Cholecystectomy

Cholecystectomy is surgical removal of gallbladder.

Indications

 * symptomatic gallstone disease (cholecystolithiasis);
 * gallbladder cancer;
 * biliary tree cancer.

In gallstone disease patients is prefered cholecystectomy in one hospitalization. It means, that the patient with biliary colic should undergo this surgery as soon as possible (after treatment of acute stage of his disease). Delayed surgery brings risk of another biliary colic before planned cholecystectomy.

Contraindications
Absolute contraindications are: Relative contraindications are acute cholecystitis, obstuctive jaundice, peritoneal adhesions or intraabdominal tumors.
 * generalised abdominal infection;
 * late stage of pregnancy;
 * serious bleedind disorders.

Preparation of the patient
Every patient should undergo before cholecystectomy: Every patient getting undergo laparoscopic cholecystectomy should be prepared for conversion (open surgery).
 * abdominal sono (USG);
 * MRCP (is prefered more than ERCP);
 * CT (in case staging of malignant disease);
 * and common internal examination.

Methods of cholecystectomy
Laparoscopic cholecystectomy is definitely prefered more than open surgery. Laparoscopic surgery is less invasive. It is connected with better and schorter patients recovery, shorter hospitalization and sooner patients return to work.

Laparoscopic cholecystectomy
The first port is introduced in subumbilical area. Then is created kapnoperitoneum with maximal intraperitoneal preassure 12 mmHg. Into subumbilical port is introduced optical instrument and the surgeon can check peritoneal cavity. After that can be introduced other 3 ports for laparoscopic instruments (trocars). There are two ways of gallbladder structures preparation:
 * 1) anterograde preparation – the preparation starts on gallbladders body (removal of peritoneum) and contnues to cystic duct nad cystic artery, which are clipped and divided;
 * 2) retrograde preparation – it starts by preparation of cystic duct and cystic artery, their clippind and deviding and then the surgeon continous in preparation of gallbladder.

All the important stuctures in this area (cystic duct, cystic artery, hepatic artery, common hepatic duct, left and right hepatic duct and portal vein) are covered by peritoneum.

After the preparation of gallblader is finished, it is evacuated from peritoneal cavity via subumbilical port. Then is introduced a drain.

Complications
The most serious complications are:
 * injuries to biliary system (ductes) – 0,3–0,5% of all cholecystectomies, there is a danger of biliary leakage and peritonitis, biliary obstruction;
 * bleeding (hepatic artery or portal vein injury);
 * peroperative injury of gallbladder with biliary leakage;
 * pneumothorax;
 * subcutaneous emphysema;
 * herniation in scar.

Conversion
Conversion mens change of operative technique during operation. In this case it is change during laparoscopic cholecystectomy to open cholecystectomy. It happens in 1–5% of planned laparoscopic cholecystectomies. The reasons are:
 * peroperative complications (massive bleeding or biliary system injury which can not be fixed by laparoscopic technique);
 * peroperative finding of serious peritoneal adhesions (caused by peritonitis or previous abdominal surgery);
 * peroperative finding of serious liver cirrhosis and suspected portal hypertension (it means high risk of bleeding during operation).

Open cholecystectomy
Open cholecystectomy is indicated in patients with serious galbladder, biliary tree or liver pathology (especially tumors). There is several options for incisions: The operative steps (anterograde or retrograde preparation ) and complications are the same as in laparoscopic cholecystectomy.
 * oblique subcostal incision (Kochers incision) – is usually prefered;
 * upper midline incision;
 * paramedian incision.

New methods

 * SILS – operative methode using one multiport serving for optical instrument and several laparoscopical instruments;
 * NOTES (New Open Trends in Miniinvasive Surgery) – operative methode using preformed holes of human body, in case of cholecystectomy it means transvaginal or transgastrical performed miniinvasive operation.

Related articles

 * Biliary Colic
 * Cholelithiasis