Cholecystectomy with or Without Cholangiography – Laparoscopic

Overview

Since its initial performance by Muhe in 1985, and subsequent description and dissemination in the late 1980s, laparoscopic cholecystectomy has not only transformed the surgical management of gallbladder disease, it has fostered a revolution in surgical practice oriented on the principle of minimally invasive access to the body's internal organs. Second only to inguinal hernia repair in terms of the number of operations done annually by general surgeons in the United States, this technique has firmly established itself as the procedure of choice for symptom-producing disease of the gallbladder. For most surgeons and surgeons in training, experience with laparoscopic cholecystectomy forms the introduction to and foundation for the development and maintenance of clinical laparoscopic skills. Review of the appropriate application of this technique, as well as a careful consideration of its conduct, is thus fundamental to the contemporary practice of surgery.

Indications

The most common indication for laparoscopic cholecystectomy is symptomatic cholelithiasis, which most frequently presents as intermittent biliary colic. Typical episodes localize to the right upper quadrant or epigastrium, may radiate to the back or right shoulder, often occur in postprandial fashion and especially after fatty food intake, and resolve spontaneously after a period of minutes to hours. Associated less specific symptoms such as bloating, nausea, and vomiting are common. Middle-aged female patients are the most likely group affected. Pregnancy, hemolytic disorders, rapid weight loss, and prior ileal resection may also be predisposing factors that heighten suspicion for the diagnosis. Patients with such a presentation should be evaluated with abdominal ultrasound, and a differential diagnosis that includes cardiac ischemia, right lower lobe pneumonia, peptic and reflux disease, malabsorptive disorders, and inflammatory or motility disturbances of the gastrointestinal tract should be considered. In patients with a negative ultrasound, microlithiasis or biliary dyskinesia may be considered. Radionuclide scanning with an iminodiacetic acid derivative and cholecystokinin-analog administration, allowing calculation of a gallbladder ejection fraction, should be considered in settings of typical symptoms and no evidence of cholelithiasis on ultrasound. An ejection fraction of less than 35% is considered abnormal and is indicative of dyskinesia, although sphincter of Oddi dysfunction or periampullary pathology unrelated to the gallbladder may cause similarly abnormal emptying function and should be considered as possible confounding issues in appropriate settings.

Fortunately, in the setting of a diminished ejection fraction, 75% or more of patients note symptomatic improvement with cholecystectomy alone. A reasonable strategy in the absence of more overt signs of a process distal to the gallbladder, such as elevated liver function studies or a dilated common bile duct (CBD) on ultrasound, would therefore be to offer cholecystectomy in such settings, deferring sphincter of Oddi manometry or other specialized evaluations for patients who do not experience relief after removal of the gallbladder. In specialized centers, endoscopic ultrasound and evaluation of bile for cholesterol crystals are available and are sometimes helpful in clarifying the diagnosis, when it remains unclear after more standard evaluations.

Acute cholecystitis may be the initial presentation of cholelithiasis in up to 20% of patients who develop symptomatic gallstone disease. These patients have lingering pain associated with persisting tenderness in the right upper quadrant, often with concomitant inflammatory signs such as leukocytosis and fever. Again, ultrasound is the most helpful diagnostic tool and may show signs of acute inflammation, such as gallbladder wall thickening or pericholecystic fluid. Nonvisualization of the gallbladder on radionuclide scanning may also be a means of inferring the diagnosis of acute cholecystitis as a harbinger of cystic duct obstruction, which is the underlying pathology of the disease entity. In less typical presentations, computed tomography (CT) may make the diagnosis while looking for other possible pathologies, again by showing inflammatory changes of the gallbladder, although the majority of gallstones are radiolucent.

Patients with acute cholecystitis are usually admitted and prepared for surgery within 24 to 48 hours. If presentation is later in the course of the illness, 72 hours or more, it may be advisable to treat the patient medically with antibiotics, and in severe cases or in highly comorbid settings, percutaneous drainage of the gallbladder should be done with surgery deferred for 4 to 6 weeks to allow the advanced inflammatory process to subside. Patients so managed have an approximately 25% relapse rate if the gallbladder is not removed within 6 to 8 weeks.

