Procedure
Cholecystectomy
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Cholecystectomy
, Laparoscopic Cholecystectomy
Epidemiology
Laparoscopic Cholecystectomy is the most common abdominal surgery in Europe and U.S. (900,000 cases per year)
Indications
Biliary Colic
Biliary Dyskinesia
Calcified Gallbladder
Acute Cholecystitis
Urgently perform within 72 hours of onset
Choledocholithiasis
Perform after
Common Bile Duct Stone
is cleared with
ERCP
Gallstone
Pancreatitis
Perform after
Pancreatitis
resolves, before hospital discharge
Contraindications
Laparoscopic Cholecystectomy
Gallbladder cancer (absolute contraindication)
Uncontrolled
Coagulopathy
(absolute contraindication)
Advanced
Cirrhosis
or liver failure
Coagulopathy
Peritonitis
Sepsis
Advantages
Laparoscopic Cholecystectomy (preferred)
Decreased pain and
Disability
Much earlier return to work time
Shorter hospital stay (often outpatient)
Lower mortality
Laparoscopic: 8 to 16 per 10,000 patients
Open: 66 to 74 per 10,000 patients
Shea (1996) Ann Surg 224:609-20 [PubMed]
Treatment cost slightly less than open Cholecystectomy
Better cosmetic result
Management
Timing of Surgery - Early surgery is safe and preferred
Incidence
of technical complications is the same
Reduces total illness duration by 30 days
Hospitalization time reduced by 5-7 days
Direct medical cost savings reduced by > $2000
Death rate slightly lower with early surgery
References
Stevens (2006) Am J Surg 192:756-61 [PubMed]
Management
Antibiotic prophylaxis
Indications: Patients at high risk of
Wound Infection
Age over 60 years old
Diabetes Mellitus
Acute
Biliary Colic
within 30 days of surgery
Jaundice
Acute Cholecystitis
Ascending Cholangitis
Protocol
Cefazolin
1 g IV within one hour of skin incision for one dose
Continue other antibiotics as indicated (e.g.
Ascending Cholangitis
)
References
Choudhary (2008) J Gastrointest Surg 12(11): 1847-53 [PubMed]
Complications
Conversion from laparoscopy to open laparotomy
Rates
Uninflamed gallbladder: 2-15%
Acute Cholecystitis
: 6-35%
Risk factors
Male gender
Over age 60 years
History of upper abdominal surgery
Ultrasound
with thickened gallbladder wall
Acute Cholecystitis
References
Tayeb (2005) J Postgrad Med 51(1): 17-20 [PubMed]
Complications
Common Bile duct injury (Bile leak)
Typically presents within 3 days of Laparoscopic Cholecystectomy
Laparoscopic: 36 to 47 per 10,000 patients
Open: 19 to 29 per 10,000 patients
Shea (1996) Ann Surg 224:609-20 [PubMed]
Diagnosis
Ultrasound
will show a free fluid collection around the biliary duct
ERCP
: Dye extravasates
Ultrasound
guided needle aspiration will reveal brown bile (as opposed to post-operative
Hematoma
)
References
Weinstock in Majoewsky (2012) EM:RAP 12(3): 3
Complications
Other
Dropped
Gallstone
Gallstone
drops during resection into the peritoneum
Results in infection, forming an abscess or phlegmon
References
Abraham (2014) Am Fam Physician 89(10): 795-802 [PubMed]
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