LAPAROSCOPIC CHOLECYSTECTOMY 
- Removal of gallbladder by keyhole surgery

Indications:

(i)  Symptomatic gallstones - Pain, nausea and vomiting from gallstones

(ii) Complications from gallstones - infection, pancreatitis, jaundice

(iii) Polyps more than 10mm/suspicion of cancer of gallbladder(eg porcelain gallbladder)

(iv) Acalculous cholecystitis - when gallbladder is gangrenous, emphysematous or perforated

Procedure

General anaesthesia. Intravenous antibiotics also given to reduce risk of infection. Blood thinning injection given to reduce risk of deep venous thrombosis. 

4 small cuts on abdomen - to allow placement of a 12mm port, 10mm port and two 5mm ports. Telescope passed in.

Carbon dioxide gas insufflation to lift abdominal wall up for view.

Dissection to free gallbaldder from liver and identify  cystic duct & cystic artery clearly in Calot's triangle (this move is to avoid damaging the bile duct)

Metal clips to gallbladder(cystic) artery and cystic duct.

X-ray of bile duct performed after dye is injected to exclude stones in bile duct(Operative cholangiogram)

The cystic duct is then clipped and cut. The gallbladder is then detached from the liver. The gallbladder is then placed in an endoscopic plastic bag.

Drain tube may be used at end of case.

The gallbladder is removed from the incision near the belly button in the endoscopic plastic bag(this bag prevents spillage of stones and contamination of the skin)

Wounds are closed with dissolvable 3/0 Vicryl sutures, Steristrips & Tegaderm dresssings

POSTOP

After the operation, you will wake up in recovery.  The nurse will ask you to frequently cough and take deep breaths as well as to move your legs while in bed.

Once back in the ward, you should ask the nurse to allow you first sit out of bed and then accompany you when you first walk.

If in pain, you can ask for pain killers - but note : Morphine, Endone and other opioids can cause nausea and constipation 

The drain tube(if used) is removed the following day if there is no bile leak.

Discharge usually on the next day if able to mobilize comfortably and tolerate food. 

The Tegaderm dressings can be changed the next day if soaked. Leave the Tegaderm dressing(plastic dressing with a white pad) on for 2 weeks, Steristrips(white tapes under the Tegaderm) for 3 weeks.

Risks

Stone in bile duct - may need exploration of bile duct during operation or further surgery(ERCP)

Bile leak (1 in 200)/bile duct injury(1 in 230) - may need reoperation

Spillage of stones out of gallbladder - the gallbladder can be torn when it is retracted during the surgery

Need for open surgery(1 in 20) - especially if acutely inflammed

Bleeding and haematoma

Injury to bowel, blood vessel and other organs, adhesions

Wound infection, scar or keloid, hernia at port site

Gas embolus

Heart attack, stroke, anaesthetic reactions, chest infections, blood clots in legs/lungs, death

Postop abdominal distension, gas pain in shoulder, loose bowel action/diarrhoea. Persisting symptoms despite surgery

Alternatives

Percutaneous Cholecystostomy - usually in patients who are too sick for the whole surgery to remove the gallbladder. A drain is left in the gallbladder. After 1-2 weeks, a tract forms. This is gently dilated and the gallstones in the gallbladder is removed with a wire basket. 

Extracorporeal Shock Wave Lithotripsy - shattering the gallstones smaller but this may cause more symptoms/complications as the smaller stones are passed down the bile duct and risks getting stuck causing jaundice and acute pancreatitis.  Hence ESWL is not as helpful for gallstones as it is for kidney stones

Oral dissolution therapy - Chenodoxycholic acid & Ursodeoxycholic acid(600mg daily). The former is no longer used due to many side effects.  The latter is expensive. Very slow - reduces size of a non-calcified gallstone by 1mm a month.  Does not work for calcified stones. Need functioning gallbladder and cystic duct to be open. Risks of gallstones falling out of gallbladder and causing acute pancreatitis & jaundice.  

Other methods :

Statins - may reduce risks of forming cholesterol gallstones.

Exetimibe - this inhibits absorption of cholesterol from the small intestine.  

Monoterpenes - Rowachol. May help dissolve gallstones. 

Topical contact dissolution - Historically, a small cathether was inserted into the gallbladder and a solvent such as methyl ether and later ethyl proprionate(a food additive) was injected in. Takes hours to do. 

With all these methods, there is a risk of long term gallstone recurrence.

Other surgical techniques :

Mini laparoscopy - using thinner laparoscopic instruments. But the umbilical incision still has to be large enough to take out the gallbladder with the gallstones in it

Single incision laparoscopy(SIS) - putting all the ports in the umbilical site. Longer incision in one area. Makes the operation longer. Can be robot assisted as well - but longer time to do.

Natural orifice transluminal endoscopic surgery(NOTES) : Through the vaginal or stomach so as not to leave scars on the stomach. Higher risks and longer operation. 

Robot assisted cholecystectomy - the set up time under general anaesthesia  would be roughly the time of a normal straightforward cholecystectomy

Operative Cholangiogram - X-ray of the bile duct with contrast

This is usually performed during the gallbladder surgery. 
Benefits:
1. Can detect stones in bile duct(4%) 
2. May help avoid bile duct injury
Alternative - injecting florescent material (indocyanine green) to show the biliary tree (experimental at this stage)