Chapter 11. Laparoscopic Cholecystectomy

• Biliary colic.
• Chronic cholecystitis.
• Acute cholecystitis.
• Acalculous cholecystitis.
• Gallstone pancreatitis.
• Choledocholithiasis.

Absolute

• Inability to tolerate an operation under general anesthesia (eg, patients with end-stage cardiopulmonary disease or hemodynamic instability).
• Suspicion of gallbladder cancer based on preoperative imaging.

Relative

• Pregnancy (first or third trimester).
• Previous abdominal operations precluding laparoscopic access.
• Cirrhosis, portal hypertension, or bleeding disorders.

• The patient should be supine with the arms perpendicular to the body or tucked to the side.
• After general anesthesia, the abdomen is prepped from nipple to pubis and sterilely draped.
• The primary surgeon stands on the patient's left side, while the assistant stands on the patient's right.

• Orogastric tubes and Foley catheters, if placed preoperatively, are removed at the end of the procedure.
• Diet is advanced as tolerated.
• Oral pain medications are prescribed.
• Patients undergoing laparoscopic cholecystectomy are typically discharged on the day of surgery; open cholecystectomy usually requires a short hospital stay (eg, 1–3 days).
• Ambulation should be initiated as soon as possible.

• Veress needle or trocar injury to great vessels or bowel.
• Must be recognized early and repaired, either laparoscopically or after conversion to open surgery, depending on the injury and the surgeon's experience.
• Bile leak.
  • May occur from the cystic duct stump or a bile duct injury to the common bile duct.
  • Patients usually present several days after cholecystectomy with symptoms that include abdominal pain, fever, nausea, anorexia, and jaundice.
  • Evaluation should include ultrasound to evaluate for free abdominal fluid and, if the diagnosis remains uncertain, HIDA scan to demonstrate biliary extravasation.
  • Treatment includes percutaneous abdominal drain placement for biloma and ERCP with stenting, sphincterotomy, or both.
  • Failure to control the bile leak with ERCP implies the need for reoperation (laparoscopic or open), with repair depending on the etiology of the leak.
• Bile duct injury.
  • Most frequently occurs because of misidentification of anatomic structures (common bile duct or aberrant right hepatic duct mistaken for the cystic duct).
  • Can also result from overzealous use of electrocautery or clips to control bleeding in the region of the porta hepatica, or due to excessive traction on the cystic duct and common bile duct during dissection.
  • Management depends on the nature and severity of the injury, when it is recognized (intraoperatively vs postoperatively), and the relative experience of the surgeon with biliary reconstruction techniques.
  • In some circumstances, patients are best managed by prompt referral to a tertiary medical center with expertise in hepatobiliary surgery.
• Retained spilled stones.
  • Spillage of stones occurs in more than 10% of laparoscopic cholecystectomies.
  • Although rarely resulting in serious complications (eg, intra-abdominal abscess), spilled stones should be retrieved as completely as possible using a specimen bag.
• Retained common bile duct stones.
  • Patients may present with abdominal pain, jaundice, light-colored stools, dark urine, pancreatitis, cholangitis, elevated liver function tests (bilirubin, alkaline phosphatase, transaminases), or dilated common bile duct or intrahepatic ducts on ultrasound.
  • Primary ...