Introduction:
It is a minimally invasive surgical procedure done to remove an infected gallbladder. In the early 1990s, laparoscopic cholecystectomy replaced open surgery to remove the gallbladder. The gallbladder is an organ that is pear-shaped and located below the liver and above the abdomen on the right side. The gallbladder stores and collects the digestive juice produced by the liver, which is bile. Bile is produced by the liver and released into the intestine for the digestive process; changes occur in the composition of bile by the changes in the diet, lifestyle, hormonal influences, medications, etc.
Thus, the formation of hard pieces of bile is called gallstones. A few symptoms associated with gallstones are vomiting, occasional abdominal aches, and nausea after meals. Gallstones may move out of the gallbladder and block the flow of normal bile, which leads to a gallbladder infection called cholecystitis.
Symptoms of cholecystitis include intense, persistent aches in the abdomen, nausea, vomiting, and fever. If the gallstone remains asymptomatic and does not cause any discomfort, it means no need for intervention; if it is symptomatic, treatment is required. That is the surgical removal of gallbladder-cholecystitis. Laparoscopic cholecystitis is a minimally invasive procedure performed through small incisions with a camera to view the abdomen. Surgery is done under anesthesia, and patients' recovery phase is faster.
What Is Laparoscopic Cholecystectomy?
Laparoscopic cholecystectomy is a minimally invasive procedure to surgically remove an infected and inflamed gallbladder. This technique replaced open surgeries in the early 1990s. Now laparoscopic cholecystitis is indicated for cholecystitis-(acute cholecystitis and chronic cholecystitis).
Cholelithiasis is symptomatic, biliary dyskinesia, acalculous cholecystitis, gallstone pancreatitis, and gallbladder masses/polyps. In the case of gallbladder cancer, open cholecystectomy is the best option and is preferred over the laparoscopic procedure.
The gallbladder prevalence increases with age, and females are more prone to develop gallbladder stones than males. At an average age of 50 to 65, 20 percent of women and 5 percent of men have gallbladder stones. Seventy-five percent of gallbladder stones are cholesterol, and 25 percent are pigmented. In both cases, the symptoms remain the same.
What Are the Anatomy and Physiology To Be Considered in Cholecystectomy?
The gallbladder is present in the lower part of the liver, under liver segments 4b and 5. It is 10 centimeters in length and can hold 50cc of bile fluid. The liver is divided into the right and left lobes by a line drawn from the liver to the inferior vena cava. Four anatomical parts of the gallbladder are the fundus, body, infundibulum, and neck.
The cystic duct arises from the common bile duct and inserts into the neck of the gallbladder. The branch of the cystic duct from the common bile duct denotes the commencement of the common hepatic duct superiorly. The blood supply to the gallbladder is from the cystic artery, which initiates from the right hepatic artery.
The hepatocystic triangle (triangle of Calot) is an anatomical landmark for surgery constructed by the cystic duct laterally, medially by the common hepatic duct, and the liver edge superiorly. This triangle is important surgically because this is the location for the common path of the cystic artery to the gallbladder. The sentinel lymph node of the gallbladder lives within the hepatocystic triangle, also known as Lund's node.
What Are the Indications of Laparoscopic Cholecystectomy?
Laparoscopic cholecystectomy is done in acute and chronic cholecystitis, symptomatic cholelithiasis in hypofunction or hyperfunction biliary dyskinesia, acalculous cholecystitis, gallstone pancreatitis, gallbladder masses, or polyp.
What Are the Contraindications of Laparoscopic Cholecystectomy?
It is not indicated in uncorrectable coagulopathy or metastatic disease if the patient cannot tolerate general anesthesia. Early in cancer, laparoscopic gallbladder procedure was contraindicated, but now few studies support laparoscopic procedure in gallbladder cancer.
How Is the Procedure of Laparoscopic Cholecystectomy Done?
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The equipment required for the procedure is
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Two laparoscopic monitors.
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One laparoscope, including a camera cord and light source.
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Carbon dioxide source and tubing for insufflation.
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5 mm to 12mm trocars.
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Laparoscopic instruments: Atraumatic graspers, Maryland grasper, clip applier electrocautery, and a retrieval bag.
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Scalpel (11/15 blade), forceps, needle driver, and absorbable sutures.
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Major open tray for possible conversion.
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The personnel required are an operating surgeon, surgical assistant, and scrub tech or nurse.
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Preparation is done before the surgery and involves medical optimization of the patient should be done before surgery. Antibiotics should be given within 30 minutes of incision preoperatively as per protocol. An aseptic surgical field is created; this allows for open surgery if needed.
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After giving anesthesia and intubation, laparoscopic cholecystectomy begins. Initially, insufflation of the abdomen was done to 15 mmhg using carbon dioxide. Four small incisions were made for the placement of the trocar. Using the camera and a long instrument gallbladder is retracted over the liver. This provides exposure to the hepatocystic triangle. Dissection is done to gain a critical view of safety.
This view is characterized as (1) clearance of fibrous and fatty tissue from the hepatocystic triangle, (2) the presence of only two tubular structures entering into the base of the gallbladder, and (3) the split of the lower third of the gallbladder from the liver to view the cystic plate. After the view is gained, the surgeon can proceed as he has isolated the cystic duct and artery. Both structures are clipped and transected carefully.
Electrocautery is then utilized to separate the gallbladder from the liver bed completely. Hemostasis should be acquired after the abdomen deflates to 8 mmHg for 2 minutes. This is operated to prevent skipping potential venous bleeding that can be tamponaded by raised intra-abdominal pressure (15 mmHg). The gallbladder is removed from the abdomen. All trocars should be withdrawn under direct visualization. Closure of port sites is specific for surgeons; this author suggests fascial closure of trocar areas more prominent than 5 mm to prevent incisional hernias in the postoperative time.
What Are the Complications of Laparoscopic Cholecystectomy?
Common side effects include bleeding, infection, and damage to surrounding tissues. Bleeding is a common complication as the liver is included. Iatrogenic injury of the common bile/hepatic duct is common. Leakage of bile is another complication during the procedure. If leakage is present, it is associated with symptoms of fever and abdominal pain and may be features of hyperbilirubinemia present. Sphincterotomy and splinting are done to manage high leakage.
Conclusion
If a patient is admitted to the hospital with gallstones, physicians, nurses, and primary care providers must be educated about available treatment options. The laparoscopic procedure is the most commonly done treatment for cholecystitis, but the patient should be educated about that if the needed surgeon switches to the open procedure. There is always a risk of injury to the bile duct. Patients who have no symptoms are advised to have a low-fat diet, a healthy lifestyle, maintain low body weight, and regular exercise is recommended.
