Cholecystectomy is one of the most common surgical procedures performed in the United States, with over 700,000 procedures performed each year.¹ Open cholecystectomy, first performed by Carl Langenbuch in 1882, had been the primary treatment of gallbladder disease through the early 1990s.² In 1985, the first endoscopic cholecystectomy was performed by Erich Mühe of Böblingen, Germany. Shortly thereafter, pioneers in France and the United States coupled a video camera with a laparoscope to allow the surgeon and the entire surgical team to more easily view the operative field and performed cholecystectomies with laparoscopic equipment. Since then, laparoscopic cholecystectomy has been adopted around the world, and subsequently been recognized as the gold standard for the treatment of gallstone disease.^3,4 The first laparoscopic cholecystectomy in the United States was performed in 1988, and by 1992, the National Institutes of Health (NIH) Consensus Development Conference stated that laparoscopic cholecystectomy provides a safe and effective treatment for most patients with symptomatic gallstones.⁵ Currently, it is estimated that approximately 90% of cholecystectomies in the United States are performed using a laparoscopic approach.⁶

The advantages of laparoscopic over open cholecystectomy have been well documented. These advantages include earlier return of bowel function, less postoperative pain, improved cosmesis, shorter length of hospital stay, earlier return to full activity, decreased wound infections and incision hernia formation, and decreased overall cost.^4,5,7,8 There has been an increase in the rate of cholecystectomies subsequent to the introduction of laparoscopic cholecystectomy accompanied by evidence of lower clinical thresholds for operative therapy of gallbladder disease.^9,10

Symptomatic Cholelithiasis

There are multiple indications for cholecystectomy, with the most common being symptomatic cholelithiasis, also termed “biliary colic” (Table 62-1). Biliary colic typically presents as a severe and episodic right upper abdominal or epigastric pain that can radiate to the back. Attacks frequently occur within 1 to 2 hours postprandially or awaken the patient from sleep. Most often, the postprandial pain will be associated with meals that are high in fat content. These episodes typically last between 30 minutes and 6 hours and can be associated with nausea and vomiting.

Once a patient begins to experience symptoms, there is a greater than 80% chance that he or she will continue to have symptoms in the future or develop a complication. These complications may result from obstruction of the gallbladder outlet, causing acute cholecystitis, or migration of a stone into the common bile duct, causing cholangitis or pancreatitis. Because there are no effective medical therapies for cholelithiasis, any patient who develops symptoms from gallstone disease should be offered laparoscopic cholecystectomy, given their medical comorbidities do not pose a prohibitive operative risk.

Patients being considered for laparoscopic cholecystectomy should undergo a complete medical history and physical examination. The history should focus on confirming that the patient’s symptoms are consistent with biliary colic and determining whether they have symptoms indicative of complications of gallstone disease, such as acute cholecystitis, choledocholithiasis, or gallstone pancreatitis. Additionally, a complete medical history is required to determine the patient’s overall surgical risk. Patients with symptomatic cholelithiasis do not typically manifest any signs on physical exam, even when they are in the midst of a pain episode. This is because their pain is visceral in nature, without associated inflammation that would cause local peritonitis and somatic pain. As a result, if a patient has significant right upper quadrant tenderness on exam, it should be suspected that they have acute cholecystitis or another inflammatory process.

Patients being evaluated for gallstone disease should have a complete metabolic panel, including liver function tests (LFTs), and a complete blood count (CBC). Elevations in the LFTs, especially direct bilirubin, may suggest biliary obstruction from choledocholithiasis. Elevations in amylase and, more specifically, lipase may indicate gallstone pancreatitis. A leukocytosis is suggestive of acute cholecystitis.

In a patient with typical biliary colic, the only diagnostic imaging study necessary prior to laparoscopic cholecystectomy is an abdominal ultrasound revealing gallstones. Ultrasound demonstrates the size and number of stones, the thickness of the gallbladder wall, the presence or absence of pericholecystic fluid, the diameter of the common bile duct (CBD), and other components of the biliary ductal system. Gallstones are seen as rounded hyperechoic echoic shapes on ultrasound that cause hypoechoic “shadowing” deep to their location on the ultrasonic image (Fig. 62-1). Other nonbiliary disorders such as hepatic lesions or steatosis, masses in the pancreas, or renal tumors may also be diagnosed. If a patient with gallstones has atypical symptoms, however, a more extensive workup including upper gastrointestinal contrast radiography or endoscopy, computed tomography, or cardiac and pulmonary evaluation may be appropriate to rule out significant nonbiliary disease processes.

