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CHOLECYSTECTOMY

Prepared by: Heron Jayson E. Bayanin

BSN 3-1 Group 1

Cholecystectomy is the surgical removal of the gallbladder. It is

the most common method for treating symptomatic  gallstones

Surgical options include the standard procedure, called

laparoscopic cholecystectomy, and an older more invasive

procedure, called open cholecystectomy.

Why does gallbladder need to be removed?

The gallbladder is a small, pear-shaped pouch in the

upper-right part of your abdomen (tummy). It stores bile, which

is the digestive fluid produced by the liver that helps to break

down fatty foods.

Bile is made from cholesterol, bile salts and waste products.

When these substances are out of balance, small, hard stones

called gallstones can form. Gallstones often cause no symptoms

and, in many cases, remain undetected.

However, in a small number of cases, gallstones can become

trapped in a duct (an opening or channel), irritate and inflame

the gallbladder, or move out of the gallbladder and into other

parts of the body.

This can lead to a range of symptoms, such as:

 

a sudden intense pain in your abdomen

  feeling and being sick

   jaundice (yellowing of the skin and the whites of the

eyes)

There are several non-surgical ways to break down gallstones,

but they are only effective in around less than 1 in 10 cases and

are rarely a viable option.

For most people with painful gallstones it is recommended that

their gallbladder is removed.

Open Surgery:A traditional open cholecystectomy is a major abdominal surgery

in which the surgeon removes the gallbladder through a 5- to 7-

inch incision. Patients usually remain in the hospital at least 2 to

3 days and may require several additional weeks to recover at

home.

Laparoscopic Surgery:

Laparoscopic cholecystectomy requires several 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 and a video camera are placed into

the abdominal cavity. The camera illuminates the surgical field

and sends a magnified image from inside the body to a video

monitor, giving the surgeon a close-up view of the organs and

tissues. The surgeon watches the monitor and performs the

operation by manipulating the surgical instruments through the

operating ports.

To begin the operation, the patient is placed in the  supine

position on the operating table and anesthetized. A scalpel is

used to make a small incision at the umbilicus. Using either

a Veress needle or Hasson technique the abdominal cavity is

entered. The surgeon inflates the abdominal cavity with carbon

dioxide to create a working space. The camera is placed through

the umbilical port and the abdominal cavity is inspected.

Additional ports are opened inferior to the ribs at

the epigastric,midclavicular, and anterior axillary positions. The

gallbladder fundus is identified, grasped, and retracted

superiorly. With a second grasper, the gallbladder infundibulumis retracted laterally to expose and open Calot's Triangle (the

area bound by the cystic artery, cystic duct, and common

hepatic duct). The triangle is gently dissected to clear the

peritoneal covering and obtain a view of the underlying

structures. The cystic duct and the cystic arteryare identified,

clipped with tiny titanium clips and cut. Then the gallbladder is

dissected away from the liver bed and removed through one of

the ports. This type of surgery requires meticulous surgical skill,

but in straightforward cases can be done in about an hour.

Recently, this procedure is performed through a single incision in

the patient's umbilicus. This advanced technique is called

Laparoendoscopic Single Site Surgery or "LESS".

How is laparoscopic cholecystectomy performed?

Many thousands of laparoscopic cholecystectomy have been

performed in the USA and this operation has an excellent safety

record. Some of the important steps in the operation are as

follows:

 

General anesthesia is utilized, so the patient is as

throughout the procedure.

  An incision that is approximately half an inch is m

around the umbilicus ( belly button), three other

quarter to half inch incisions are made for a tota

four incisions. Four narrow tubes called laparosc

ports are placed through the tiny incisions for the

laparoscopic camera and instruments.

  A laparoscope (which is a long thin round instrum

with a video lens at its tip) is inserted through thbutton port and connected to a special camera. T

laparoscope provides the surgeon with a magnifi

view of the patient's internal organs on a televisi

screen.

  Long specially designed instruments are inserted

through the other three ports that allow your su

to delicately separate the gallbladder from its

attachments to the liver and the bile duct and th

remove it through one of the ports from the abd

 

Your surgeon may occasionally perform an X-ray

a cholangiogram, to exam for stones in the bile d

  After the gallbladder is removed from the abdom

then the small incisions are closed

Procedural Risk and Complications

Laparoscopic cholecystectomy does not require the

abdominal muscles to be cut, resulting in less pain, quicke

healing, improved cosmetic results, and fewer complicatio

such as infection and adhesions. Most patients can be

discharged on the same or following day as the surgery, a

return to any type of occupation in about a week. Further

flexible instruments are being used in laparoscopic surger

some surgeons. Using the SPIDER surgical system, they ca

perform the cholestectomy through a single incision throu

navel. These patients often recover faster than traditiona

methods, and have an almost invisible scar.

