Cholecystectomy

Cholecystectomy is the operation for removal of the gall bladder.

Traditionally the surgery is carried out through an incision in the right side
of the upper abdomen. More recently the surgery has been carried out
through a laparoscope employing 3 or 4 small incisions.

Anatomy and Physiology

The gall bladder is a small pear shaped organ located beneath the liver in
the right side of the upper abdomen.

Gallbladder and liver as seen through the

laparoscope. Courtesy S. Dorfman, M.D.

The gallbladder is a small pear shaped organ located beneath the liver in
the right side of the upper abdomen. The cystic duct carries bile from the
gallbladder and joins the common hepatic duct to form the common bile
duct. The common bile duct then empties into the beginning of the small
intestine. The main purpose of the gallbladder is to concentrate and store
bile. It releases bile by ejecting it through the common bile duct into the
small intestine when fatty foods are eaten. The bile aids in the digestion
of fatty foods. However, one can live without the gallbladder without
suffering symptoms.
Pathology

Stones may form in the gall bladder, which block the flow of bile resulting
in pain in the right upper abdomen. Gallstones can lodge in the terminal
part of the common bile duct that opens into the small intestine. Here the
stones can also block the flow of pancreatic juice from the pancreatic
duct that joins the common bile duct. This may result in a severe
inflammation of the pancreas called pancreatitis. The exact cause of gall
bladder disease is unknown. Some studies suggest that gallstones may
be related to how the body handles cholesterol and bile acids that are
synthesized in the liver and stored in the gall bladder. While some people
may have no symptoms even in the presence of gallstones, others may
have gallbladder problems even in the absence of stones.

Making the Diagnosis

Those individuals most likely to have gallbladder attacks are:

Women, especially in their 40s.

Women who have been pregnant . The risk of gallstones may
increases with each pregnancy.
Overweight men and women.
People who eat large quantities of dairy products, animal fats
and fried foods.
Family history of gallbladder disease.

Gallbladder disease with stones may be associated with bloating, nausea

or vomiting and in severe cases fever and other signs of infection. There
may be intolerance to fatty foods. The symptoms of gallstones may occur
after eating fried or oily foods, or a heavy meal. The symptoms may recur
frequently and may be disabiling.

The diagnosis of gallstones is helped by the use of special tests:

Blood tests may be taken to detect jaundice or elevation of

enzymes that occur as a result of blockage to the flow of bile
Ultrasound of the abdomen. This test employs sound waves to
scan the abdomen for gallstones. The echoes from the sound
waves are recorded and imaged on a screen. The presence, size
and position of the gallstones can be determined as well as
gallbladder wall thickness and the size of the common bile duct
HIDA scan. This scan employs a radioactive isotope to evaluate
the function of the gallbladder

The Procedure

Removal of the gallbladder is classically carried out through an

incision in the right upper abdomen
The gallbladder is directly exposed and dissected off the liver
and surrounding structures and removed
If indicated, a dye study of the common bile duct can be
 performed to determine the presence of stones in the common
bile duct. When present, open exploration of the common bile
duct can be performed
This operation is now employed in cases where it may be
dangerous or difficult to perform a laparoscopic cholecystectomy
such as technical difficulties due to dense abdominal adhesions
from previous surgery, highly inflamed and adherent gallbladder
or when the anatomy of the gallbladder is not clearly visible
through a laparoscope
The recovery period and hospital stay is usually 4-5 days

In some cases, it may not be possible to remove the gallbladder through

a laparoscope. In these cases, this operation is usually transformed into
an open cholecystectomy. In some cases, gallstones that are lodged in
the common bile duct causing obstruction may be removed by
exploration of the common bile duct at open surgery.

Laparoscopic Cholecystectomy

Today, the standard of care is usually a laparoscopic

cholecystectomy
The laparoscope is a long tube with lenses at one end that are
connected by fiber optics to a small television camera at the
other. The fiber optics also carries light into the abdomen from a
special light source. This system allows the surgeon to see and
operate within the abdomen
The procedure is usually performed under general anesthesia
Antibiotics are given intravenously prior to the surgery to reduce
the rate of infection
After anesthesia is begun, the skin is prepared with antiseptic
solution and 3-4 small incisions (called port sites) are made on
the abdominal wall
A special needle (Veress needle) is inserted into the abdomen to
inflate the abdomen with carbon dioxide gas. This distends the
abdomen and creates space to insert the instruments
The laparoscope and laparoscopic instruments with long handles
are inserted through the incisions into the abdomen. The entire
operation is then performed while viewing the organs magnified
on a television screen
 Gallbladder held by grasping forceps after being
dissected off of liver
The gallbladder is dissected off the surrounding structures. The
cystic duct that attaches the gallbladder to the common bile duct
is dissected and divided between metal clips

Separating cystic duct from surrounding tissues

Clips placed on cystic duct

 In some cases, a tiny catheter may be inserted into the cystic
duct to inject dye and take X-rays to visualize any stones that
may be blocking the common bile duct. If common bile duct
stones are present, they may be removed with laparoscopic
common bile duct exploration, by opening up the abdomen and
exploring the duct or by ERCP (see below)
After the cystic duct is divided, the gallbladder is further
dissected off the liver bed and a tiny artery that supplies blood to
the gallbladder called the cystic artery is divided between metal
clips. The gallbladder is then further dissected off the liver
avoiding spillage of bile into the abdominal cavity

Cystic duct cut after gallbladder is removed

In some cases, the gallbladder is shrunk by suctioning out bile.
The gallbladder is then removed through one of the ports in the
abdominal wall and the tiny incisions in the abdominal wall are
closed after removing any gas left in the abdominal cavity. When
there is spillage of bile, the local abdominal cavity is thoroughly
cleansed with saline solution and a small drain may be left in
place. This may be removed the same evening or the next day,
when drainage ceases

ERCP

ERCP (Endoscopic Retrograde Cholangio-Pancreatography) is a

procedure usually performed by an endoscopist. This procedure
is useful when a stone obstructs the common bile duct
The common bile duct is approached using a special endoscope
inserted through the stomach and small intestine to the entrance
of the common bile duct
An X-ray study of the common bile duct is performed using a
dye. A papillotomy (cutting the muscle of the lowest portion of the
common bile duct) is performed to enlarge the duct opening and
facilitate stone removal
A small catheter and instruments may be passed into the duct to
remove the stones
A small catheter will occasionally be left in the duct for temporary
 drainage

Complications

The incidence of complications after cholecystectomy is relatively low.

Complications of a general anesthetic,

Postoperative bleeding
Injury to the bile ducts or right hepatic artery
Biliary leak
Wound infection
Injury to other abdominal organs
Pulmonary embolism
Deep vein thrombosis
Respiratory or urinary infections

After Surgery

The patient usually has minimal pain that is well controlled with
medication. Frequently, patients are discharged home on the same
evening after laparoscopic cholecystectomy or the next day morning with
a prescription for pain medication. Patients eat a normal light diet on the
day after surgery and may be able to return to light work in 3-4 days. It is
preferable to avoid exertion and heavy work for a several weeks though
one can take regular walks.

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