Laparoscopic Single-Site Cholecystectomy

Chapter 13 Laparoscopic Single-Site Cholecystectomy



Alexander Rosemurgy, Harold Paul, Natalie Donn, Kenneth Luberice, Michelle Vice, Sharona Ross


The videos associated with this chapter are listed in the Video Contents and can be found on the accompanying DVDs and on Expertconsult.com.image


Rapid change is occurring in surgery and specifically in minimally invasive surgery. Concepts only imagined 20 years ago are now within our grasp, such as “scarless” laparoscopy. Scarless laparoscopy ensures that the postoperative scar is hidden within the umbilicus.


This evolutionary approach to laparoscopy is given many names with many associated acronyms, such as laparoendoscopic single-site (LESS) surgery, single-incision laparoscopic surgery (SILS), and single-port access (SPA) surgery, to mention but a few. Although this approach is new, adoption is occurring quickly and broadly, and many different operations have been undertaken using this approach. Because the term LESS surgery has been introduced into the domain of common use, it is the authors’ choice for denoting this approach. We believe that LESS surgery will become the standard approach for laparoscopic operations in the years to come and is quickly finding its role as a favored approach for cholecystectomy.


Transumbilical laparoscopic single-site operations should not violate the tenets of conventional laparoscopy and should be performed with the same safety and efficacy.



Operative indications


The advent of LESS surgery has not changed the indications for cholecystectomy. Cholecystectomy is generally considered for patients with symptomatic cholelithiasis, cholecystitis, biliary dyskinesia, and malignancy.



Cholelithiasis and Chronic Cholecystitis


Chronic cholecystitis is gallbladder inflammation virtually always occurring with cholelithiasis. The primary presentation of chronic cholecystitis is pain. Ranging from constant discomfort to episodes weeks and months apart, the frequency of attacks is quite variable. Lasting usually hours, attacks are distinct and significant enough that many patients accurately recall them.


Other symptoms of chronic cholecystitis may include nausea and vomiting with each episode, along with bloating and belching. Patients with asymptomatic gallstones account for two thirds of patients with cholelithiasis. Asymptomatic gallstones are generally not an indication for cholecystectomy unless the patient is undergoing another abdominal procedure (e.g., bariatric surgery).



Choledocholithiasis


Choledocholithiasis may be detected during an assessment for biliary tract symptoms, during cholecystectomy (with intraoperative cholangiogram), or after cholecystectomy. Diagnosed preoperatively, the bile duct should be cleared by endoscopic sphincterotomy, unless laparoscopic common bile duct exploration is in the surgeon’s armamentarium, followed by LESS cholecystectomy. If undocumented choledocholithiasis is determined by cholangiography during LESS cholecystectomy, various options can be undertaken, including the following:



• Conversion to open cholecystectomy with common bile duct exploration


• LESS or laparoscopic cholecystectomy and common bile duct exploration


• LESS cholecystectomy with postoperative endoscopic sphincterotomy and stone extraction


Patients diagnosed with choledocholithiasis after undergoing cholecystectomy are best treated with endoscopic sphincterotomy and stone extraction.



Acute Cholecystitis


Acute cholecystitis occurs in two forms: acalculous and calculous. The latter form is much more common and occurs when the cystic duct becomes obstructed and gallbladder drainage or emptying ceases. Patients generally present with right upper quadrant pain and elevated white blood cell count with an excess number of early forms of polymorphonuclear leukocytes (i.e., bands). Clinically, patients with acute cholecystitis will also have fever and anorexia.


It is still a controversy whether patients with acute cholecystitis should promptly undergo cholecystectomy or should undergo the procedure after a period of treatment with systemic antibiotics.


Acalculous cholecystitis is a consequence of systemic hemodynamic collapse, or at least diversion of necessary blood flow away from the gallbladder such that patchy focal necrosis (or more) of the gallbladder results. Occasionally, acalculous cholecystitis can be temporized by drainage of the gallbladder so that pressures in the gallbladder can be reduced to promote blood flow throughout the gallbladder wall. In more extreme cases, a necrotic gallbladder can be drained percutaneously.



Biliary Dyskinesia


Gallbladder dyskinesia can lead to bothersome symptoms. Usually these symptoms are postprandial and involve right upper quadrant pain or epigastric pain and, with time, can lead to weight loss. The hallmarks of biliary dyskinesia are the lack of cholecystolithiasis on imaging of the gallbladder and a diminished gallbladder ejection fraction on study with biliary scanning and stimulation of the gallbladder with cholecystokinin (CCK).



Preoperative evaluation, testing, and preparation


Ideal operative candidates for LESS cholecystectomy do not have acute cholecystitis, are without notable comorbidities, are not morbidly obese, are not excessively tall, and do not have a history of prior abdominal surgery. Although some of these parameters describing the ideal patient are general and ill defined, some are readily obvious.


Testing specific for gallbladder pathology or disease is an essential prerequisite to cholecystectomy. Given appropriate indications, such as symptoms consistent with biliary dyskinesia or chronic cholecystitis, an ultrasound of the gallbladder and right upper quadrant is a minimum in the evaluation process and may be all that is necessary given documentation of gallstones, gallbladder sludge, or similar findings. Other imaging studies, such as computed tomography and magnetic resonance imaging, can show stones or the equivalent in the gallbladder but are beyond the necessary ultrasound unless being obtained for reasons other than documentation of chronic gallbladder pathology.


For patients with suspected acalculous biliary dyskinesia, a biliary scan with CCK analog administration is appropriate to determine gallbladder filling and ejection fraction. As previously noted, an ejection fraction of less than 35% is abnormal, but an ejection fraction of less than 25% is generally considered an indication for cholecystectomy, if consistent with the patient’s symptoms.


No discussion of testing for gallbladder disease would be complete without mentioning the need for a thorough physical examination. Notable findings on physical examination indicative of liver disease, gastrointestinal bleeding, or other diseases or disorders should lead to further evaluation. Similarly, a laboratory profile, including liver function tests, complete blood count, urine analysis, and a chemistry profile, is warranted. An electrocardiogram is indicated for most patients older than 40 years and for selected younger patients.


Before the cholecystectomy, a thorough informed consent should be obtained. Given the intent to undertake LESS cholecystectomy, a consent should be obtained for single-incision laparoscopic cholecystectomy through the umbilicus, possible multiple-incision laparoscopic cholecystectomy, possible open cholecystectomy, and possible intraoperative cholangiogram. Conversion from the LESS approach to another approach, including a conventional laparoscopic approach or an open cholecystectomy, is not to be interpreted by the patient as failure but rather as good judgment.


Patients are counseled to shower the morning of the cholecystectomy. Patients void before transport to the operating suite, and a bladder catheter is not generally employed. Preoperative antibiotics are given with induction of anesthesia and patients are prepped with alcohol. A povidone-iodine-impregnated barrier is applied as the patient is draped.

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Jul 20, 2016 | Posted by in GASTOINESTINAL SURGERY | Comments Off on Laparoscopic Single-Site Cholecystectomy

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