Other complicating illnesses such as gallstone pancreatitis, choledocholithiasis, and cholangitis may complicate cholelithiasis; these are typically manifested by elevations of serum enzymes, which include amylase, lipase, and liver function enzymes respectively. Elevation of these laboratory markers, clinical jaundice, and dilation of the biliary system on ultrasonography or CT should raise suspicion of the diagnosis. Magnetic resonance cholangiopancreatography (MRCP) or endoscopic retrograde cholangiopancreatography (ERCP) should be considered if the diagnosis remains unclear or nonoperative therapeutic intervention is needed.

Percutaneous transhepatic cholangiographic (PTC) approaches may also be considered, particularly if prior foregut surgery limits endoscopic access to the biliary system. In these settings, older or comorbid patients whose presenting illness was clearly related to choledocholithiasis, and who do not have lingering symptoms from residual cholelithiasis after common duct clearance by ERCP or PTC, do not necessarily need subsequent cholecystectomy, and the majority will not require a delayed cholecystectomy for symptoms over their remaining lifespan. In younger patients, cholecystectomy is appropriate after resolution of the acute common duct stone-related diathesis.

For patients with spontaneously resolving gallstone pancreatitis, it is important to remove the gallbladder after resolution of the pancreatitis, which typically will include spontaneous offending common duct stone passage, or there will be a 25% to 30% risk of recurrent pancreatitis over the next 6 to 8 weeks. Centers with facility in laparoscopic CBD exploration have reported good results with combined removal of the gallbladder and clearance of the choledocholithiasis. This approach should be considered, where local expertise allows, and offers cost and length-of-stay advantages over strategies utilizing separate ERCP and laparoscopic cholecystectomy procedures, provided the patient is stable for a general anesthetic with regard to any common duct pathology.

Other more rare indications for laparoscopic cholecystectomy may include concern for neoplastic risk in the setting of calcification of the gallbladder wall (“porcelain gallbladder”), enlarging gallbladder polyps, or very large (>3 cm) gallstones. Most gallbladder polyps are simply cholesterol depositions in the gallbladder wall, and are therefore treated based on symptoms rather than out of concern for neoplastic risk. Enlarging polyps or those greater than 1 cm in size may rarely be adenomatous and premalignant, and in such settings cholecystectomy is advised regardless of symptoms.

Because of the prevalence of cholelithiasis on imaging studies, a final question on indications for cholecystectomy relates to the issue of asymptomatic gallstones. Most patients with asymptomatic stones do not develop subsequent symptomatic disease, and 60% to 70% or more in some series remain asymptomatic long term. Exceptions where “prophylactic” cholecystectomy should be considered would include patients who are immunocompromised, awaiting organ transplantation, and those with sickle cell disease. Patients with diabetes do not have an increased risk of fulminant acute disease, and other than their comorbid status, they are not at risk for advanced initial presentation; accordingly, prophylactic cholecystectomy is not recommended in the setting of diabetes.

Contraindications to laparoscopic cholecystectomy are limited to patients in whom general anesthesia and pneumoperitoneum are precluded, such as with acute cardiopulmonary disease. In these settings, nonoperative strategies may serve the patient best. Advanced cirrhosis, suspicion of gallbladder carcinoma, necrotic gallbladder with extensive surrounding inflammation, Mirizzi's syndrome, concomitant acute cholangitis with sepsis unamenable to endoscopic or other nonoperative therapy, and cholecystoenteric fistulous disease are other settings in which an open approach may be advantageous. The surgeon's experience and ability to safely delineate the anatomy, determine the appropriateness of the laparoscopic approach in more complicated settings, and attend to patient safety is always the most important consideration. Pregnancy is not a contraindication to laparoscopic cholecystectomy, but the operation should be deferred until after delivery when possible. If operation during gestation is necessary, the second trimester is the most advantageous time because of the heightened risk of spontaneous abortion in the first trimester and limited peritoneal access and risk of premature labor in the third trimester.

