Overview of Laparoscopic Cholecystectomy
Laparoscopic cholecystectomy is a type of surgery that uses small cuts and a tiny camera to remove the gallbladder, which is often done when it is diseased. This method of surgery has been the preferred method for gallbladder removal since the early 1990s due to it being less invasive than traditional surgeries.
This type of surgery is typically recommended for conditions like cholecystitis (inflammation of the gallbladder), gallstones causing symptoms, irregular gallbladder function, inflammation of the gallbladder without gallstones, inflammation of the pancreas due to gallstones, and abnormal growths or polyps in the gallbladder. It should be noted that the same conditions may also call for an open cholecystectomy, a more invasive surgery. For cases involving gallbladder cancer, open cholecystectomy is usually the preferred method.
Around 20 million people in the United States have gallstones. Each year, about 300,000 gallbladder removal surgeries are performed. Even though 10-15% of people have gallstones without showing any symptoms, about 20% of those who do show symptoms (like abdominal pain, also known as biliary colic), may end up having complications like acute cholecystitis, pancreatitis due to gallstones, choledocholithiasis (gallstones in the common bile duct), and gallstone ileus (blockage of the intestine caused by a gallstone).
The chances for a person to develop gallstones increase with age. Women are more likely to form gallstones than men. If you look at people who are between 50 and 65, about 20% of women and 5% of men have gallstones. It’s also worth mentioning that 75% of all gallstones are made up of cholesterol, whereas the remaining 25% are pigmented or colored gallstones. Regardless of what the gallstones are made of, the signs and symptoms they cause remain the same.
Anatomy and Physiology of Laparoscopic Cholecystectomy
The gallbladder is a small organ that sits below the liver, specifically under two segments of the liver known as 4b and 5. It can be up to 4 inches (about 10 cm) long and can hold up to about 1.7 ounces (50 cc) of bile, a fluid produced by the liver to help digest fats.
The gallbladder is divided into four parts: the fundus, body, infundibulum, and neck. The structure of the biliary ducts, which are tubes that carry bile, can vary significantly from person to person.
The cystic duct is a tube that connects the gallbladder to the common bile duct, a larger tube that carries bile from the liver and gallbladder into the small intestine. The blood supply to the gallbladder comes primarily from the cystic artery, which in most cases comes from the right hepatic artery, a major blood vessel of the liver. However, the path and origin of the cystic artery can vary a lot between individuals.
The hepatocystic triangle, also known as the triangle of Calot, is an area marked by the cystic duct on one side, the common hepatic duct on another, and the edge of the liver on the third side. This triangle is important for surgeons because it’s typically the route the cystic artery takes to the gallbladder. The sentinel lymph node of the gallbladder, also known as Lund’s node, is found within this triangle.
Why do People Need Laparoscopic Cholecystectomy
The reasons a doctor might recommend this procedure include conditions like:
– Cholecystitis: This is an inflammation of the gallbladder that can be either sudden (acute) or long-term (chronic).
– Symptomatic cholelithiasis: This is when there are gallstones producing symptoms such as abdominal pain, vomiting, and other digestive issues.
– Biliary dyskinesia: This refers to the abnormal movement of bile due to either too little (hypofunction) or too much (hyperfunction) activity in the biliary system that involves the gallbladder and bile ducts.
– Acalculous cholecystitis: This is inflammation of the gallbladder without the presence of gallstones.
– Gallstone pancreatitis: This is when a gallstone lodges in a bile duct and causes inflammation of the pancreas, a condition that can lead to severe abdominal pain.
– Gallbladder masses or polyps: These are abnormal growths in the gallbladder that could be benign (not cancerous) or malignant (cancerous).
When a Person Should Avoid Laparoscopic Cholecystectomy
There are certain situations where surgery might not be suitable. These can be:
- If a person can’t handle the feeling of their belly being filled with gas (a condition known as pneumoperitoneum) or if they’re too unwell to sleep through surgery using general anesthesia.
- If a person can’t stop bleeding due to a blood condition called uncorrectable coagulopathy.
- If the person has widespread cancer or metastatic disease.
However, even if someone has gallbladder cancer, they may still be able to undergo a laparoscopic cholecystectomy (a type of surgery that removes the gallbladder using small holes instead of a big cut), according to current research.
Equipment used for Laparoscopic Cholecystectomy
The following equipment is needed for this medical procedure:
Two screens used for viewing inside the body during the surgery. These are known as laparoscopic monitors. These screens are paired with a special camera attached to a laparoscope, which is a thin, lighted tube that lets the doctor see inside your body. This laparoscope will be either 5 or 10 millimeters in size, and can angle at either 0 or 30 degrees.