Acute Cholecystitis

Acute cholecystitis occurs when a gallstone or sludge becomes lodged in the gallbladder-cyst duct junction, creating bile stasis in the gallbladder, which in turn leads to inflammation and infection. In contrast to biliary colic, patients with acute cholecystitis usually present to the emergency department with unrelenting right upper quadrant or epigastric pain, and can additionally have fevers and more severe nausea and vomiting. On physical exam, they can be febrile and tachycardic, but the most consistent exam finding is right upper quadrant tenderness, which is not typically present with biliary colic. Murphy sign is the traditional physical exam test for evaluating for acute cholecystitis. To elicit it, the examiner palpates the right upper quadrant immediately below the costal margin and asks the patient to inspire deeply. This maneuver moves the diaphragm inferiorly and brings the gallbladder into contact with the anterior abdominal wall under the examiner’s hand, which causes pain in the setting of cholecystitis. Thus, if the patient abruptly ceases inspiration due to pain, he or she is found to have a positive ­Murphy sign. A positive Murphy sign has been shown to have a sensitive of 97% and a specificity of 48% in ­diagnosing acute cholecystitis, with cholescintigraphy used as the “gold standard.”¹¹

Laboratory evaluation can reveal an elevated white blood cell count in patients with acute cholecystitis, although their liver function tests, especially the direct bilirubin, should be relatively normal given there is no biliary obstruction. Abdominal ultrasound should reveal the presence of gallstones and can additionally show 2 signs that are specific to cholecystitis: thickening of the gallbladder wall to greater than 4 mm and pericholecystic fluid. When combined, these findings have a sensitivity of 88% and specificity of 80% in diagnosing acute cholecystitis.¹² However, in our experience, the presence or absence of these ultrasound findings does not correlate well with the degree of inflammation found at the time of subsequent operation.

A thorough history and physical examination, combined with findings on abdominal ultrasound, should be sufficient to confirm a diagnosis of acute cholecystitis in almost all instances; however, if doubt exists, cholescintigraphy (also known as a HIDA scan) can be used. Cholescintigraphy is a nuclear medicine study in which a radiotracer, ^99mTc-hepatic iminodiacetic acid (HIDA), is injected intravenously and selectively taken up by the liver. The tracer is then excreted into the biliary tree, and a lack of uptake into the gallbladder signifies an obstruction of the cystic duct and thus a diagnosis of cholecystitis. Cholescintigraphy has a sensitivity of greater than 95% and a specificity of 90% in diagnosing acute cholecystitis.¹³

Patients with acute cholecystitis should be admitted to the hospital, placed on bowel rest, volume resuscitated with isotonic intravenous fluid, and treated with intravenous antibiotics that cover gram-negative and anaerobic bacteria. Although some patients may improve with this conservative treatment, recurrence rates are high, and if the patients have acceptable operative risk, almost all patients with acute cholecystitis should undergo cholecystectomy for definitive treatment. This timing of this operation has long been a topic of considerable debate, with some advocating initial treatment with antibiotics and then performing a cholecystectomy on an elective basis several weeks later after the acute inflammation has abated. However, as more data have emerged during the laparoscopic era, it is becoming clear that a strategy of early cholecystectomy during the initial hospitalization for acute cholecystitis is safe and carries significant benefits. A randomized trial involving over 600 patients compared a strategy of early laparoscopic cholecystectomy (within 24 hours) with one of initial antibiotic therapy and interval cholecystectomy between 7 and 45 days later and found that the early surgery group had fewer complications (12% vs 34%), a shorter overall hospital length of stay, and lower hospital costs.¹⁴ A meta-analysis of 15 randomized controlled trials showed that early surgery for cholecystitis resulted in short hospital stays with lower costs and higher patient satisfaction and quality of life, while perioperative mortality and morbidity were similar between the early and delayed surgery groups.¹⁵

Patients who are too high risk for surgery based on either their underlying medical comorbidities or sepsis due to severe cholecystitis can be treated with gallbladder decompression. This is generally done using a transabdominal cholecystostomy tube, placed under ultrasound or computed tomography (CT) guidance. Other options include endoscopic drainage with a transpapillary tube inserted during endoscopic retrograde cholangiopancreatography (ERCP) or a transduodenal tube inserted under endoscopic ultrasound (EUS) guidance. These drainage modalities are generally effective in resolving the acute inflammatory ­process¹⁶; however, they are temporary solutions, and if the tube is subsequently removed, patients are at a high risk of developing recurrent symptoms due to gallstones. For this reason, gallbladder decompression should be reserved for the sickest patients in whom early surgery would pose a prohibitive risk.

