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/suspicion of cancer of gallbladder(eg porcelain gallbladder)

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 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

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 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. 

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

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

Oral dissolution therapy - risks of gallstones recurring/poor outcome for large gallstones

Cholecystostomy - removing the stones alone : usually in patients who are too sick for the whole surgery to remove the gallbladder

Lithotripsy - shattering the stones smaller but this may cause more symptoms/complications

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