Laparoscopic cholecystectomy

This is an extension of minicholecystectomy but it introduces a completely new concept into abdominal surgery. Laparoscopic cholecystectomy is rapidly replacing open cholecystectomy as the procedure of choice in developed countries.

 

The operation is performed through four laparoscopic ports inserted through the abdominal wall in the right upper quadrant (Fig. 34) 1257. The dissection is viewed on a television screen placed beside the operating table and the image is obtained from a television camera attached to a telescope inserted through the subumbilical port.

 

The cystic duct and the cystic artery are dissected out in exactly the same way as a conventional cholecystectomy, except that subtle alterations in manual dexterity and specialized instruments are required (Fig. 35) 1258. Clips are used to occlude the cystic duct and the cystic artery. It is perfectly possible to cannulate the cystic duct for cholangiography (Fig. 36) 1259. The gallbladder is dissected from the liver bed using diathermy or sharp dissection: this is often the most difficult part of the operation. The gallbladder is extracted from the abdominal cavity through the umbilical or epigastric incision which may need to be enlarged. A drain can be left to the gallbladder bed if desired. The procedure takes slightly longer than conventional cholecystectomy but postoperative recovery is faster. Pain and sepsis in the wounds are less of a problem (Fig. 37) 1260. It remains to be seen whether the mortality and morbidity associated with this procedure are better than those after conventional cholecystectomy.

 

Postoperative care

Most patients recover rapidly, irrespective of the method used for removing the gallbladder. Very few want anything to drink until the following day, except after a laparoscopic procedure when some patients will be able to eat and drink almost as soon as they return to the ward. Unless there is bile in the drain it can usually be removed after 24 h. Prolonged ileus is uncommon and most patients eat on the second postoperative day. After a conventional operation patients need to stay in hospital for 4 or 5 days, compared to 2 or 3 days after a laparoscopic or minicholecystectomy. Most patients need 6 to 8 weeks away from work after a conventional operation, whereas after a laparoscopic procedure 2 weeks is usually sufficient.

 

Cholecystostomy

Surgical drainage of the gallbladder is rarely necessary: percutaneous ultrasound-guided drainage can now achieve the same result with less disturbance to the patient. On the other hand the surgeon may embark on an urgent cholecystectomy only to realize that the pathology is too severe to allow a safe operation. In these circumstances it is much better simply to drain the gallbladder with a large tube after removing all the stones, allow the inflammation to settle and to remove the gallbladder 6 weeks later.

 

Partial cholecystectomy

In the same circumstances an alternative to cholecystostomy is partial cholecystectomy. The gallbladder is evacuated of bile and stones and, starting at the fundus, it is dissected away from the liver as far as possible towards the neck of the gallbladder. Part of the wall of the gallbladder may be left in the gallbladder fossa if dissection of the gallbladder away from the liver bed proves difficult. Once the dissection has proceeded as close to the cystic duct and Calot's triangle as is safe, the remainder of the gallbladder is excised and its neck is oversewn. Operative cholangiography is not usually possible, but it is important to try and be sure that any stones in the cystic duct are removed and to leave a drain to the gallbladder bed.

 

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