The laparoscope works by pumping carbon dioxide gas into your abdomen. This is done with a carbon dioxide source and specific tubing for ‘insufflation’ (blowing gas into a body part). This gas provides an unobstructed view of your internal organs by creating more space for the doctor to work.
The doctor will make small openings in your abdomen for a set of special instruments called ‘trocars’. On average, three smaller ones (5 millimeters each) and one larger size (10 to 12 millimeters) will be used.
The operation also requires a variety of laparoscopic instruments. These are typically long, thin tools that can be inserted through the small incisions. They include graspers that don’t harm tissue, a Maryland grasper, a clip applier, and an electrocautery tool. The electrocautery tool uses electric current to cut tissue or to stop bleeding. A retrieval bag is also required to collect and remove any tissues or stones removed during the procedure.
For the surgery, the doctor will need a scalpel (a surgical knife, either 11 or 15 blade), forceps (a tool that looks like tweezers), a needle driver (holds the needle while sutures are placed), and absorbable sutures (medical threads that can be absorbed by the body over time).
Finally, there’s a chance that the doctor might need to switch from a less-invasive operation to a more traditional one (an ‘open’ operation). To be prepared for this possibility, a major open tray containing the necessary tools are also kept on hand.
Who is needed to perform Laparoscopic Cholecystectomy?
The team for your operation includes a main doctor, known as the operating surgeon, who will be on your left side. There’s also another doctor who helps out, called the surgical assist, who will be on your right side. Additionally, a specially trained nurse or technician, referred to as a scrub tech/nurse, will be on your left side. All of these individuals work together to make sure your operation goes smoothly and safely.
Preparing for Laparoscopic Cholecystectomy
Before starting surgery, the patient’s health conditions should be assessed and stabilized. They should be given antibiotics half an hour before the surgery begins. This is done to prevent any possible infections from spreading at the time of surgery. The surgeons will prepare a clean and sterile area on the body for surgery. This area will be around the upper part of the belly (right and left side) extending down to the pubic area. The sterile area should be prepared in a way that it allows for open surgery if necessary.
The patient generally lies flat on their back during surgery. However, once the surgery starts, the patient is lightly tilted back with a slight lean to the left. This position makes the gallbladder the highest point in the surgical area, and the important structures next to it move away from it. This makes the surgical procedure more manageable and safer for the patient.
How is Laparoscopic Cholecystectomy performed
After the patient has been put to sleep and a breathing tube has been inserted, the gallbladder removal surgery can commence.
First, the belly is inflated to a certain pressure using carbon dioxide gas. This helps in creating space to work in. After this, four small cuts are made in the belly to place special instruments known as trocars. These will help guide the surgical instruments inside. A camera and long instruments are then used to pull the gallbladder over the liver to expose an area called the hepatocystic triangle.
Now, the surgeon begins to meticulously and carefully dissect this area to get what’s called the “critical view of safety”. This is an important step to make sure the surgery is safe. It is achieved when (1) all the tissue around the hepatocystic triangle is clear, (2) there are only two tube-like structures going into the base of the gallbladder, and (3) the lower part of the gallbladder is separated from the liver permitting a view to the cystic plate.
Once this view is properly achieved, the surgeon can safely proceed to isolate what’s called the cystic duct and artery. These are important structures that need to be cut off before the gallbladder can be removed. They are clipped and carefully cut. Then, using some special instruments like an electrocautery or harmonic scalpel (which use electricity or ultrasound to cut and seal tissue), the gallbladder is completely separated from the liver.
To make sure there’s no bleeding, the pressure inside the belly is reduced for a couple of minutes. This technique helps to spot any possible minor vein bleeding which could be hidden by high pressure. The removed gallbladder is then placed in a pouch and taken out of the abdomen. All the instruments (trocars) are removed while the surgeon can see inside the patient’s abdomen. The way the small cuts in the belly are closed will depend on the surgeon’s preference.
To conduct the procedure, a small tube with a camera at the end, called a laparoscope, is inserted at the belly button area using a special viewing device called an optical viewing trocar. An incision is made using a knife and trocar is advanced slowly into the belly. This is done while viewing through the laparoscope to avoid injury to any organs. Once inside the abdomen, the laparoscope is repositioned to avoid vital structures inside the abdomen and the needle used to inflate the belly (Veress needle) is removed. Other instruments are then inserted through other small incisions above and to the sides of the gallbladder. The patient’s position and the operating table’s position might be adjusted during the procedure for better access and visibility.
