CHOLECYSTECTOMY

Prepared by: Heron Jayson E. Bayanin

BSN 3-1 Group 1

Cholecystectomy is the surgical removal of the gallbladder. It is
the most common method for treating symptomatic gallstones
Surgical options include the standard procedure, called
laparoscopic cholecystectomy, and an older more invasive
procedure, called open cholecystectomy.

Why does gallbladder need to be removed?

The gallbladder is a small, pear-shaped pouch in the
upper-right part of your abdomen (tummy). It stores bile, which
is the digestive fluid produced by the liver that helps to break
down fatty foods.
Bile is made from cholesterol, bile salts and waste products.
When these substances are out of balance, small, hard stones
called gallstones can form. Gallstones often cause no symptoms
and, in many cases, remain undetected.
However, in a small number of cases, gallstones can become
trapped in a duct (an opening or channel), irritate and inflame
the gallbladder, or move out of the gallbladder and into other
parts of the body.
This can lead to a range of symptoms, such as:
a sudden intense pain in your abdomen
feeling and being sick
jaundice (yellowing of the skin and the whites of the
eyes)
There are several non-surgical ways to break down gallstones,
but they are only effective in around less than 1 in 10 cases and
are rarely a viable option.
For most people with painful gallstones it is recommended that
their gallbladder is removed.

Open Surgery:
A traditional open cholecystectomy is a major abdominal surgery
in which the surgeon removes the gallbladder through a 5- to 7-
inch incision. Patients usually remain in the hospital at least 2 to
3 days and may require several additional weeks to recover at
home.

Laparoscopic Surgery:

Laparoscopic cholecystectomy requires several small incisions in
the abdomen to allow the insertion of operating ports, small
cylindrical tubes approximately 5 to 10 mm in diameter, through
which surgical instruments and a video camera are placed into
the abdominal cavity. The camera illuminates the surgical field
and sends a magnified image from inside the body to a video
monitor, giving the surgeon a close-up view of the organs and
tissues. The surgeon watches the monitor and performs the
operation by manipulating the surgical instruments through the
operating ports.

To begin the operation, the patient is placed in the supine
position on the operating table and anesthetized. A scalpel is
used to make a small incision at the umbilicus. Using either
a Veress needle or Hasson technique the abdominal cavity is
entered. The surgeon inflates the abdominal cavity with carbon
dioxide to create a working space. The camera is placed through
the umbilical port and the abdominal cavity is inspected.
Additional ports are opened inferior to the ribs at
the epigastric,midclavicular, and anterior axillary positions. The
gallbladder fundus is identified, grasped, and retracted
superiorly. With a second grasper, the gallbladder infundibulum
is retracted laterally to expose and open Calot's Triangle (the
area bound by the cystic artery, cystic duct, and common
hepatic duct). The triangle is gently dissected to clear the
peritoneal covering and obtain a view of the underlying
structures. The cystic duct and the cystic arteryare identified,
clipped with tiny titanium clips and cut. Then the gallbladder is
dissected away from the liver bed and removed through one of
the ports. This type of surgery requires meticulous surgical skill,
but in straightforward cases can be done in about an hour.
Recently, this procedure is performed through a single incision in
the patient's umbilicus. This advanced technique is called
Laparoendoscopic Single Site Surgery or "LESS".

How is laparoscopic cholecystectomy performed?

Many thousands of laparoscopic cholecystectomy have been
performed in the USA and this operation has an excellent safety
record. Some of the important steps in the operation are as
follows:

General anesthesia is utilized, so the patient is asleep
throughout the procedure.
An incision that is approximately half an inch is made
around the umbilicus ( belly button), three other
quarter to half inch incisions are made for a total of
four incisions. Four narrow tubes called laparoscopic
ports are placed through the tiny incisions for the
laparoscopic camera and instruments.
A laparoscope (which is a long thin round instrument
with a video lens at its tip) is inserted through the belly
button port and connected to a special camera. The
laparoscope provides the surgeon with a magnified
view of the patient's internal organs on a television
screen.
Long specially designed instruments are inserted
through the other three ports that allow your surgeon
to delicately separate the gallbladder from its
attachments to the liver and the bile duct and then
remove it through one of the ports from the abdomen.
Your surgeon may occasionally perform an X-ray, called
a cholangiogram, to exam for stones in the bile duct.
After the gallbladder is removed from the abdomen
then the small incisions are closed

Procedural Risk and Complications

Laparoscopic cholecystectomy does not require the
abdominal muscles to be cut, resulting in less pain, quicker
healing, improved cosmetic results, and fewer complications
such as infection and adhesions. Most patients can be
discharged on the same or following day as the surgery, and can
return to any type of occupation in about a week. Furthermore,
flexible instruments are being used in laparoscopic surgery by
some surgeons. Using the SPIDER surgical system, they can
perform the cholestectomy through a single incision through the
navel. These patients often recover faster than traditional
methods, and have an almost invisible scar.

