CHOLECYSTECTOMY

Cholecystectomy is the removal of the gall bladder that is among the most popularly performed surgical techniques in the US and every year, almost 1.2 million surgical removals of the gall bladder are performed. The gold standard for cholecystectomy was the open technique before 1991 that included carrying out a cholangiogram intraoperatively. After this procedure, patients usually had to spend two to six days at the hospital. However, by the late 1980s, after the arrival of laparoscopic techniques and surgeries, laparoscopic cholecystectomy has become the gold standard approach (1). With this technique, the overall outcome of elective cholecystectomy increased by thirty percent. In the present times, ninety-two percent of cholecystectomies are performed laparoscopically. However, in less affluent areas, the open technique for cholecystectomy is still common (2).

INDICATIONS

The indications have decreased for performing the open cholecystectomy after the initiation of the laparoscopic technique. Open cholecystectomy in two to ten percent of the cases is performed when there is a need to convert from laparoscopic technique to open technique. There could be several reasons. The indications to change laparoscopic cholecystectomy to open technique includes uncontrolled bleeding, stones stored in the bile duct, injury to the bile duct, anatomical variances, adhesions, extreme inflammation, and exploration of the common bile duct. An open cholecystectomy is planned in case of cancer of the gall bladder, cirrhosis, extensive surgeries of the upper abdomen with adhesions, and the presence of other diseases, especially diabetes mellitus (3,4). The laparoscopic technique of cholecystectomy is indicated for treating biliary dyskinesia, acute and chronic cholecystitis, symptomatic cholelithiasis, gallstone pancreatitis, acalculous cholecystitis, and gall bladder polyps/masses (5).

PROCEDURE STEPS

Open Cholecystectomy: The patient is prepped and anesthetized. An incision is made at the upper midline or right subcostal region (Kocher’s incision). Retractors and packs are used to gain adequate exposure. The surgeon identifies all the porta hepatis structures and grasps the gall bladder with clamps and manipulates it to achieve good visualization. The surgeon then decides whether to remove the gall bladder from the Calot’s triangle or the top-down manner.

While dissection Calot’s triangle, the peritoneum covering the cystic artery and duct is incised posteriorly and anteriorly. The fundus of the gall bladder is grabbed with sponge-holding forceps and it is retracted towards the anterior end of the body. This stretches the cystic duct. Firstly, the cystic duct is identified by the surgeon and divided similarly to the cystic artery between hemoclips. Either using a harmonic scalpel or electrocautery, the gall bladder is detached from the liver bed and removed (6). The surgeon closes the abdomen in the standard fashion of multilayers.

Laparoscopic Cholecystectomy: The procedure begins after administrating anesthesia to the patient and intubation. With carbon dioxide, the abdomen is inflated to 15mmHg. The next step is the placement of the trocar for which small cuts are made. One is made supraumbilical, one subxiphoid, and two are at the right subcostal. With the help of long instruments and a laparoscope having a camera at the end, the gall bladder is withdrawn over the liver. This exposes the hepatocystic triangle. Mindful dissection is executed to gain an evaluative safety view.

This view includes cleaning any fatty and fibrous tissue around the hepatocystic triangle, making sure only two tube-shaped structures enter into the gall bladder’s base, and lastly, visualization of the cystic plate when the gall bladder is separated from the liver from its lower third portion. After accomplishing this view, the isolation of cystic artery and duct is carried out which is then clipped. Both structures are then transected. The gall bladder is detached and then removed from the liver bed either with a harmonic scalpel or electrocautery (7).

COMPLICATIONS

The complication rate of open cholecystectomy is higher than the laparoscopic technique (sixteen percent versus nine percent respectively) (8,9). Since the size of the incision is large than the laparoscopic surgery, a great chance of hematoma, formation of hernia and wound infection with the open technique is present (10). The common complication of laparoscopic cholecystectomy is not limited but includes infections, bleeding, and damage to the near structures. Given the vascular nature of the liver, the prevailing complication is bleeding. Iatrogenic injury to the common hepatic/bile duct is the most serious complication. When these structures are injured, an additional surgery needs to be performed to avert the bile flow into the intestines (11).

References

1. Gallstones and laparoscopic cholecystectomy. NIH Consens Statement. 1992 Sep 14;10(3):1–28.
2. Silverstein A, Costas-Chavarri A, Gakwaya MR, Lule J, Mukhopadhyay S, Meara JG, et al. Laparoscopic Versus Open Cholecystectomy: A Cost-Effectiveness Analysis at Rwanda Military Hospital. World J Surg. 2017 May;41(5):1225–33.
3. Stanisic V, Milicevic M, Kocev N, Stanisic B. A prospective cohort study for prediction of difficult laparoscopic cholecystectomy. Ann Med Surg 2012. 2020 Dec;60:728–33.
4. Quillin RC, Burns JM, Pineda JA, Hanseman D, Rudich SM, Edwards MJ, et al. Laparoscopic cholecystectomy in the cirrhotic patient: predictors of outcome. Surgery. 2013 May;153(5):634–40.
5. Strasberg SM. Tokyo Guidelines for the Diagnosis of Acute Cholecystitis. J Am Coll Surg. 2018 Dec;227(6):624.
6. Parra-Membrives P, Díaz-Gómez D, Vilegas-Portero R, Molina-Linde M, Gómez-Bujedo L, Lacalle-Remigio JR. Appropriate management of common bile duct stones: a RAND Corporation/UCLA Appropriateness Method statistical analysis. Surg Endosc. 2010 May;24(5):1187–94.
7. Wakabayashi G, Iwashita Y, Hibi T, Takada T, Strasberg SM, Asbun HJ, et al. Tokyo Guidelines 2018: surgical management of acute cholecystitis: safe steps in laparoscopic cholecystectomy for acute cholecystitis (with videos). J Hepato-Biliary-Pancreat Sci. 2018;25(1):73–86.
8. Antoniou SA, Antoniou GA, Koch OO, Pointner R, Granderath FA. Meta-analysis of laparoscopic vs open cholecystectomy in elderly patients. World J Gastroenterol. 2014 Dec 14;20(46):17626–34.
9. Coccolini F, Catena F, Pisano M, Gheza F, Fagiuoli S, Di Saverio S, et al. Open versus laparoscopic cholecystectomy in acute cholecystitis. Systematic review and meta-analysis. Int J Surg Lond Engl. 2015 Jun;18:196–204.
10. Kuga D, Ebata T, Yokoyama Y, Igami T, Sugawara G, Mizuno T, et al. Long-term survival after multidisciplinary therapy for residual gallbladder cancer with peritoneal dissemination: a case report. Surg Case Rep. 2017 Dec;3(1):76.
11. Schreuder AM, Busch OR, Besselink MG, Ignatavicius P, Gulbinas A, Barauskas G, et al. Long-Term Impact of Iatrogenic Bile Duct Injury. Dig Surg. 2020;37(1):10–21.