گردشگری سلامت مجتمع آموزشی پژوهشی درمانی خیّرین سلامت

Cholecystectomy

Cholecystectomy is the surgical removal of the gallbladder. Cholecystectomy is a common treatment of symptomatic gallstones and other gallbladder conditions. In 2011, cholecystectomy was the 8th most common operating room procedure performed in hospitals in the United States. Cholecystectomy can be performed either laparoscopically, using a video camera, or via an open surgical technique.

The surgery is usually successful in relieving symptoms, but up to 10% of people may continue to experience similar symptoms after cholecystectomy, a condition called postcholecystectomy syndrome. Complications of cholecystectomy include bile duct injury, wound infection, bleeding, retained gallstones, abscess formation and stenosis (narrowing) of the bile duct.

Gallbladder anatomy

Medical use

Pain and complications caused by gallstones are the most common reasons for removal of the gallbladder. The gallbladder can also be removed in order to treat biliary dyskinesia or gallbladder cancer.

Gallstones are very common but 50–80% of people with gallstones are asymptomatic and do not need surgery; their stones are noticed incidentally on imaging tests of the abdomen (such as ultrasound or CT) done for some other reason. Of the more than 20 million people in the US with gallstones, only about 30% will eventually require cholecystectomy to relieve symptoms (pain) or treat complications.

Biliary colic

Biliary colic, or pain caused by gallstones, occurs when a gallstone temporarily blocks the bile duct that drains the gallbladder. Typically, pain from biliary colic is felt in the right upper part of the abdomen, is moderate to severe, and goes away on its own after a few hours when the stone dislodges. Biliary colic usually occurs after meals when the gallbladder contracts to push bile out into the digestive tract. After a first attack of biliary colic, more than 90% of people will have a repeat attack in the next 10 years. Repeated attacks of biliary colic are the most common reason for removing the gallbladder, and lead to about 300,000 cholecystectomies in the US each year.

Acute cholecystitis

Cholecystitis, or inflammation of the gallbladder caused by interruption in the normal flow of bile, is another reason for cholecystectomy. It is the most common complication of gallstones; 90-95% of acute cholecystitis is caused by gallstones blocking drainage of the gallbladder. If the blockage is incomplete and the stone passes quickly, the person experiences biliary colic. If the gallbladder is completely blocked and remains so for a prolonged period, the person develops acute cholecystitis.

Pain in cholecystitis is similar to that of biliary colic, but lasts longer than 6 hours and occurs together with signs of infection such as fever, chills, or an elevated white blood cell count. People with cholecystitis will also usually have a positive Murphy sign on physical exam - meaning that when a doctor asks the patient to take a deep breath and then pushes down on the upper right side of their abdomen, the patient stops their inhalation due to pain from the pressure on their inflamed gallbladder.

5-10% of acute cholecystitis occurs in people without gallstones, and for this reason is called acalculous cholecystitis. It usually develops in people who have abnormal bile drainage secondary to a serious illness, such as people with multi-organ failure, serious trauma, recent major surgery, or following a long stay in the intensive care unit.

People with repeat episodes of acute cholecystitis can develop chronic cholecystitis from changes in the normal anatomy of the gallbladder. This can also be an indication for cholecystectomy if the person has ongoing pain.

Cholangitis and gallstone pancreatitis

Cholangitis and gallstone pancreatitis are rarer and more serious complications from gallstone disease. Both can occur if gallstones leave the gallbladder, pass through the cystic duct, and get stuck in the common bile duct. The common bile duct drains the liver and pancreas, and a blockage there can lead to inflammation and infection in both the pancreas and biliary system. While cholecystectomy is not usually the immediate treatment choice for either of these conditions, it is often recommended to prevent repeat episodes from additional gallstones getting stuck.

Gallbladder cancer

Gallbladder cancer (also called carcinoma of the gallbladder) is a rare indication for cholecystectomy. In cases where cancer is suspected, the open technique for cholecystectomy is usually performed.