An uncommon but potentially serious complication is injury to
the common bile duct, which connects the gallbladder and liver.
An injured bile duct can leak bile and cause a painful and
potentially dangerous infection. Many cases of minor injury to
the common bile duct can be managed non-surgically. Major
injury to the bile duct, however, is a very serious problem and
may require corrective surgery. This surgery should be
performed by an experienced biliary surgeon.
[2]


Abdominal peritoneal adhesions, gangrenous gallbladders, and
other problems that obscure vision are discovered during about
5% oflaparoscopic surgeries, forcing surgeons to switch to the
standard cholecystectomy for safe removal of the gallbladder.
Adhesions and gangrene, of course, can be quite serious, but
converting to open surgery does not equate to a complication.
A Consensus Development Conference panel, convened by
the National Institutes of Health in September 1992, endorsed
laparoscopic cholecystectomy as a safe and effective surgical
treatment for gallbladder removal, equal in efficacy to the
traditional open surgery. The panel noted, however, that
laparoscopic cholecystectomy should be performed only by
experienced surgeons and only on patients who have symptoms
of gallstones.
In addition, the panel noted that the outcome of laparoscopic
cholecystectomy is greatly influenced by the training,
experience, skill, and judgment of the surgeon performing the
procedure. Therefore, the panel recommended that strict
guidelines be developed for training and granting credentials in
laparoscopic surgery, determining competence, and monitoring
quality. According to the panel, efforts should continue toward
developing a noninvasive approach to gallstone treatment that
will not only eliminate existing stones, but also prevent their
formation or recurrence.

One common complication of cholecystectomy is inadvertent
injury to analogous bile ducts known as Ducts of Luschka,
occurring in 33% of the population. It is non-problematic until
the gall bladder is removed, and the tiny supravesicular ducts
may be incompletely cauterized or remain unobserved, leading
to biliary leak post-operatively. The patient will develop biliary
peritonitis within 5 to 7 days following surgery, and will require a
temporary biliary stent. It is important that the clinician
recognize the possibility of bile peritonitis early and confirm
diagnosis via HIDA scan to lower morbidity rate. Aggressive pain
management and antibiotic therapy should be initiated as soon
as diagnosed.

During Laparoscopic Cholecystectomy, gallbladder perforation
can occur due to excessive traction during retraction or during
dissection from the liver bed. It can also occur during extraction
from the abdomen. Infected bile, pigment gallstones, male
gender, advanced age, perihepatic location of spilled gallstones,
more than 15 gallstones and an average size greater than 1.5 cm
have been identified as risk factors for complications. Spilled
gallstones can be a diagnostic challenge and can cause
significant morbidity to the patient. Clear documentation of
spillage and explanation to the patient is of utmost importance,
as this will enable prompt recognition and treatment of any
complications. Prevention of spillage is the best policy.
[3]

Biopsy

After removal, the gallbladder should be sent for pathological
examination to confirm the diagnosis and look for an incidental
cancer. If cancer is present, a reoperation to remove part of the
liver and lymph nodes will be required in most cases

Long Term Prognosis

A minority of the population, from 5% to 40%, develop a
condition called postcholecystectomy syndrome, or
PCS.
[5]
Symptoms can include gastrointestinal distress and
persistent pain in the upper right abdomen.
As many as twenty percent of patients develop chronic diarrhea.
The cause is unclear, but is presumed to involve the disturbance
to the bile system. Most cases clear up within weeks, though in
rare cases the condition may last for many years. It can be
controlled with medication.
[6]


Living without a gallbladder

You can lead a perfectly normal life without a gallbladder. The
organ can be useful but it's not essential. Your liver will still
produce bile to digest food.
However, some people who have had their gallbladder removed
have reported symptoms of bloating and diarrhoea after eating
fatty or spicy food. If certain foods do trigger symptoms, you
may wish to avoid them in the future. Read more about making
changes to your diet after gallbladder surgery.
Some people may also experience pain and indigestion as a
result of a stone being left inside a bile duct. This will require
further surgery to remove the stone.