Section 5 Gastrointestinal Tract and Abdomen
21 Cholecystectomy and Common Bile Duct ExplorationPreoperative evaluation, operative planning, operative technique, complications, and special problems for laparoscopic cholecystectomy are discussed, and operative technique for open cholecystectomy is described.
Foreseeing Technical Challenges in Laparoscopic CholecystectomyBefore performing laparoscopic cholecystectomy, the surgeon can predict which patients are likely to be technically challenging. These include patients who have a particularly unsuitable body habitus, those who are highly likely to have multiple and dense peritoneal adhesions, and those who are likely to have distorted anatomy in the region of the gallbladder.
Morbidly obese patients present specific difficulties. Small, muscular patients have a noncompliant abdominal wall, resulting in a small working space in the abdomen and necessitating high inflation pressures to obtain reasonable exposure.
Patients with a history of multiple abdominal operations, especially in the upper abdomen, and those who have a history of peritonitis are likely to pose difficulties because of peritoneal adhesions. These adhesions make access to the abdomen more risky and exposure of the gallbladder more difficult.
Patients who have undergone gastroduodenal surgery, those who have any history of acute cholecystitis, those who have a long history of recurrent gallbladder attacks, and those who have recently had severe pancreatitis are particularly difficult candidates for laparoscopic cholecystectomy. These patients may have dense adhesions in the region of the gallbladder, the anatomy may be distorted, the cystic duct may be foreshortened, and the common bile duct may be very closely and densely adherent to the gallbladder. Such patients are a challenge to the most experienced laparoscopic surgeon. When such problems are encountered, conversion to open cholecystectomy should be considered early in the operation.
Few Contraindications to Laparoscopic CholecystectomyThere are few absolute contraindications to laparoscopic cholecystectomy. Certainly, no patient who poses an unacceptable risk for open cholecystectomy should be considered for laparoscopic cholecystectomy, because it is always possible that conversion will become necessary. Of the relative contraindications, surgical inexperience is the most important.
Patients with cirrhosis or portal hypertension are at high risk for morbidity and mortality with open cholecystectomy. If absolutely necessary, laparoscopic cholecystectomy may be attempted by an experienced surgeon. The risk of bleeding can be minimized by rigorous preoperative preparation, meticulous dissection with the help of magnification available through the laparoscope, and use of the electrocautery.
Patients with bleeding diatheses, such as hemophilia, von Willebrand disease, and thrombocytopenia, may undergo laparoscopic cholecystectomy. They require appropriate preoperative and postoperative care and monitoring, and a hematologist should be consulted.
Patients in whom preoperative imaging gives rise to a strong suspicion of gallbladder cancer should probably undergo open surgical management.
Ascites and hernia?
Neither ascites nor hernia is a contraindication to laparoscopic cholecystectomy. Ascites can be drained and the gallbladder visualized. Large hernias may present a problem, however, because with insufflation, the gas preferentially fills the hernia. Patients with large inguinal hernias may require an external support to minimize this problem and the discomfort related to pneumoscrotum. Patients with umbilical hernias can have their hernias repaired while they are undergoing laparoscopic cholecystectomy. For such patients, the initial trocar should be placed by open insertion according to the Hasson technique, with care taken to avoid injury to the contents of the hernia. The sutures required to close the hernia defect can be placed before insertion of the initial trocar. A similar technique can be applied to patients with incisional hernias, although for large incisional hernias, laparoscopic cholecystectomy may have no advantages over open cholecystectomy if a large incision and dissection of adhesions are required. Patients with stomas may also undergo laparoscopic cholecystectomy, provided that the appropriate steps are taken to prevent injury to the bowel during placement of trocars and division of adhesions.
Pregnancy?
Questions have been raised about whether laparoscopic cholecystectomy should be performed in pregnant patients; it has been argued that the increased intra-abdominal pressure may pose a risk to the fetus. Because of the enlarged uterus, open insertion of the initial trocar is mandatory, and the positioning of other trocars may have to be modified according to the position of the uterus. Inflation pressures should be kept as low as possible, and prophylaxis of deep vein thrombosis (DVT) is recommended. Despite these potential problems, safe performance of laparoscopic cholecystectomy and other laparoscopic procedures in pregnant patients is increasingly being described in the literature. If cholecystectomy is necessary before delivery, the second trimester is the best time for it.
With more difficult open cases, a retrograde or so-called fundus down approach is usually employed. Staying as close to the gallbladder wall as is possible, the surgeon uses electrocautery or sharp and digital blunt dissection to remove the gallbladder from the liver bed, continuing downward to the cystic duct and artery [see Figure]. Anatomic variations of the duct and artery must always be anticipated. These structures can be very difficult to identify and safely dissect in cases of severe inflammation and markedly edematous tissues. In such cases, palpation and gentle digital blunt dissection of the duct and artery between thumb and index finger is useful [see Figure]. Opening the gallbladder to remove stones or aspirate bile or pus may be necessary when it is tense and distended or necrotic and gangrenous. As with laparoscopic cholecystectomy, it is critical to identify the cystic duct and artery and their anatomic relations to the gallbladder and common bile duct before division and to avoid injury to the common bile duct or common hepatic duct. The cystic duct and artery may be suture ligated or divided between clips. Stones found in the cystic duct should be gently milked back into the gallbladder.
Value of chemoprophylaxis in elective cholecystectomy
http://www.medscape.com/medline/abstract/17178957?cid=med&src=nlbest