Contraindications

There are no specific contraindications for cholecystectomy, and in general it is considered a low-risk surgery. However, anyone who cannot tolerate surgery under general anesthesia should not undergo cholecystectomy. People can be split into high and low risk groups using a tool such as the ASA physical status classification system. In this system, people who are ASA categories III, IV, and V are considered high risk for cholecystectomy. Typically this includes very elderly people and people with co-existing illness, such as end-stage liver disease with portal hypertension and whose blood does not clot properly. Alternatives to surgery are briefly mentioned below.

Procedure

Pre-operative preparation

Before surgery, a complete blood count and liver function tests are usually obtained. Prophylactic treatment is given to prevent deep vein thrombosis. Use of prophylactic antibiotics is controversial; however, a dose may be given prior to surgery to prevent infection in certain people at high risk. Gas may be removed from the stomach with an OG or NG tube. A Foley catheter may be used to empty the patient's bladder.

Laparoscopic cholecystectomy

Laparoscopic cholecystectomy uses several (usually 4) small incisions in the abdomen to allow the insertion of operating ports, small cylindrical tubes approximately 5 to 10 mm in diameter, through which surgical instruments are placed into the abdominal cavity. The laparoscope, an instrument with a video camera and light source at the end, illuminates the abdominal cavity and sends a magnified image from inside the abdomen to a video screen, giving the surgeon a clear view of the organs and tissues. The cystic duct and cystic artery are identified and dissected, then ligated with clips and cut in order to remove the gallbladder. The gallbladder is then removed through one of the ports.

As of 2008, 90% of cholecystectomies in the United States were done laparoscopically. Laparoscopic surgery is thought to have fewer complications, shorter hospital stay, and quicker recovery than open cholecystectomy.

Single incision

Single incision laparoscopic surgery (SILS) or laparoendoscopic single site surgery (LESS) is a technique in which a single incision is made through the navel, instead of the 3-4 four small different incisions used in standard laparoscopy. There appears to be a cosmetic benefit over conventional four-hole laparoscopic cholecystectomy, and no advantage in postoperative pain and hospital stay compared with standard laparoscopic procedures. There is no scientific consensus regarding risk for bile duct injury with SILS versus traditional laparoscopic cholecystectomy.

Natural orifice transluminal

Natural orifice transluminal endoscopic surgery (NOTES) is an experimental technique where the laparoscope is inserted through natural orifices and internal incisions, rather than skin incisions, to access to the abdominal cavity. This offers the potential to eliminate visible scars. Since 2007, cholecystectomy by NOTES has been performed anecdotally via transgastric and transvaginal routes. As of 2009 the risk of gastrointestinal leak, difficulty visualizing the abdominal cavity and other technical limitations limited further adoption of NOTES for cholecystectomy.

Open cholecystectomy

In open cholecystectomy, a surgical incision of around 8 to 12 cm is made below the edge of the right rib cage and the gallbladder is removed through this large opening, typically using electrocautery. Open cholecystectomy is often done if difficulties arise during a laparoscopic cholecystectomy, for example, the patient has unusual anatomy, the surgeon cannot see well enough through the camera, or the patient is found to have cancer.^[33] It can also be done if the patient has severe cholecystitis, emphysematous gallbladder, fistulization of gallbladder and gallstone ileus, cholangitis, cirrhosis or portal hypertension, and blood dyscrasias .

Biopsy

After removal, the gallbladder should be sent for pathological examination to confirm the diagnosis and look for any incidental cancer. Incidental cancer of the gallbladder is found in approximately 1% of cholecystectomies. If cancer is present in the gallbladder, it's usually necessary to re-operate to remove parts of the liver and lymph nodes and test them for additional cancer.

Post-operative management

After surgery, most patients are admitted to the hospital for routine monitoring. For uncomplicated laparoscopic cholecystectomies, people may be discharged on the day of surgery after adequate control of pain and nausea. Patients who were high-risk, those who required emergency surgery, and/or those undergoing open cholecystectomy usually need to stay in the hospital several days after surgery.