Currently there is no evidence for prophylactic cholecystectomy to prevent gallstone formation (grade B). Cholecystectomy cannot be recommended for any group of patients having asymptomatic gallstones except in those undergoing major upper abdominal surgery for other pathologies (grade B). Laparoscopic cholecystectomy is the preferred treatment for all patient groups with symptomatic gallstones (grade B). Patients with gallstones along with common bile duct stones treated by endoscopic sphincterotomy should undergo cholecystectomy (grade A). Laparoscopic cholecystectomy with laparoscopic common bile duct exploration or with intraoperative endoscopic sphincterotomy is the preferred treatment for obstructive jaundice caused by common bile duct stones, when the expertise and infrastructure are available (grade B).
About 5% to 25% of the adult western population have gallstones. About 2% to 4% become symptomatic each year. Most common symptoms are upper abdominal pain, biliary colic, and dyspepsia. Biliary colic is defined as “a steady right upper quadrant abdominal pain lasting for more than half an hour,” which may be associated with radiation to the back and nausea and may force patients to stop their activities. Dyspepsia is defined as the presence of three or more of the following symptoms: belching, flatulence, nausea, intolerance to fatty food, bloating of the abdomen, epigastric discomfort, and acid regurgitation. The complications of gallstones include acute cholecystitis (including empyema, when the gallbladder is filled with pus), acute gallstone pancreatitis, obstructive jaundice, and rarely small bowel obstruction (gallstone ileus). The relationship between gallstones and gallbladder cancer is controversial. Some studies suggest a strong association between gallstones and gallbladder cancer. Other studies have questioned this association, as only a small proportion of patients (11%) with gallbladder cancer had gallstones for more than 1 year.
Cholecystectomy (removal of gallbladder) is the preferred option in the treatment of gallstones. Medical treatment (bile acid dissolution therapy) or extracorporeal shock wave lithotripsy (ESWL) has a low rate of cure and high rate of recurrent gallstones. In patients not suitable for cholecystectomy because of their general medical condition, percutaneous cholecystostomy (temporary drainage of gallbladder through a tube inserted under radiological guidance) may be considered in an emergency situation. When the patient’s condition has improved, cholecystectomy, medical treatment, or ESWL may be considered. The role of nonsurgical management in the treatment of gallstones is discussed elsewhere in this issue.
Cholecystectomy can be performed by a key-hole operation (laparoscopic cholecystectomy), by a small-incision cholecystectomy (incision <8 cm in length), or by traditional open operation (incision >8 cm in length) . There is considerable controversy in the indications, timing, and the route of access for the removal of gallbladder. In this article, these controversies are presented. The strength of evidence has been graded as grade A for randomized controlled trials and meta-analyses and grade B for other evidence such as well-designed controlled and uncontrolled studies as recommended by the manuscript guidelines for authors of Gastroenterology Clinics of North America .
Approaches and risks of cholecystectomy
Cholecystectomy can be performed by a key-hole operation (laparoscopic cholecystectomy), by a small-incision cholecystectomy (incision <8 cm in length), or by traditional open operation (incision >8 cm in length). The complications after cholecystectomy depend on the clinical presentation. The overall perioperative mortality varies between 0% and 0.3%. The overall incidence of bile duct injuries requiring corrective surgery varies between 0.1% and 0.3%. Corrective surgery for bile duct injury carries its own risks including perioperative mortality (1% to 4%), secondary biliary cirrhosis (11%), anastomotic stricture (9% to 20%), and cholangitis (5%). The quality of life can be poor several years after the corrective surgery. Apart from the serious complications of perioperative mortality and bile duct injury and its sequelae, other complications of cholecystectomy include
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Bile leak treated conservatively (0.1% to 0.2%), radiologically (0% to 0.1%) or endoscopically (0.05% to 0.1%) or by operation (0% to 0.05%)
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Peritonitis requiring reoperation (0.2%)
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Postoperative bleeding requiring operation (0.1% to 0.5%)
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Intra-abdominal abscesses requiring operation (0.1%)
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Other minor complications such as wound infection.
In addition to these complications, in laparoscopic cholecystectomy, there is an additional 0.02% risk of major bowel or vessel injury during insertion of the trocar. Currently, there is no evidence to suggest that there is any difference between the different techniques (open or Hassan’s method vs closed or Veress needle method) of laparoscopic entry (grade A). The choice of route of access (laparoscopic vs small-incision vs open cholecystectomy) varies with the indications for cholecystectomy and is discussed under the different indications for cholecystectomy.