Asymptomatic Cholelithiasis

Patients with asymptomatic (ie, incidentally discovered) gallstones have a less than 20% chance of ever developing symptoms, and the risks associated with prophylactic operation outweigh the potential benefit of surgery in almost all patients.¹⁷ Prophylactic cholecystectomy for asymptomatic cholelithiasis can be justified in certain circumstances, such as in patients with sickle cell disease, those undergoing open bariatric surgery, those requiring long-term total parental nutrition, or possibly patients who are therapeutically immunosuppressed after solid organ transplantation. Patients with sickle cell disease often have hepatic or vaso-occlusive crises that can be difficult to differentiate from acute cholecystitis.¹⁸ In patients who have undergone bariatric surgery, the development of gallstones is markedly increased during the period of rapid weight loss, with an incidence of approximately 30%.^19,20 Removing the gallbladder at the time of bariatric surgery can abolish ­gallstone-related morbidity relatively easily. This approach was adopted by many bariatric surgeons during open bariatric procedures, but this practice has largely been abandoned with the advent of laparoscopic bariatric surgery, because the potential morbidity of an added laparoscopic cholecystectomy in the patient with morbid obesity appears greater than the potential later risk of cholelithiasis-related ­complications.^21,22 In transplant patients, there is concern that immunosuppression may mask the signs and symptoms of inflammation until overwhelming infection has occurred.²³ Recommendations in the literature range from mandatory screening and treatment of biliary disease before transplantation, to prophylactic cholecystectomy 6 months after transplantation, to expectant management of all asymptomatic patients.^24,25 Other possible indications for prophylactic laparoscopic cholecystectomy include individuals who may not have access to modern health care facilities for an extended time period, such as missionaries and military personnel, and patients who are already undergoing an abdominal operation for other reasons. Prophylactic cholecystectomy has been occasionally advocated in diabetics. There is no evidence to support this policy but good evidence to support a strategy of early cholecystectomy in the symptomatic patient. Diabetics tend to present with acute cholecystitis more frequently once they become symptomatic and withstand complications less well.

Functional Gallbladder Disorder

Functional gallbladder disorder (FGD) refers to patients who experience symptoms typical of biliary colic in the absence of gallstones and, in the past, has been referred to as gallbladder dyskinesia, biliary dyskinesia, ­gallbladder spasm, and/or acalculous biliary disease. The exact etiology of FGD is unknown, but it is thought to be a result of gallbladder dysmotility. FGD is often a diagnosis of exclusion, after evaluating for other common causes of upper abdominal and lower chest pain such as peptic ulcer disease, gastroesophageal reflux disease, pancreatitis, irritable bowel syndrome, musculoskeletal causes, and angina. Consensus guidelines developed by the Rome Committee have established criteria for the diagnosis of FGD.²⁶ The most recent Rome III guidelines require that the patient’s pain must be located in the epigastrium and/or right upper quadrant and additionally meet all of the 8 criteria listed in Table 62-2. Additionally, patients must have normal LFTs and no gallstones on abdominal ultrasound. The strict list of inclusion criteria based on symptoms is meant to limit the number of cholecystectomies performed for FGD and increase the likelihood that such an operation will result in a resolution of said symptoms. The diagnosis of FGD is confirmed with cholescintigraphy. After the radiotracer is observed at maximal levels in the gallbladder, an infusion of cholecystokinin (CCK) is given to stimulate gallbladder contraction. The percentage of tracer ejected from the gallbladder in response to CCK is then measured, with an ejection fraction less than 35% to 40% being indicative of FGD. Patients with gallbladder ejection fractions below this threshold have markedly better symptomatic outcomes after cholecystectomy.²⁷ According to the Rome III consensus, patients with an ejection fraction greater than 40% should be more carefully evaluated for alternative etiologies of their pain.