Technique

The patient is positioned with arms abducted on arm boards and dual monitors off the patient's shoulders, so they are respectively in a direct visual line for the surgeon standing on the patient's left and the first assistant opposite. If there is a high likelihood of cholangiographic guided intervention such as laparoscopic CBD duct exploration, it is helpful to tuck the arms to facilitate positioning of C-arm fluoroscopy and additional equipment that may be used. A foot board is useful to prevent the patient sliding on the table when in reverse Trendelenburg position.

Preparation is done from the nipples to the groins and should always include areas needed for laparotomy, should it become necessary. Antibiotic prophylaxis is controversial in elective settings but is still our routine practice: a single dose, given at the time of anesthetic induction. Bacterobilia is present in up to 25% of elderly patients and approximately 10% of the overall population, although the clinical significance is rare in uncomplicated settings. General anesthesia is required, and initial carbon dioxide pneumoperitoneum may be achieved with an open technique or with a Veress needle. Because it facilitates safety in reoperative settings and creates a port site suitable for subsequent organ extraction, we prefer to use an open approach. A paraumbilical entry is made, as dictated by prior surgical scars and the position of the umbilicus in relation to the gallbladder fossa; stay sutures are placed, and a Hasson-type trocar is secured. Initial insufflation should be done at low-flow settings to avoid vasovagal responses and to ensure safe positioning until visually confirmed with laparoscope introduction.

A 15 mm Hg pressure limit is typically utilized, and lower pressure settings may be appropriate with pregnancy or cirrhosis. We prefer to use a 5 or 10 mm, 30-degree angled laparoscope for its visual versatility. Additional trocars are placed under laparoscopic visualization in the epigastrium, just to the patient's right of the falciform ligament (typically 10 mm) and the right subcostal area in the midclavicular and anterior axillary lines (typically 5 mm). Sizes may be decreased to 5 mm at all sites if a 5 mm laparoscope and clip applier are employed. Smaller (2 mm) and so-called needlescopic trocars have been employed but are without added significant cosmetic or recovery benefit, and these may be of limited efficacy in settings of obesity or advanced gallbladder pathology.

Various “single site” techniques have also been more recently described and typically involve placement of multiple trocars through a single paraumbilical incision and juxtaposed fascial trocar insertion sites. These techniques provide a single incision cosmetically but may limit the surgeon's retraction and exposure options compared with standard technique; their ultimate utility and efficacy remain a subject of study, especially in more complicated cases.

The patient is placed in reverse Trendelenburg position after initial trocar placement, and it is sometimes helpful, particularly if there is an enlarged left hepatic lobe or pregnancy, to rotate patients slightly to their left to facilitate exposure and venous return respectively. The gallbladder is elevated in a cephalad direction by grasping the fundus from the right lateral trocar, and the infundibulum is grasped via the midclavicular trocar and retracted laterally, toward the patient's right, to open the hepatocystic triangle. Surgeons may have assistants provide this retraction, or they may control the infundibulum themselves, which facilitates bimanual manipulation and dissection.

The visceral peritoneum is then opened over the area of the gallbladder/cystic duct junction by grasping and pulling in the opposite direction of the infundibular retraction, namely medially and inferiorly. Subsequent grasping and tearing of the investing peritoneum of the triangle itself, alternating anteriorly and posteriorly as the assistant provides opposing traction and exposure, allows the entire triangle to be divested of its peritoneal covering before any structures within it are developed. Cautery is avoided until all structures have been so exposed, and the anatomy clearly delineated, to avoid injury to biliary or vascular structures that may variably, but not uncommonly, be present and require preservation.

The cystic duct and artery are then developed by gentle dissection from the investing areolar tissues using sweeping, spreading, and gentle teasing motions of the dissecting forceps. The cystic duct and artery in particular are carefully traced to their junctions with the gallbladder proper and are developed to allow control with clips. Care should be taken to note the position of the CBD prior to clip application and to use cholangiography liberally if the anatomy is uncertain or appears atypical. It is very helpful to keep in mind the common variations of cystic duct and cystic arterial anatomy as the dissection is accomplished. A so-called critical view is a useful concept at this phase, meaning that before any structures are clipped or divided, the cystic duct and artery are developed adequately to see their course to the gallbladder, with the infundibulum retracted laterally and hepatic parenchyma visible posteriorly through the window developed between those structures.