Primary prevention
Certain groups of patients have a high risk of development of gallstones. These include patients undergoing gastrectomy for gastric malignancy (14% to 26% of patients develop gallstones within 5 years) and patients undergoing gastric bypass procedures for morbid obesity (22% to 28% of patients develop gallstones within 1 year). Some surgeons perform routine prophylactic cholecystectomy because of the high incidence of gallstones in these patients. Other surgeons, however, do not recommend routine prophylactic cholecystectomy, because most patients developing gallstones are asymptomatic. Currently, a randomized controlled trial is underway to investigate whether prophylactic cholecystectomy is indicated in patients undergoing gastrectomy for gastric cancer. Currently, prophylactic cholecystectomy to prevent gallstone formation is not recommended in any group of patients (grade B).
Primary prevention
Certain groups of patients have a high risk of development of gallstones. These include patients undergoing gastrectomy for gastric malignancy (14% to 26% of patients develop gallstones within 5 years) and patients undergoing gastric bypass procedures for morbid obesity (22% to 28% of patients develop gallstones within 1 year). Some surgeons perform routine prophylactic cholecystectomy because of the high incidence of gallstones in these patients. Other surgeons, however, do not recommend routine prophylactic cholecystectomy, because most patients developing gallstones are asymptomatic. Currently, a randomized controlled trial is underway to investigate whether prophylactic cholecystectomy is indicated in patients undergoing gastrectomy for gastric cancer. Currently, prophylactic cholecystectomy to prevent gallstone formation is not recommended in any group of patients (grade B).
Asymptomatic gallstones
The distinction between symptomatic and asymptomatic gallstones can be difficult, as symptoms can be mild and varied. The different symptoms attributable to gallstones include upper abdominal pain, biliary colic, and dyspepsia. About 92% of patients with biliary colic, 72% of patients with upper abdominal pain, and 56% of patients with dyspepsia have relief of symptoms after cholecystectomy. Cholecystectomy for asymptomatic gallstones is a matter of frequent debate in the management of gallstones. The annual incidence of complications of gallstones in asymptomatic patients is 0.3% acute cholecystitis, 0.2% obstructive jaundice, 0.04% to 1.5% of acute pancreatitis, and rarely gallstone ileus. As mentioned previously, the causative association between gallstones and gallbladder cancer has not been proven. As gallbladder surgery can be associated with life-threatening or life-changing postoperative complications, cholecystectomy for asymptomatic gallstones is not recommended routinely in any group of patients. This includes patients at risk of gallstone-related complications such as diabetic patients, children with sickle cell disease, children in general, and patients undergoing organ transplantation (grade B). The controversies surrounding routine cholecystectomy for asymptomatic gallstones is far from resolved. Some surgeons recommend that routine prophylactic cholecystectomy is indicated in children with sickle cell disease because of the proportion and severity of complications related to gallstones in children with sickle cell disease (more than 70% of children required cholecystectomy because of gallstone symptoms or complications after a mean period of 3 years). Other surgeons recommend cholecystectomy in all children with gallstones irrespective of whether they have sickle disease or not, as the natural history of gallstones in children is not known. It should be noted, however, that the complications related to cholecystectomy such as bile duct injury are present in the pediatric age group also. There were two bile duct injuries in 109 children in this study. Although other studies with more than 100 patients each did not report any bile duct injury, the risk of bile duct injury and its consequences should not be neglected in the pediatric age group.
One special situation is the presence of asymptomatic gallstones in patients undergoing major abdominal surgery for other pathologies. Concomitant cholecystectomy along with the major abdominal procedure does not appear to significantly increase the postoperative morbidity or hospital stay, and some surgeons advocate routine cholecystectomy. Considering that adhesions related to a major operation may make further minimal access surgeries difficult or impossible, it appears reasonable to offer cholecystectomy to patients with asymptomatic gallstones undergoing major abdominal operations (grade B).
Symptomatic patients without complications
Patients with symptomatic gallstones are generally offered cholecystectomy. This is based on several longitudinal studies on the natural history of symptomatic gallstones without complications (grade B). These studies assess the hospital admissions and the complications that patients with symptomatic gallstones developed. The number of hospital admissions varied from 2.5 hospital admissions per 100 patients per month to 23 hospital admissions per 100 patients per month, possibly because of the severity of the symptoms at inclusion in the study. By 1 year, 14% of patients develop acute cholecystitis; 5% of patients develop gallstone pancreatitis, and 5% of patients develop obstructive jaundice. Other studies report an annual complication risk of 1% in patients with mild symptoms. Of the later studies, one was a randomized controlled trial comparing cholecystectomy and observation. In this trial, in a mean follow-up period of 4 years, 50% of the patients in the observation group had undergone cholecystectomy. The timing of cholecystectomy for patients with biliary colic is controversial. There is no reason to delay cholecystectomy in these patients other than for resource implications. One randomized controlled trial of urgent versus elective laparoscopic cholecystectomy for biliary colic showed a decrease in the hospital stay and complications related to gallstones in the urgent group. Another randomized controlled trial of the same comparison did not show any difference in the hospital stay or complications related to gallstones. Considering that urgent cholecystectomy needs prioritization ahead of other surgeries, with no evidence for additional benefit of urgent cholecystectomy over elective cholecystectomy, elective cholecystectomy appears sufficient in patients with biliary colic (grade B). Systematic reviews of randomized controlled trials show that there is no difference in the complication rates between laparoscopic, small-incision, and open cholecystectomy performed for symptomatic uncomplicated gallstones. However, laparoscopic and small-incision cholecystectomies have a significantly shorter post-operative hospital stay and are hence preferable to open cholecystectomy (grade A).
