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| Laparoscopic Cholecystectomy |
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| What
is Gall bladder? |
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| The gallbladder is a pear-shaped organ
that lies beneath the liver in the right-upper abdomen.
The gallbladder is connected to the liver (which produces
the bile) by the hepatic duct. Its function is to store
bile. When food containing fat reaches the small intestine,
a hormone called cholecystokinin is produced by cells
in the intestinal wall and is carried to the gall bladder
via the bloodstream. The hormone causes the gall bladder
to contract, forcing bile into the common bile duct. A
valve, which opens only when food is present in the intestine,
allows bile to flow from the common bile duct into the
duodenum (upper intestine) where it functions in the process
of fat digestion. |
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| What
is cholecystitis? |
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|
 Cholecystitis
is an inflammation of the gallbladder wall and nearby
abdominal lining. Cholecystitis can occur suddenly or
gradually over many years. Acute cholecystitis is the
sudden onset of inflammation of the gallbladder, resulting
in severe, steady upper abdominal pain (biliary colic),
which may occur repeatedly. Chronic cholecystitis is
long-standing inflammation of the gallbladder characterized
by repeated attacks of pain (gallbladder attacks) over
a prolonged period.
At least 95% of people with acute cholecystitis have
gallstones. Gallstones are stones which are formed in
the gallbladder. The Gall Bladder stores and concentrates
bile. Sometimes the substances contained in bile crystallize
in the gall bladder, forming stones. These small, hard
concretions are more common in persons over 40, especially
in women and the obese. Rarely, acute cholecystitis
occurs in a person without gallstones (acalculous cholecystitis).
In these cases the cause can be any major injury, operation
or burn, bacterial infection in the bile duct system,
tumor of the pancreas or liver.
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| What
are the symptoms of cholecystitis? |
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 A
gallbladder attack, whether in acute or chronic cholecystitis,
begins as severe, steady abdominal pain (biliary colic).
The person typically feels a sharp pain when a doctor
presses on the upper right part of the abdomen. The pain
may worsen when the person breathes deeply and often extends
to the lower part of the right shoulder blade. The pain
may become excruciating; and may be accompanied by nausea
and vomiting. The pain usually lasts more than 12 hours.
Within a few hours, the abdominal muscles on the right
side become rigid. Fever occurs in about one third of
people but is less likely in older people. The fever tends
to be mild at first, and then rises gradually to above
100° F (38° C). Typically, an attack of cholecystitis
subsides in 2 to 3 days and completely disappears in a
week. If the attack persists, it may signal a serious
complication. This disorder initially produces symptoms
similar to those of indigestion, especially after a fatty
meal is consumed. This may be accompanied by nausea and
vomiting. But when a stone becomes lodged in the bile
duct, it produces severe pain. Many people also remain
asymptomatic. The symptoms of cholecystitis may resemble
gastric pain but one must always consult their physician
for a proper diagnosis. |
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| How
is it diagnosed? |
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Doctors diagnose cholecystitis, both acute and chronic,
based on the person's symptoms and the results of tests
that suggest gallbladder inflammation. The physician
will perform a careful abdominal examination to confirm
the diagnosis. The enlarged, tender gallbladder may
be felt by the physician through the abdominal wall.
Pressure in the upper right corner of the abdomen may
cause the patient to stop breathing in, due to an increase
in pain. This is called Murphy's sign. Besides this,
few diagnostic procedures may be advised. They include:
- Blood tests: Increased levels of white blood cells
suggest inflammation or infection or both. There may
also be increase in bilirubin levels.
- Ultrasound (Also called sonography.) - A diagnostic
imaging technique which uses high-frequency sound
waves to create an image of the internal organs. Ultrasounds
are used to view internal organs of the abdomen such
as the liver spleen, and kidneys and to assess blood
flow through various vessels. Ultrasound scans can
also show thickening of the gallbladder wall, which
is typical of chronic cholecystitis.
- Hepatobiliary scintigraphy - Cholescintigraphy is
an imaging technique that is useful when acute cholecystitis
is difficult to diagnose. In this test, a radioactive
tracer is injected intravenously and its movement
from the liver through the biliary tract is followed.
Images are taken of the liver, bile ducts, gallbladder,
and upper part of the small intestine. If the tracer
does not fill the gallbladder, it is presumed that
the cystic duct is obstructed by a gallstone.
- Cholangiography - x-ray examination of the bile
ducts using an intravenous (IV) dye (contrast).