Although cholangiography has not been shown to clearly prevent bile duct injury, complete and properly interpreted cholangiograms do help to minimize the risk of major ductal injury. The cystic duct and artery are then clipped and divided. If the cystic duct is larger or more edematous than what may be suitable for clipping, absorbable suture with intracorporeal or extracorporeal knot technique is a suitable alternative.

It is our practice to gently tease the areolar tissues that stretch between the gallbladder infundibulum and the gallbladder fossa with a dissecting forceps before using cautery, even after division of the cystic duct and artery; this is because it is not uncommon to encounter an accessory cystic artery or, more rarely, a right hepatic biliary ductal or arterial branch. If identified, such structures are carefully developed and controlled or spared as appropriate. Once this is done, the gallbladder is then mobilized off the hepatic fossa, with cautery applied with either a hook instrument or laparoscopic scissors, as the surgeon's preference dictates. The hook is useful for allowing the operator to create and direct added tension in addition to that provided by the assistant.

It is important for the surgeon to keep the dissection on the plane between the gallbladder and liver capsule to minimize the risk of bile spillage, bleeding, and postoperative bile leaks from terminal ductules in the hepatic parenchyma. Cautery application is limited during the dissection to 2 or 3 second applications to minimize the risk of establishing capacitance circuits in the abdomen that may then lead to bowel or other visceral injury. It is also important to avoid cautery application adjacent to any clips staying in the patient, as conduction of the current to these can lead to delayed thermal injuries, which can include strictures and leaks. The camera operator should carefully work during this phase, as throughout the procedure, to ensure that no instrument introduction or cautery application takes place outside the visual field, which may dynamically alter as tension and cautery are applied.

Prior to final delivery of the gallbladder, the operative area is reinspected for any evidence of bleeding, bile leakage, or insecure clips, after which the gallbladder is fully released. Reducing the insufflation pressure settings to watch for venous bleeding in the liver bed that may otherwise be offset by the pressure of the pneumoperitoneum may be wise, particularly in patients with portal hypertension. The gallbladder is then delivered via the umbilical incision after transferring the laparoscope to the epigastric port. A bag may be utilized but is not necessary if the gallbladder was not entered during dissection. If the gallbladder was entered, any spilled stones should be retrieved if possible. Scooping forceps are useful for this purpose. Although delayed sequelae of spilled stones are relatively rare compared with the number of cases in which some degree of bile spill occurs (up to 30% in some series), a variety of delayed inflammatory and infectious complications have been described, so such a spill is clearly not innocuous.

The trocars are removed under laparoscopic guidance to observe for bleeding. The fascia at the umbilical site is closed with absorbable suture, and stay sutures are placed during Hasson insertion. Fascia is typically not closed at the remaining sites, although closure of the 10 mm epigastric site may be done at the surgeon's discretion using a suture-passing device under laparoscopic guidance. Skin closure is accomplished with absorbable subcuticular suture, and dressings are applied.

In complicated settings such as acute cholecystitis, several adjunctive or alternative techniques may be useful. Perhaps the most useful technique with a tensely distended, acutely inflamed, or gangrenous gallbladder is to aspirate the organ before grasping. This can be done with a laparoscopic aspiration needle introduced through a port or a large length and caliber (14 to 18 gauge) spinal or intravenous access needle introduced directly through the abdominal wall. The gallbladder may also be opened with scissors and suctioned, although this may lead to a higher risk of stone spillage, if this entry site is not readily and persistently controlled with a grasper or suture closure through the subsequent dissection. Toothed graspers may be helpful in controlling the gallbladder once decompressed but may also increase the risk of further tearing and spill during dissection.

Adhesions are typically present in such advanced inflammatory settings but are often acute and edematous, and blunt sweeping on the plane directly on the gallbladder wall will typically allow freeing of the structure to allow subsequent grasping and retraction. As the infundibulum is exposed, continued dissection of the inflamed tissue planes is safest if it proceeds from right lateral to medial, as this achieves added retraction freedom and often allows the critical structure dissection to be commenced only after optimizing retraction and exposure.