Acute cholecystitis
Most surgeons recommend surgery after a complication of gallstone. This is because of the high risk of recurrence of the cholecystitis, non-resolution of the cholecystitis, and other complications during the waiting period (grade B). There has been one randomized controlled trial comparing delayed cholecystectomy (conservative treatment followed by elective cholecystectomy) and observation in patients with mild cholecystitis. Gallstone related events and hospital admissions occurred in 19% and 10% of the patients belonging to the delayed cholecystectomy group, and these events occurred in 36% and 12% of patients belonging to the observation group. This difference was not statistically significant. After a mean follow-up period of 60 months, 24% of the patients in the observation group had undergone cholecystectomy. There was no difference in the number of gallstone related complications. However, the study was underpowered to measure even a 17% difference in the gallstone complication rate. Besides, delayed cholecystectomy is not the optimal option in the treatment of acute cholecystitis. Systematic reviews with meta-analysis of randomized controlled trials have shown that early cholecystectomy (performed within 1 week of onset of symptoms) is superior to delayed cholecystectomy in terms of reduction in the gallstone-related complications during the waiting time. Earlier fears that early laparoscopic cholecystectomy was not safe and resulted in increased conversion to open cholecystectomy are unfounded. Early cholecystectomy is the treatment of choice for acute cholecystitis. It shortens hospital stay and results in considerable cost savings (grade A). Evidence from randomized controlled trials show that early laparoscopic cholecystectomy for acute cholecystitis has similar morbidity as compared with early mini-incision cholecystectomy and early open cholecystectomy for acute cholecystitis but is associated with a shorter hospital stay. Early laparoscopic cholecystectomy performed within 1 week of onset of symptoms is the treatment of choice for patients with acute cholecystitis (grade A).
Pancreatitis
Gallstone pancreatitis is caused by migration of stones into the common bile duct with subsequent obstruction to the bile duct, the pancreatic duct, or both. This causes increase in pancreatic duct pressure, resulting in unregulated activation of trypsin and pancreatitis. Gallstones are the most common cause for acute pancreatitis. The overall mortality of acute pancreatitis is between 3% and 10%. The role of early endoscopic sphincterotomy in the management of gallstone pancreatitis is controversial. Although the total number of complications is fewer after early endoscopic sphincterotomy for predicted severe pancreatitis, there is no reduction in either the local pancreatic complications or the overall mortality for predicted mild or severe pancreatitis. There is of no benefit of early endoscopic sphincterotomy for patients with acute gallstone pancreatitis without cholangitis. Irrespective of the role of endoscopic sphincterotomy in pancreatitis, endoscopic sphincterotomy alone is not a definitive treatment for common bile duct stones. In a systematic review of randomized controlled trials, a policy of observation alone after endoscopic sphincterotomy increased the risk of mortality and gallstone-related complications compared with prophylactic cholecystectomy. Hence, cholecystectomy is recommended after an attack of gallstone pancreatitis (grade A). There have been two randomized controlled trials investigating the timing of cholecystectomy. In one trial, the mortality and morbidity were higher when the cholecystectomy was performed within 48 hours of admission compared with cholecystectomy performed after 48 hours of surgery but within the same hospital admission. In the other trial, the patients were operated between 3 days and 14 days after hospital admission for pancreatitis in the early group and after 3 months in the delayed group. There was no difference in the postoperative mortality or morbidity between the two groups. Of the nine patients allocated to the delayed group, however, one patient (11%) developed another attack of pancreatitis, and two patients developed abdominal pain while waiting for surgery. Both these studies were conducted in the era of open cholecystectomy and were underpowered to detect reasonable differences in mortality and morbidity. There has been no trial on the timing of surgery in the laparoscopic surgery. For those patients who undergo pancreatic necrosectomy or debridement after failed percutaneous drainage for infected pancreatic necrosis, it is reasonable to perform cholecystectomy at the same time. For the remaining patients who do not require surgical interventions on the pancreas, laparoscopic cholecystectomy can be performed safely when the general condition improves and can be completed laparoscopically in 85% to 90% of patients with mild pancreatitis and in about 60% of patients with severe pancreatitis. Cholecystectomy is completed in the remaining patients by conversion to an open procedure. Some authors recommend laparoscopic cholecystectomy as soon as the serum amylase and the abdominal tenderness start to decrease rather than waiting for amylase to return to normal and for the patient to be free from abdominal pain. This approach was based on their observation that such an approach was safe, did not result in a high rate of conversion to open cholecystectomy, and resulted in a shorter hospital stay compared with the traditional early cholecystectomy group (ie, waiting for amylase to return to normal and relief from abdominal symptoms). Considering that early laparoscopic cholecystectomy is safe and can be completed successfully in most patients with mild acute pancreatitis, delaying laparoscopic cholecystectomy seems unnecessary and can expose the patient to further gallstone-related complications. Thus, cholecystectomy in the same admission appears to be the preferable option in patients with mild gallstone pancreatitis (grade B). The general condition and the severity of the pancreatic disease will determine the timing of the cholecystectomy in patients with severe pancreatitis. Cholecystectomy appears safe as soon as the general condition of the patient improves and the pancreatic necrosis becomes sterile if infected (or remains sterile if not infected) (grade B). Considering that laparoscopic cholecystectomy is safe and seems to be the preferred option (most cholecystectomies in the United Kingdom and the United States are performed laparoscopically), laparoscopic cholecystectomy can be recommended as the preferred approach in patients with gallstone pancreatitis (grade B).
