Laparoscopic Cholecystectomy

Introduction

What is it?

Cholecystectomy means the surgical removal of the gallbladder. Laparoscopic (keyhole) cholecystectomy is routinely performed to minimise scarring, reduce pain and wound problems, and speed up recovery.

Location of Gall bladder in the belly. The yellow structure is the Liver, the Gall bladder (in green) peeps out from beneath it and is attached to its lower surface.

What is a Gall bladder

A gallbladder is a small, pouch-like organ that lies under the liver in the upper right side of the abdomen. It has the function of storing bile, a fluid produced by the liver that helps break down fatty foods.

Picture of the gall bladder attached to the lower surface of the Liver. Bile is created in Liver, it drains in the duodenum (part of the small bowel) though the Common hepatic duct. It is normal stored in the gall bladder - which is attached as a side branch of the Common hepatic duct - the Cystic duct.

What are gall stones?

Gallstones are ‘stones’ that form in the gallbladder as a result of an imbalance in the substances that make up bile, These stones do not cause any symptoms in most people, however, they can occasionally block the flow of bile, causing repeated attacks of abdominal pain. In some cases, the stones can cause inflammation of the gallbladder (acute cholecystitis). Gallstones are usually diagnosed with an ultrasound scan.

Why is it done?

It is done to reduce the risk of complications from gall stones.

Will I need to do any preparation?

As with any surgery, you will be asked to attend a pre-operative assessment to find out more about your health in general and be given appropriate advice before the operation. This might include blood tests, urine tests and pregnancy test for women.

Assessment of the Common Bile Duct (CBD)

Before proceeding with laparoscopic cholecystectomy it is important to confirm that there are no blockages to the normal passage of bile from the liver into the duodenum. This is because sometimes a stone in the gallbladder can dislodge and get stuck in the Common bile duct. If this is the case then the stone can be extracted first via ERCP or plans to remove it during the cholecystectomy can be made by performing an 'on-table-cholangiogram'.

Relevant tests to indicate the Common bile duct is not obstructed include blood tests (liver function tests), Biliary ultrasound (a blocked bile duct tends to be larger than normal) and MRCP (Magnetic Resonance Cholangio-Pancreaticogram).

You will be asked to stop eating for at least 6 hours and stop drinking for at least 2 hours before the operation. You may be allowed to take your usual medication with sips of water.

Technique

Anaesthesia

The procedure is done under general anaesthesia with you asleep.

What does it involve?

The procedure can be divided into a number of steps:

1. Creation of pneumo-peritoneum

Pneumo-peritoneum is the filling up of the belly cavity with gas. This lifts the front of the belly off the structures inside to create space in which the surgeon can work.

A small cut 2 to 3 cm long is made at the belly button. First a trocar (plastic sleeve) is inserted through which carbon dioxide gas is pumped to create the pneumo-peritoneum.

Then the laparoscope is inserted. The laparoscope contains a camera connected to a TV monitor and a light source to provide the view of the inside of the abdomen.

2. Insertion of remaining trocars

Several small cuts 0.5 to 1cm are made in the abdomen in order to insert smaller trocars. Through these trocars, instruments such as scissors and forceps can be inserted into the abdomen.

Port placement for Laparoscopic Cholecystectomy. The port at the belly button allows the laparoscopic camera to enter. The other ports allow instruments to perform the operation.

3. Dissection of Calot's triangle

The vital structures that need to be cut are organised into a triangular space called Calot's triangle. Dissecting this triangle involved separating the structures from one another. Once the structures are freed up, the cystic duct and artery are surgically clipped in order to secure these structures against leakage or bleeding.

Calot's triangle is the name given to the arrangement of structures under the Liver. It is an imaginary triangle with edges defined by the Cystic duct, the Common hepatic duct and the lower edge of the Liver.

4. Cutting of Cystic artery and Cystic duct and separation of gall bladder.

The cystic artery and duct are cut with scissors and the gall bladder is separated from the liver. Any bleeding points from the attached liver surface are sealed.

Here the Gall bladder is being pushed up by an instrument to expose the Cystic artery and the Cystic duct. These structures are freed up in the previous step of dissecting Calot's triangle.

5. Delivering of gall bladder through main port and closure

The gallbladder is pulled out of the abdomen through one of the cuts. Usually the first cut is starched a little larger to allow the gall bladder to be pulled out, usually in a bag.

Sometime a drain in inserted (flexible plastic tube) which drains away any blood of bile that leaks inside following the operation.

One in 20 to 30 keyhole operations cannot be completed safely and need to be converted into an open operation. This occurs when there is intense inflammation or scarring of the gallbladder, excessive bleeding, or inability to see the vital structures clearly.

How long does it take?

It usually takes from 30-90 minutes depending on the level of complexity of the operation.

Post procedure course (follow-up)

You will be taken to the day surgery unit or ward after spending some time in the recovery area for the anesthesia drugs to wear off. The nurses will monitor your progress and administer painkillers. Your doctor might administer antibiotics to reduce the risk of infection during and after the surgery.

You may wake up with a flexible plastic tube attached to your tummy (a drain). This is there to drain away any residual fluid in the belly after the operation and monitor for any leak of bile from the operation.

How long will I stay in hospital?

Most patient are often able to leave the hospital the same day as their surgery, though sometimes a one-night stay in the hospital may be needed. Patients are expected to spend two or three days recovering in the hospital wards

What care will I need at home?

The recovery period varies depending on your procedure:

Laparoscopic cholecystectomy: In general, you can expect to go home once you are able to eat and drink without pain and are able to walk unaided. It takes about a week to fully recover from the surgery.

Open cholecystectomy:. Once at home, it may take four to six weeks to fully recover.

Will I need someone to stay with me?

You will need someone with you overnight for the first 24 hours after having a General Anaesthetic.

Will I need any special equipment when I go home?

No.

What follow up care is needed?

None providing the procedure has not been complicated. You may be required to check your liver function blood tests in the community with your General Practitioner.

When can I start my normal activities again (e.g. driving, sports or work?)

As soon as comfort allows.

Are there alternative procedures?

It is possible to dissolve the stones or even shatter them into small pieces but these techniques involve unpleasant drugs and side effects, have a high failure rate and recurrence of gallstones. Their use is often limited to patients who are not suitable for surgery. There are no good alternative to surgical removal of the gallbladder. If the gallbladder is infected or inflamed, antibiotics can be used but it will not treat the underlying cause of gallstones.

What may happen if I don’t have the procedure?

Repeated attacks of abdominal pain may occur if the gallstones blocks the drainage of bile and the gallbladder squeezes against the gallstones. In some cases, serious problems can develop if there is a buildup of bile in the gallbladder causing inflammation and infection around the gallbladder and/or the bile duct. In addition, the gallstone may block the drainage of digestive enzymes from the pancreas causing inflammation of pancreas (pancreatitis).