- Endoscopic retrograde cholangiopancreatography (ERCP)
- a procedure that allows the physician to diagnose
and treat problems in the liver, gallbladder, bile
ducts, and pancreas. The procedure combines x-ray
and the use of an endoscope - a long, flexible, lighted
tube. The scope is guided through the patient's mouth
and throat, then through the oesophagus, stomach,
and duodenum. The physician can examine the inside
of these organs and detect any abnormalities. A tube
is then passed through the scope, and a dye is injected
which will allow the internal organs to appear on
an x-ray.
- Computed tomography scan (CT or CAT scan) - a diagnostic
imaging procedure using a combination of x-rays and
computer technology to produce cross-sectional images
(often called slices), both horizontally and vertically,
of the body. A CT scan shows detailed images of any
part of the body, including the bones, muscles, fat,
and organs. CT scans are more detailed than general
x-rays.
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| How
is cholecystitis treated? |
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| The approach taken to treat cholecystitis
depends upon: |
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- Extent of the disease
- Age, overall health, and medical history of the
patient
- Tolerance of specific medicines, procedures, or
therapies
- Expectations for the course of the disease
- Patient's opinion or preference
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| For acute cholecystitis, initial treatment
includes bowel rest, intravenous hydration, intravenous
antibiotics and pain management. Whether it is acute or
chronic cholecystitis, the physician then takes a step
to identify the cause. If the cause is gallstones, then
he may suggest the conventional solution in which the
gall bladder itself is removed. And if the physician feels
that it is best to remove the gall bladder, he may advice
the patient to undergo Cholecystectomy after the acute
phase subsides. Cholecystectomy merely means removal of
the gallbladder. In acalculous cholecystitis, immediate
surgery is necessary to remove the diseased gallbladder.
Cholecystectomy again can be done by conventional method
(also called open method) or by the laparoscopic method.
We wish to provide our patients with complete information
about the available treatments. So we are discussing (below)
both the conventional and new methods. |
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| The
conventional method |
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| The conventional method, also called
open method was initially the only standard treatment.
This was the common treatment offered both for gallstone
removal or gallbladder removal. This procedure required
a 3 to 7 day stay in the hospital and a 3 to 7 inch incision
and scar on the abdomen. The surgeon makes an abdominal
incision under the right side of the rib cage, which cuts
through the skin and muscle. The gallbladder is then located
and removed. |
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| Latest
Methods |
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Laparoscopic Cholecystectomy is now the gold standard
treatment and is the commonest operation performed laparoscopically
worldwide. Gynaecologists have long used this technique
to tie the Fallopian tubes and to inspect the female
reproductive organs. Now the use of laparoscopy has
been expanded to include removing a diseased gallbladder.
The first documented laparoscopic Cholecystectomy was
performed by Erich Mühe in Germany in 1985. Currently,
over 90% of cholecystectomies are performed laparoscopically;
making it the most common procedure performed in general
surgery practice.
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| It is a minimally invasive approach
that involves specialized video equipment and instruments
that allow a surgeon to remove the gallbladder through
four tiny incisions, most of which are less than a half-centimetre
in size. |
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| Before
the procedure |
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| After deciding upon the line of treatment
of the case, the physician will explain the procedure
to the patient. He will also give an opportunity to the
patient and his relatives to ask any queries or doubts.
In addition to a complete medical history, the physician
may perform a physical examination to ensure that the
patient is in good health. In an otherwise healthy person,
little is required to prepare for surgery. Depending on
the age, gender, and health problems, some routine blood
tests, an EKG and a chest x-ray may be needed. In fit
patients, the only investigations needed are ultrasound
examination, haemoglobin estimation, and liver function
tests. Blood is also collected for group determination
and keeping a couple of bottles on the standby. Endoscopic
retrograde cholangiopancreatography (ERCP) is performed
when ductal stones are suspected on the basis of clinical,
biochemical and ultra-sound criteria. The surgeon will
also make note if there is any history of allergy to any
medication or anesthetic agents. One should be very open
with their surgeon and must let him know about all medications
he is taking. In general, all blood thinners need to be
stopped 3-5 days before surgery. |
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| The physician fixes up the surgery
date and the patient is given an outline of the schedule.
The patient will be instructed to refrain from eating
8 hours before surgery. On the day of the surgery, the
patient is required to sign a consent form. The patient
is again thoroughly examined by the physician. Based upon
the patient's medical condition, the physician may request
the specific preparation. Gallbladder operations are performed
under general anaesthesia. An IV line will be placed in
the arm for fluids and then the patient is brought into
the operation room. |
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| During
the procedure |
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 The
anaesthesiologist and nurses keep using monitors to
check the heart rate and breathing rate during the procedure.