Use of a suction/irrigation device is critical in preserving the field of view in such cases where bleeding from the inflamed surfaces can otherwise complicate visualization, and such a device often proves to be a very useful blunt dissecting instrument as well in such settings. If appropriate visualization and exposure cannot be achieved with this approach, conversion to an open procedure should be done in the interest of patient safety.

A dome or fundus-down dissection technique is also potentially useful in cases of advanced inflammation or fibrosis that obscures visualization of the hepatocystic triangle via standard techniques. In this setting, the liver may be elevated by a variety of retractors, either table or handheld, and the gallbladder is dissected off the hepatic bed so that infundibular dissection is circumferential down to the level of the cystic duct and artery. The surgeon should also remember that cholangiography can be obtained by injection into the gallbladder if needed to delineate anatomy and guide safe operative decisions, provided no impacted stone obstructs the gallbladder/cystic duct junction.

Another technique sometimes required in the setting of advanced inflammatory disease is that of leaving a portion of the posterior wall of the gallbladder on the liver. This may be done if the dissection off the liver bed is not possible in an area of advanced fibrotic change. In such settings, the surgeon should remain cognizant of the possibility of neoplasia, and if suspected, conversion to an open procedure with oncologically appropriate wide excision of the gallbladder bed and regional lymphadenectomy would be advised. If a portion of the posterior wall is left on the hepatic bed because of advanced fibrosis and nonneoplastic disease that renders removal of that portion of the gallbladder unduly hazardous, the residual mucosa is cauterized, and a temporary drain is often left in place. Drain placement is sometimes helpful in settings of advanced inflammation in general, as a means to evacuate fluid and monitor for low-grade bile leaks from the liver bed area following such difficult dissections, and this may be readily done laparoscopically by advancing a grasper from the lateral retracting port through the epigastric trocar with retrograde drain positioning.

According to national databases, conversion to an open procedure is required in 5% to 10% of cases, and in up to 25% of cases with severe inflammation. The surgeon should be aware that common duct injuries have been shown to be more likely very early in a surgeon's learning curve with the procedure but also later in their application of the technique, likely representing a willingness to employ it with more advanced disease as experience and confidence have grown. A paramount commitment to patient safety, steady progress of the dissection, adequate visualization and exposure, and clear delineation of all anatomy before structure division will appropriately serve the surgeon in the decision about whether to convert to an open approach. In any event, such a decision should not be seen as a failure but rather an appropriate judgment in the interest of patient safety.

As a final comment on the technique of laparoscopic cholecystectomy, there is growing interest in the concept of natural orifice transluminal endoscopic surgery (NOTES) approaches to cholecystectomy. Clinical experience has been described with both transgastric and transvaginal NOTES approaches to cholecystectomy. Many of the initial reports involve hybrid techniques with laparoscopic or transabdominal access along with the transluminal approach. Meaningful benefits of this technique, as well as the risks and technical limits of such approaches, if and when they are applied on a widespread scale, remain to be determined. Expanded endoscopic and laparoscopic instrumentation capabilities will be a likely beneficial outcome of this area of endeavor, regardless of its eventual broader clinical applications or lack thereof.

Complications

The most common intraoperative complications encountered are bleeding and stone spillage. The latter is mentioned above and is estimated in the literature to occur in up to 30% of cases. Spillage is more likely to occur in settings of advanced or acute inflammation and should be addressed with a judicious effort to retrieve all spilled stones owing to the relatively rare, but not insignificant, well-described risk of delayed infectious and other complications of retained spilled stones. When encountered, bleeding is often seen during the dissection of the structures in the hepatocystic triangle, especially in the setting of advanced acute inflammation or chronic fibrosis. In such cases bleeding typically arises from an inadvertent trauma to a cystic artery or other communicating branch of the right hepatic artery.