Gallbladder Polyps and Porcelain Gallbladder

Other indications for cholecystectomy include the radiographic findings of gallbladder polyps and porcelain gallbladder. Gallbladder polyps are typically an incidental finding that affects approximately 5% of the population, with a higher percentage in Asian populations.²⁸ Polyps can be cancer (adenocarcinoma), benign neoplasia (typically adenomas), or cholesterolosis (a clinically insignificant accumulation of cholesterol on the wall of the gallbladder). Polyps that are larger than 20 mm almost always represent a malignancy. Such patients should undergo radical cholecystectomy and lymph node dissection, an operation that is discussed elsewhere in this text. Polyps between 10 and 20 mm in size are at higher risk of malignancy, but when present, such cancers are usually in an early stage. As such, these patients are typically treated with laparoscopic cholecystectomy without liver resection. Polyps less than 10 mm in size have a low risk of cancer and can be observed with surveillance ultrasound to monitor for growth, which can be done on a yearly basis initially. Multiple small polyps usually signify cholesterolosis, and the gallbladder should be removed only if the patient complains of biliary colic symptoms.

Porcelain gallbladder refers to a calcification of the entire gallbladder wall and has an associated risk of gallbladder cancer. Earlier studies estimated the incidence of gallbladder cancer to be between 12% and 60%, but recent studies suggest that the overall risk is lower, at 7% or less in more recent series.^28,29 Traditionally, radiographic evidence of porcelain gallbladder was seen as an indication for cholecystectomy, but this algorithm has been challenged by some recent authors who recommend a strategy of surveillance imaging in the absence of another indication for cholecystectomy, such as biliary colic.²⁹ Early in the era of minimally invasive surgery, porcelain gallbladder was seen as a contraindication to the use of a laparoscopy,³⁰ but this dogma has also largely been abandoned, and it is now viewed as a perfectly safe initial approach to such patients.³¹

Choledocholithiasis and Gallstone Pancreatitis

Although covered in further detail elsewhere in this text, choledocholithiasis and gallstone pancreatitis are important additional indications for laparoscopic cholecystectomy. It is important to understand that in the setting of these diseases, cholecystectomy is a prophylactic operation, rather than a therapeutic one, performed to prevent further migration of gallstones into the CBD. Therefore, when treating patients with choledocholithiasis, the surgeon must come up with a separate plan for dealing with the CBD stone. There are 3 options: either via laparoscopic CBD exploration at the time of cholecystectomy, or with ERCP before or after cholecystectomy. In patients with gallstone pancreatitis, cholecystectomy should be delayed until after the patient’s pancreatic inflammation resolves, although in most cases, the gallbladder should be removed during the same hospitalization in order to prevent early recurrences.

The number of absolute and relative contraindications to performing laparoscopic cholecystectomy has decreased over the past 20 years as minimally invasive surgical instrumentation and skills have improved (Table 62-3). Absolute contraindications include the inability to tolerate general anesthesia or laparotomy, refractory coagulopathy, and diffuse peritonitis with hemodynamic compromise. Diffuse peritonitis with hemodynamic compromise represents a surgical emergency in which attempted laparoscopic cholecystectomy is not prudent, because the etiology is not clear or secure and the pneumoperitoneum may lead to vascular collapse. Standard open laparotomy allows rapid determination of the etiology and more expeditious management of the disorder. Suspicion of gallbladder malignancy mandates that standard open resection be undertaken. This is because of persistent concerns regarding adequacy of resection and the possibility of gallbladder perforation (occurring in 20%-30% of laparoscopic cholecystectomies) with intraperitoneal dissemination of cancer.

Relative contraindications are dictated primarily by the surgeon’s philosophy and experience. These include previous upper abdominal surgery with extensive adhesions, cirrhosis, portal hypertension, severe cardiopulmonary disease, morbid obesity, and pregnancy. In most patients, little is lost by initiating a laparoscopic cholecystectomy with conversion to laparotomy if the laparoscopic approach is deemed too risky.