Possible Complications of Laparoscopic Cholecystectomy
There can be certain complications after the surgery involving the liver. These can include bleeding, infection, and harm to the structures nearby. The liver has a rich supply of blood vessels, so bleeding can be a common issue, especially if there is an unexpected variation in the structure of the arteries. Skilled surgeons are aware of this and take care to avoid major blood loss.
The most serious issue could be unintentional damage to the common bile or hepatic ducts during the surgery. These ducts carry bile, a digestive fluid, from the liver. If they’re injured, another surgery may be needed to redirect the flow of bile into the digestive tract. This often requires a surgeon who specializes in liver and gallbladder surgeries.
In some cases, a less invasive approach to the surgery might have to be switched to a traditional “open” procedure. While this isn’t a complication itself, it does mean a larger cut on the belly, which could cause more pain afterward and leaves a more noticeable scar. However, the need to switch to an open procedure is becoming infrequent as surgeons gain more experience. It’s important to note that this change isn’t a mistake, but a considered choice by a seasoned surgeon for the patient’s safety.
After the procedure, there could be a leak of bile which could lead to symptoms like non-specific stomach pain and fever. This can sometimes cause a condition where there is too much bilirubin, a waste product, directly entering the bloodstream. Patients with these complications usually show signs within a week after the operation. In these cases, initial management involves imaging tests like ultrasound or a CT scan.
If there are leftover gallstones in the bile duct, a procedure to widen the duct (biliary sphincterotomy) may be required. More severe bile leaks might need the same procedure, along with the insertion of a tube or stent to hold the duct open. If the CT scan or ultrasound don’t provide clear enough results, a type of imaging study that tracks the flow of bile (a HIDA scan), is recommended.
What Else Should I Know About Laparoscopic Cholecystectomy?
Gallbladder disease can happen when your gallbladder isn’t working properly and the bile it stores is too concentrated. Your gallbladder is supposed to empty itself when you digest your food through a process involving different body chemicals and signals. However, this doesn’t always happen correctly.
If there’s too much cholesterol in your gallbladder this can cause gallstones to form. There are also pigmented gallstones which can occur due to blood cell diseases or infections. When the gallbladder or the tubes that drain it (bile ducts) can’t empty, it makes it more likely for gallstones to grow. Gallbladder disease often involves a blockage of the tube that connects it to a duct. This can be caused by gallstones or, in more severe cases, by a sudden inflammation of the gallbladder without actual blockage, which is known as acute acalculous cholecystitis. If your gallbladder is blocked and it tries to excrete bile for digestion, it might cause the gallbladder to become inflamed.
Gallbladder disease symptoms usually include pain in the top right side of your stomach or in the central area of your stomach. This pain often starts 30 minutes to 2 hours after you eat fatty food. The pain can last from one to 2 hours, even more than 24 hours. If the pain lasts more than 24 hours, it’s often a sign of more serious infection, known as acute cholecystitis. The pain often spreads to the right side and occasionally to the right shoulder. Other symptoms may include feelings of nausea, vomiting, fever, chills, and diarrhea. Less common symptoms might feel like heartburn, stomach ulcers, and indigestion. Pain can come and go and it’s usually connected to eating fatty foods. As the disease develops, the pain might be more regular.
Your doctor will take a detailed medical history and give you a physical examination. They might do what’s called a Murphy’s Sign. This involves pressing on your stomach while you take deep breaths. If it hurts this might be a positive Murphy’s Sign.
Your doctor might also carry out some blood tests to check if you have an increased number of white blood cells (leukocytosis), elevated total bilirubin, alkaline phosphatase, and possible transaminitis. You might also get your amylase/lipase levels tested. Elevation in these can indicate gallstone pancreatitis.
The doctor may use imaging tests to help diagnose the disease. An abdominal ultrasound can identify gallstones or other obstructions in your gallbladder, while an MRI or a more invasive test (ERCP) can provide a visualization of the bile and pancreatic ducts.
Another imaging test called a Hepatobiliary iminodiacetic acid (HIDA) Scan can be used to watch the flow of a radioactive tracer through the liver, gallbladder, bile ducts, and small intestine. If you don’t have gallstones, a substance called cholecystokinin (CCK) can be added during the HIDA scan to help diagnose acalculous cholecystitis. If the results show an ejection fraction of less than 35%, this usually indicates a poorly functioning gallbladder. If you feel the same sort of pain when cholecystokinin is given to you, this could mean that removing your gallbladder (cholecystectomy) might help with your symptoms. CCK should not be given if you have gallstones, as this might move the gallstones into the bile duct.
