(Removal of the Gallbladder using Keyhole Surgery)

Laparoscopic cholecystectomy is recommended for individuals who have symptomatic gallstones or confirmed gallbladder disease, and providing that other possible conditions have been excluded.

Laparoscopic cholecystectomy is now the gold-standard treatment for gallstones and gallbladder disease. It was developed in the early 1990’s, and has since all but replaced the old-fashioned, traditional operation of open cholecystectomy.

The procedure is performed under a standard general anaesthetic.

A small incision (~1cm) is made close to the umbilicus. This allows the entry of the videoscope (laparoscope) and the insufflation of gas (carbon dioxide) into the peritoneal cavity, which creates a space for the surgery to be performed. Usually a further ~1cm incision and one or two ~0.5cm incisions are made in the upper abdomen for the insertion of ports and operating instruments.

The gallbladder is carefully identified, and any adhesions of abdominal tissue (common in inflammation) are slowly dissected away to reveal just the gallbladder. It is crucial at this stage to correctly identify the anatomy of the gallbladder, in particular the location of the cystic duct and cystic artery, structures that connect solely to the gallbladder. The cystic duct and cystic artery are dissected away from adjoining structures, then clipped, using staplesand divided with scissors.

If there is any doubt about the anatomy of these structures, an operative cholangiogram can be performed. This is the introduction of a small catheter into the cystic duct and the injection of radio-opaque dye under X-ray control which them images the biliary system.

The gallbladder is then carefully dissected away from the liver bed using diathermy (a device which coagulates and cuts tissue) to prevent bleeding. Once freed from the liver, the gallbladder is placed in a retrieval bag and removed via one of the ~1cm ports. The gallbladder itself is sent for analysis to confirm the diagnosis. Local anaesthetic is then infiltrated into the wounds and peritoneal cavity, and the skin incisions closed with dissolvable stitches or tissue glue.

Overall the operation takes between 45 – 90 minutes depending on the difficulty in releasing adhesions or identifying the anatomy correctly.

After the operation, patients are allowed to eat, drink and ambulate when they feel able. Some patients may be allowed to go home on the same day as their operation (day-case laparoscopic cholecystectomy) and the remainder after an overnight stay. Return to normal activity and work is rapid (two to three days), but does vary per the individual.

The traditional open operation required the use of a large slash incision, 15-20cms long under the right rib cage. This is associated with considerable post-operative pain and the dependency on powerful analgesia, as well as greater tissue trauma and blood loss. This in turn results in an inability to mobilise rapidly, placing patients at greater risk of hospital-acquired infection and deep-vein thrombosis, a slower start to eating and drinking requiring prolongation of intravenous drips, and an overall hospital admission of at least 5 – 7 days. Months after the operation, patients complain of wound pain (several nerves have to be divided in this kind of incision) which may be intractable, and there is a predisposition to the development of incisional hernia over the site. For these reasons, it is now rare to offer open cholecystectomy unless there are very good reasons why keyhole surgery cannot be offered.

• Open Conversion : In a small minority of cases, keyhole surgery may not be possible, or may be started and then converted to and open operation. This may be due to dense adhesions around the gallbladder as a consequence of previous open abdominal surgery or very severe inflammation of the gallbladder. In this situation, safe dissection of the gallbladder is no longer possible. Alternatively, if unexpected events happen during surgery, it may no longer be suitable to continue the procedure laparoscopically. Overall the nationally reported rates of conversion are between 1-in-30 and 1-in-50 operations.
• Bile duct and Visceral Injury. The most dangerous potential complication of laparoscopic cholecystectomy is damage to the bile ducts leading from the liver to the duodenum (common bile duct, common hepatic duct, right and left hepatic ducts) or the blood vessels located in the same region (hepatic arteries, hepatic portal vein). Incidence of this complication is thankfully very rare (nationally less than 1-in-200), but depending on the exact nature of the injury, the consequences can be severe, and may require further intervention and even major complex surgery to deal with it. The bowel itself may be accidentally damaged during surgery, and if not recognised have serious consequences.

Although laparoscopic cholecystectomy is often regarded as a routine operation, the implications of the very serious potential complications that can arise have lead to the recommendation that this procedure should only be carried out by Consultant Upper GI surgeons specialising in keyhole surgery, who will have had specific training in this area.

Occasionally, small stones escape from the gallbladder, and rather than passing through the common bile duct, and into the duodenum, they become trapped. These can then continue to cause symptoms, even if the gallbladder itself is removed. It is important that they are therefore identified and dealt with either prior to, or at the same time as keyhole surgery. Clues that stones may be present come from a history of jaundice or pancreatitis. Liver function tests are often abnormal (always checked prior to surgery) and sometimes their presence can be indicated on the ultrasound scan if the bile ducts are abnormally dilated. A more sensitive test for confirming the presence of entrapped stones is an MRCP (magnetic resonance cholangio-pancreatography).

If stones are identified in the common bile duct, there are two strategies for dealing with them. Firstly the patient can undergo an ERCP (endoscopic retrograde cholangio-pancreatography) prior to laparoscopic cholecystectomy. An ERCP is a procedure carried out using an endoscope. The ampulla within the duodenum is identified and cannulated. Radio-opaque dye is injected and this identifies the location and number of trapped stones. Stones can then be released by making a small cut in the sphincter muscle (sphincterotomy) and trawled out of the duct using a balloon catheter or trawling wire basket.

Alternatively, stones can be removed during laparoscopic cholecystectomy. An operative cholangiogram may be performed as described earlier to identify stones, which are then removed by the passage of a trawling wire basket or balloon catheter through the cystic duct and then into the common bile duct. This is referred to as transcystic laparoscopic exploration of the common bile duct. Another method, also during laparoscopic cholecystectomy is to make a direct cut in the common bile duct and remove the entrapped stones by flushing them using an operative choledochoscope (small, flexible telescope placed directly into the common bile duct. The bile duct is then closed with stitches placed laparoscopically, usually with a temporary drainage tube in place (t-tube). This technique is referred to as laparoscopic choledochotomy and exploration of the common bile duct.

While laparoscopic common bile duct exploration has the advantage of performing the entire procedure at one sitting, it is a more complex procedure and has a slightly greater morbidity rate that routine laparoscopic cholecystectomy. An ERCP prior to surgery does make this a two-stage procedure, but may actually be more straightforward by performing two simpler procedures. The specific treatment is dependant on the individual patient and should be discussed in detail with his or her surgeon.