The surgeon should resist the temptation to blindly use cautery or clips without first clearly delineating the anatomy. A useful technique when simple suction, irrigation, or gentle grasping and continued observation fail to allow efficient and appropriately directed control is for the assistant to use the infundibulum as a tamponade agent and push it via the grasper retracting that portion of the gallbladder into the area of bleeding. The surgeon may then place a fifth trocar into the abdomen, typically between the umbilicus and epigastric trocar sites, and work bimanually with suction and dissection to delineate the anatomy and allow safe control of the clearly delineated source. Inability to rapidly control bleeding should prompt conversion to an open approach. Bleeding from the hepatic bed is usually readily controlled with limited cautery application or with topical prothrombotic agents or argon plasma coagulation if necessary. Trocar-site bleeding is often seen during inspected trocar withdrawal if it does occur, and it is most efficiently dealt with by placement of transfascial sutures around the site using suture placement tools such as the Carter–Thompson device, which was designed for such placement.

Bile duct injury is the most feared complication of laparoscopic cholecystectomy, and although rare in experienced hands, it continues to be reported more frequently (0.3% to 1.0% incidence) than in series done via an open approach. Avoidance is best achieved by the measures outlined above, including avoidance of cautery early in the dissection or in proximity to major structures or clips that can act as conductors; clear visualization and demonstration of the anatomy, including liberal use of complete and properly interpreted cholangiography in unclear settings; optimization of visualization through careful clearance of any bleeding prior to control of structures during dissection; and exercising particular care in settings of advanced inflammatory disease.

Unfortunately, a high percentage of bile duct injuries are not recognized when they occur. If recognized, small tangential injuries of the common duct, such as a partial tear due to avulsion/retraction at the cystic duct insertion site, may be dealt with by T tube placement. More advanced injuries include full-thickness transections of the CBD, injuries associated with excision of a portion of the common duct or right hepatic duct mistaken for the cystic duct, or injuries associated with thermal energy; these should be dealt with via Roux-en- Y hepaticojejunostomy. Injuries recognized in the early postoperative period, manifested by jaundice or biloma formation, should be investigated with high-resolution cholangiography such as ERCP or percutaneous cholangiography. For partial-thickness injuries and low-volume leaks, sphincterotomy and/or stenting via one of these approaches may achieve control of the leak and allow healing. Endoscopic stenting in prolonged fashion may also allow successful nonoperative management of some partial-thickness injuries and partial strictures of the bile duct following operative injury. For more advanced injuries such as complete ductal division, obstruction, or excision, unless recognized very early in the course, the best option is a delayed hepaticojejunostomy reconstruction by a highly experienced biliary surgeon after thorough control of the leak and decompression of the biliary system with detailed cholangiographic delineation of the injury via percutaneous drains and catheters.

Other rare complications include trocar site hernias, which are typically at the umbilicus and most commonly occur when a preexisting umbilical hernia was not addressed at the time of surgery, or when inadequate fascial closure is accomplished at this site. If an umbilical hernia is present preoperatively, a useful strategy is to use the hernia as the initial access site and repair it at the end of the procedure. Changes in bowel habits with increased stool frequency is a relatively frequent complaint after cholecystectomy, occurring in up to 25% of patients; but in the vast majority, this resolves over a period of weeks to months after the surgery. If persistent, such complaints should be evaluated to exclude other sources of the change in bowel habits, and if none are identified, symptoms may be ameliorated with medical measures, such as fiber supplementation or cholestyramine administration.

Summary

Laparoscopic cholecystectomy offers a well-attested means of control for the symptoms of gallbladder disease, by far the most common intra-abdominal pathology encountered in the typical gastrointestinal surgical practice. As such, it is clearly established at this point as the procedure of choice in dealing with symptomatic disease of the gallbladder. The principles learned and repetitively applied in performing this operation form the foundation of most surgeons' skill set in minimally invasive surgical technique, both before and, by volume criteria if not otherwise, after residency training. A thorough understanding of the indications, anatomical variations, technique, and potential complications of this procedure – with attention to their prevention, recognition, and management – is thus of paramount significance in surgical education and practice.

Step 1. Surgical Anatomy

• The triangle of Calot is the most important anatomic boundary that needs to be defined when performing cholecystectomy. It is formed by the boundaries of the cystic duct, common hepatic duct, and cystic artery.

• Roughly parallel to this triangle is the hepatocystic triangle in which the cystic artery boundary is replaced with the liver edge. The only structure that should be found within this triangle is the cystic artery.

Step 2. Preoperative Considerations