessment:
Detailed history, physical examination, and baseline investigations including CBC, LFTs, renal function tests, and coagulation profile.
Imaging:
Abdominal ultrasonography is the primary modality for diagnosing gallstones and assessing gallbladder wall thickening
CT scan or MRI may be used for complex cases or suspected complications.
Anesthesia Consultation:
Assessment of fitness for general anesthesia, discussion of risks and benefits, and obtaining informed consent.
Bowel Preparation:
Usually not required for elective laparoscopic cholecystectomy, but discussed with the anesthesiologist.
Antibiotic Prophylaxis:
Administered intravenously 30-60 minutes before incision, typically a first-generation cephalosporin like Cefazolin, or alternatives for penicillin-allergic patients.
Procedure Steps
Patient Positioning And Insufflation:
Supine position, Foley catheter inserted
Abdomen is insufflated with carbon dioxide to create a pneumoperitoneum (typically 12-15 mmHg).
Trocar Placement:
Standard four-port technique: Umbilical port for camera, epigastric port for dissection, and two right subcostal ports for retraction and grasping
Variations exist based on surgeon preference and anatomy.
Identification Of Structures:
Careful dissection to identify the cystic duct and cystic artery
Crucially, the common hepatic duct and common bile duct must be clearly delineated before any clipping or division.
Cystic Duct And Artery Ligation:
The cystic duct and artery are ligated securely using clips or sutures after clear identification
Division follows ligation.
Gallbladder Dissection And Removal:
The gallbladder is dissected from the liver bed using electrocautery or ultrasonic dissector
It is then placed in an EndoCatch bag and removed through one of the larger ports.
Inspection And Drainage:
Inspection of the gallbladder bed for bleeding and bile leaks
A drain may be placed if there is significant inflammation or concern for bile leakage, though not routinely used.
Postoperative Care
Pain Management:
Adequate analgesia, often multimodal, including IV or oral NSAIDs and paracetamol
Opioids may be used for breakthrough pain
Early ambulation is encouraged.
Nausea And Vomiting:
Anti-emetics are administered as needed
Clear liquids are typically offered within a few hours post-op, advancing to a regular diet as tolerated.
Monitoring:
Vital signs, urine output, incisional sites for signs of infection or bleeding
Monitoring for symptoms of bile leak or retained stones.
Discharge Criteria:
Patient tolerating oral intake, minimal pain, able to ambulate, and voiding
Typically discharged on the same day or the next day.
Dietary Advice:
Gradual return to normal diet
Some patients may experience temporary bloating or diarrhea, which usually resolves
A low-fat diet may be recommended initially.
Complications
Early Complications:
Bleeding from cystic artery or liver bed
Bile leak from cystic duct stump or liver bed
Injury to common bile duct (CBD) or hepatic ducts
Bowel or vascular injury during trocar insertion
Postoperative nausea and vomiting.
Late Complications:
Retained CBD stones
Biliary strictures
Post-cholecystectomy syndrome (abdominal pain, bloating, diarrhea)
Incisional hernia at port sites
Adhesions.
Prevention Strategies:
Meticulous dissection and clear identification of the critical structures (cystic duct and artery) before clipping/division
Use of intraoperative cholangiography when indicated
Careful port site closure
Prompt recognition and management of any suspected complications.
Key Points
Exam Focus:
The critical view of safety (CVS) is paramount: identifying only the cystic duct and cystic artery entering the gallbladder before clipping
Common bile duct injury is a dreaded complication
Indications for intraoperative cholangiography.
Clinical Pearls:
In cases of severe inflammation or unclear anatomy, conversion to open cholecystectomy is a safe option and should not be delayed
Morcellation of stones within the gallbladder can be done if the gallbladder is too large to extract through the port
Gallbladder mucocele can mimic acute cholecystitis.
Common Mistakes:
Mistaking the common hepatic duct for the cystic duct
Inadequate visualization leading to clipping or division of incorrect structures
Prematurely dividing structures without clear identification
Delaying conversion to open surgery in difficult cases.