These may include EKG leads, a blood pressure cuff and
an oxygen mask. The patient is operated in the supine
position with a steep head-up tilt. A nasogastric tube
is inserted and the stomach aspirated. The tube is kept
in the stomach during the operation but removed at the
end of the procedure.
Laparoscopic cholecystectomy requires several small
incisions in the abdomen to allow the insertion of surgical
instruments and a small video camera. So, the surgeon
makes a small incision at the navel o insert a thin
tube carrying the video camera. The camera 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 then inflates the abdomen with carbon dioxide,
a harmless gas, for easier viewing and to provide room
for the surgery to be performed. Next, two needles-like
instruments are inserted at a different place. These
instruments serve as tiny hands within the abdomen.
They can pick up the gallbladder, move intestines around,
and generally assist the surgeon. Finally, several different
instruments are inserted to clip the gallbladder artery
and bile duct, and to safely dissect and remove the
gallbladder and stones. When the gallbladder is freed,
it is then eased out of the tiny navel incision. The
entire procedure normally takes 60 minutes. The three
puncture wounds require no stitches and may leave very
slight blemishes. The navel incision is barely visible.
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| After
the Procedure |
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| After the procedure, the patient is
taken to the recovery room for observation. The recovery
process will vary depending upon the type of procedure
performed and the type of anaesthesia that is given. Once
the blood pressure, pulse, and breathing are stable and
the patient is alert, they are shifted to the hospital
room. It is common to feel groggy and nauseated soon after
surgery and medication is available to help with these
discomforts. |
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| Benefits
and drawbacks |
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| Using advanced laparoscopic technology,
it is now possible to remove the gallbladder through a
tiny incision at the navel! With new video technology,
the laparoscope has become a miniature television camera.
Powerful magnification is now possible, showing the intestinal
organs in great detail. It is an exciting development
because it offers so much to the patient like: |
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- Less postoperative pain because it does not require
the abdominal muscles to be cut
- Shortens hospital stay
- May result in a quicker return to bowel function
- Quicker return to normal activity
- Better cosmetic results
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| But while the procedure seems very
easy for the patient, it is still an abdominal surgery.
In many instances, the surgeon may not recommend this
procedure. To decide upon the technique, the surgeon has
to carefully evaluate each case and weigh the benefit
for the patient against the risks. However, in the presence
of infection, adhesions, or variations in anatomy, this
method becomes dangerous and your surgeon may need to
make the prudent decision to continue by making the traditional
incision to safely complete the operation. This should
not be seen as a failure, but as a wise decision by your
surgeon to prevent dangerous complications. In about 5
to 10% of cases, the gallbladder cannot be safely removed
by laparoscopy. In these cases, standard open abdominal
surgery has to be the mode of treatment. The table given
below compares the laparoscopic and open surgery. |
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LAPAROSCOPIC
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OPEN
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Small Incisions (less than ½
an inch)
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Large Incision
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Hospital stay is 1 to 3 days
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Hospital stay of about 5 days
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Patients usually return to work
in 5 to 10 days
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Return to work in about 4 weeks
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Lesser risk of Infection
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Greater risk of infection
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Less pain
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More painful
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Less chance of hernias
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More chance of hernias
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| Complications |
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| An uncommon but potentially serious
complication with the new procedure is injury to the common
bile duct, which connects the gallbladder and liver. An
injured bile duct can leak bile and cause a painful and
potentially dangerous infection. Many cases of minor injury
to the common bile duct can be managed non-surgically.
Major injury to the bile duct, however, is a very serious
problem and may require corrective surgery. At this time
it is unclear whether these complications are more common
following laparoscopic cholecystectomy than following
standard cholecystectomy. |
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| Care at
home |
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| Once the patient is back at home,
it is important to keep the incision clean and dry. The
physician will give specific bathing instructions. If
stitches or surgical staples are used, they will be removed
during a follow-up office visit. If adhesive strips are
used, they should be kept dry and generally will fall
off within a few days. |
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| The incision and the abdominal muscles
may ache, especially after long periods of standing. Pain
relievers for soreness can be taken as recommended by
the physician. Aspirin or certain other pain medications
may increase the chance of bleeding. Patients must ensure
that they take only recommended medications. Walking and
limited movement are generally encouraged, but strenuous
activity should be avoided. The physician will give proper
instructions about when the patient can return to work
and resume normal activities. |
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