An uncommon but potentially serious complication is inju

the common bile duct, which connects the gallbladder an

An injured bile duct can leak bile and cause a painful and

potentially dangerous infection. Many cases of minor inju

the common bile duct can be managed non-surgically. Ma

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injury to the bile duct, however, is a very serious problem and

may require corrective surgery. This surgery should be

performed by an experienced biliary surgeon.[2]

 

Abdominal peritoneal adhesions, gangrenous gallbladders, and

other problems that obscure vision are discovered during about

5% oflaparoscopic surgeries, forcing surgeons to switch to the

standard cholecystectomy for safe removal of the gallbladder.

Adhesions and gangrene, of course, can be quite serious, but

converting to open surgery does not equate to a complication.

A Consensus Development Conference panel, convened bythe National Institutes of Health in September 1992, endorsed

laparoscopic cholecystectomy as a safe and effective surgical

treatment for gallbladder removal, equal in efficacy to the

traditional open surgery. The panel noted, however, that

laparoscopic cholecystectomy should be performed only by

experienced surgeons and only on patients who have symptoms

of gallstones.

In addition, the panel noted that the outcome of laparoscopic

cholecystectomy is greatly influenced by the training,

experience, skill, and judgment of the surgeon performing the

procedure. Therefore, the panel recommended that strict

guidelines be developed for training and granting credentials in

laparoscopic surgery, determining competence, and monitoring

quality. According to the panel, efforts should continue toward

developing a noninvasive approach to gallstone treatment that

will not only eliminate existing stones, but also prevent their

formation or recurrence.

One common complication of cholecystectomy is inadvertent

injury to analogous bile ducts known as Ducts of Luschka, 

occurring in 33% of the population. It is non-problematic until

the gall bladder is removed, and the tiny supravesicular ducts

may be incompletely cauterized or remain unobserved, leading

to biliary leak post-operatively. The patient will develop biliary

peritonitis within 5 to 7 days following surgery, and will require a

temporary biliary stent. It is important that the clinician

recognize the possibility of bile peritonitis early and confirmdiagnosis via HIDA scan to lower morbidity rate. Aggressive pain

management and antibiotic therapy should be initiated as soon

as diagnosed.

During Laparoscopic Cholecystectomy, gallbladder perforation

can occur due to excessive traction during retraction or during

dissection from the liver bed. It can also occur during extraction

from the abdomen. Infected bile, pigment gallstones, male

gender, advanced age, perihepatic location of spilled gallstones,

more than 15 gallstones and an average size greater than 1.5 cm

have been identified as risk factors for complications. Spilled

gallstones can be a diagnostic challenge and can cause

significant morbidity to the patient. Clear documentation of

spillage and explanation to the patient is of utmost importance,

as this will enable prompt recognition and treatment of any

complications. Prevention of spillage is the best policy.[3]

 

Biopsy

After removal, the gallbladder should be sent for pathological

examination to confirm the diagnosis and look for an incidental

cancer. If cancer is present, a reoperation to remove part of the

liver and lymph nodes will be required in most cases

Long Term Prognosis

A minority of the population, from 5% to 40%, develop a

condition called postcholecystectomy syndrome, or

PCS.[5]

 Symptoms can include gastrointestinal distress and

persistent pain in the upper right abdomen.

As many as twenty percent of patients develop chronic diarrhea.The cause is unclear, but is presumed to involve the disturbance

to the bile system. Most cases clear up within weeks, though in

rare cases the condition may last for many years. It can be

controlled with medication.[6]

 

Living without a gallbladder

You can lead a perfectly normal life without a gallbladder. The

organ can be useful but it's not essential. Your liver will still

produce bile to digest food.

However, some people who have had their gallbladder removed

have reported symptoms of bloating and diarrhoea after eating

fatty or spicy food. If certain foods do trigger symptoms, youmay wish to avoid them in the future. Read more about making

changes to your diet after gallbladder surgery. 

Some people may also experience pain and indigestion as a

result of a stone being left inside a bile duct. This will require

further surgery to remove the stone.