Pregnancy is a controversial relative contraindication to laparoscopic cholecystectomy because of the unknown effects of prolonged carbon dioxide (CO₂) pneumoperitoneum on the fetus. Laparoscopic cholecystectomy can be performed safely during pregnancy but only with great care.³² The timing of cholecystectomy during pregnancy is a topic of controversy and was traditionally limited to the second trimester of gestation after organogenesis is complete and prior to the uterine fundus reaching a size and height that encroaches on the operative field. However, there are no data to suggest that laparoscopy during the first trimester is more dangerous, and current society recommendations are generally in favor of performing laparoscopic cholecystectomy at any point during pregnancy as soon as symptoms arise.³³ Open insertion of the initial port in a supraumbilical or right upper quadrant position should be used to avoid injury to the gravid uterus, and the insufflation pressure should be limited to less than 12 mm Hg to avoid respiratory embarrassment and decreased vena caval return. Also, maternal hyperventilation with close monitoring of end-tidal CO₂ should be undertaken to prevent fetal acidosis. When visualization of the biliary tree is required, laparoscopic ultrasound is used in place of cholangiography in order to limit fetal radiation exposure. Finally, perioperative consultation with an experienced obstetrician is advisable, as is perioperative fetal heart monitoring.

Early experience suggested that acute cholecystitis was a relative contraindication to performing laparoscopic cholecystectomy. However, as general surgeons have gained more experience with laparoscopic cholecystectomy and laparoscopy in general, it has uniformly become the preferred initial approach to patients with cholecystitis. There is clearly a higher rate of conversion in the setting of acute cholecystitis. In particular, after 72 hours, the rate of conversion increases significantly. One should not hesitate to convert to an open cholecystectomy if significant adhesions or inflammation precludes safe dissection during laparoscopy.

Anatomy

The classic anatomy of the biliary tree is present in only 30% of individuals, so it may be said that anomalies are the rule, not the exception. As with any procedure, the knowledge of normal anatomy and common variants is critical to the success of surgical intervention. The cystic duct may join the CBD at an acute angle, travel parallel to the common duct for several centimeters prior to insertion, insert into the right hepatic duct, or be congenitally absent. The cystic artery usually arises from the right hepatic artery, but one must be absolutely sure that the cystic artery is visualized entering the gallbladder wall. Occasionally the right hepatic artery will loop up onto the surface of the gallbladder, and a very short cystic artery will arise. Furthermore, there can often be a posterior cystic artery, which can easily be injured if not recognized. The CBD begins at the junction of the cystic duct and the common hepatic duct and passes inferiorly to the ampulla of Vater. Its normal diameter is less than 6 mm, although it may be larger in elderly patients and those with biliary obstruction.

It is important to clearly identify the structures within the hepatocystic triangle, which is the ventral aspect of the area bounded by the gallbladder wall and cystic duct, the liver edge, and the common hepatic duct. Contained within the hepatocystic triangle is the eponymic Calot triangle: The boundaries of the Calot triangle include the cystic duct, cystic artery, and common hepatic duct. Aberrant anatomy is a well-recognized risk factor for biliary injury. An aberrant right hepatic duct is the most common anomaly causing problems during laparoscopic cholecystectomies. The most dangerous variant is when the cystic duct joins a low-lying aberrant right sectoral duct. Injuries to these ducts are underreported since occlusion of an aberrant duct may be asymptomatic and even unrecognized (Fig. 62-2).

Patient Preparation

As with any abdominal operation, patients are fasted for a minimum of 8 hours prior to the operation. Patients without major comorbidities are generally scheduled as outpatient procedures. Prophylactic antibiotics are up to the surgeon’s discretion; evidence suggests that most patients have a very low risk of perioperative infection, and perioperative antibiotics have not been shown to significantly decrease this risk.³⁴ Antiembolic stockings and sequential compression devices are placed on both legs to avoid pooling of blood in the lower extremities by the reverse Trendelenburg position generally used during this operation. Patients at higher risk for lower extremity deep vein thrombosis (DVT) are additionally given prophylactic-dose subcutaneous unfractionated or low-molecular-weight heparin. Following induction of general endotracheal anesthesia, an orogastric tube should be placed to decompress the stomach. The abdomen is shaved and prepared in standard sterile fashion with particular care taken to rid the umbilicus of all debris.

Laparoscopic Cholecystectomy

OPERATING ROOM SETUP

Most surgeons use 2 video monitors, 1 on each side of the operating table above the patient’s shoulders to facilitate visualization by both the surgeon and assistant. Using the American technique, the surgeon stands to the left of the patient and the first assistant stands to the patient’s right (Fig. 62-3). If a laparoscopic video camera operator is used, he or she stands to the left of the surgeon. In the French technique, the patient’s legs are abducted and the surgeon stands between the legs.