LAPAROSCOPIC CHOLECYSTECTOMIES

Cholecystectomies (removal of the gallbladder) are extremely common, and surgeons have been using the laparoscope to perform the procedure since 1989.  The liver produces bile which is needed for the digestion of fat.  The bile is concentrated and stored in the gallbladder which contracts after meals.  Gallstones form in the gallbladder, and after digestion a stone can get trapped in the gallbladder duct which will trigger a painful attack.

The typical history is right upper or upper mid abdominal pain usually after but sometimes between meals and occasionally at night. The pain can radiate to the upper back and is often followed by nausea. Labor pain, kidney stone pain, and the pain due to appendicitis have the same mechanism.  Like appendicitis, the gallbladder pressure can escalate and lead to infection, gangrene, perforation, peritonitis, multiple organ failure, and death. Unlike appendicitis, gallbladder perforation is rare.

An abdominal ultrasound is the test of choice to confirm the diagnosis.  “Gallbladder sludge” represents multiple small stones (sand and gravel are other terms) and is a positive test.   However, a negative ultrasound does not rule out gallbladder disease.  Specifically, a patient may have classic symptoms but stones that are too small to be seen on ultrasound.  Accordingly, a gallbladder (HIDA) scan can indirectly yield a diagnosis.  An abdominal CT scan can also demonstrate findings consistent with gallbladder disease or malignancy.

Patients occasionally present with disabling symptoms strongly suggestive of biliary colic with a normal work up.  Physicians are trained to treat patients and not X-rays, and surgery is offered as an option beyond a low fat diet.  Conversely, surgery is not recommended for patients who have gallstones and no symptoms.

Four small incisions are used (one for the camera, three for dissection), and the procedure usually takes less than an hour.  Patients  remain 4 hours and may go home if discharge criteria are satisfied.  Clear liquids are begun immediately and may be advanced to soft food on the first day.  Most patients return to work within a week.  Conversion to open surgery is always a possibility and is minimized by  prompt treatment.  Procrastinating elective surgery risks the possibility of an acute attack which makes laparoscopy more difficult.  Open surgery leads to far longer hospital stays, far more disability, and a much longer recovery.

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