Obstructive jaundice
Patients with gallstones develop obstructive jaundice if stones migrate into the common bile duct. Although common bile duct stones can be removed endoscopically, subsequent cholecystectomy is recommended based on a systematic review of randomized controlled trials in which a policy of observation after endoscopic sphincterotomy increased the risk of mortality and gallstone-related complications compared with routine cholecystectomy (grade A). There are no studies investigating the natural history of patients with obstructive jaundice caused by common bile duct stones. Considering that obstructive jaundice can lead to complications such as cholangitis, renal dysfunction, cardiovascular dysfunction, and coagulopathy, obstructive jaundice caused by common bile duct stones needs to be treated as an emergency (grade B). The various options for the treatment of common bile duct stones include open cholecystectomy with open common bile duct exploration, laparoscopic cholecystectomy with laparoscopic common bile duct exploration, and laparoscopic cholecystectomy with endoscopic sphincterotomy (performed preoperatively, intraoperatively, or postoperatively). A systematic review of randomized controlled trials has shown that open cholecystectomy with open common bile duct exploration has the lowest incidence of retained stones but is associated with high morbidity and mortality, particularly in elderly patients. There was no difference in the incidence of retained stones between preoperative and postoperative endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic common bile duct clearance at the time of laparoscopic cholecystectomy. The total hospital stay was shorter in the laparoscopic exploration group. One randomized controlled trial has shown that there is no difference in any of the important outcomes between laparoscopic cholecystectomy with laparoscopic common bile duct exploration and laparoscopic cholecystectomy with intraoperative endoscopic sphinterotomy. Three trials have shown that intraoperative endoscopic sphincterotomy is at least as safe and effective as preoperative endoscopic sphincterotomy followed by laparoscopic cholecystectomy and shortens hospital stay. There was no significant difference in the success rates between preoperative endoscopic sphincterotomy and intraoperative endoscopic sphincterotomy. There are no trials comparing open cholecystectomy and common bile duct exploration with laparoscopic cholecystectomy and laparoscopic common bile duct exploration. There is also no randomized controlled trial comparing open cholecystectomy with open common bile exploration to laparoscopic cholecystectomy with intraoperative endoscopic sphincterotomy. Considering that laparoscopic cholecystectomy is preferred to open cholecystectomy (a significant majority of the cholecystectomies in the United Kingdom and in the United States are performed laparoscopically), laparoscopic cholecystectomy along with laparoscopic common bile duct exploration or intraoperative endoscopic sphincterotomy can be recommended as the preferred method of treatment of patients with obstructive jaundice due to gallstones where the expertise and infrastructure are available (grade B). When these are not available, laparoscopic cholecystectomy with preoperative endoscopic sphincterotomy or postoperative endoscopic sphincterotomy may be the preferred treatment for common bile duct stones. For patients with impacted common bile duct stone not amenable to laparoscopic or endoscopic clearance, lithotripsy or open common bile duct exploration can be the other options (grade B).
Special situations
High-Risk Individuals
If patients are at high risk of surgery because of pancreatitis, jaundice, or sepsis, cholecystectomy should be offered once their general condition improves. This is because of evidence from a systematic review of randomized controlled trials, which shows leaving the gallbladder in situ after endoscopic sphinterotomy results in an increased overall mortality (grade A). In a randomized controlled trial, percutaneous cholecystostomy followed by early laparoscopic cholecystectomy (in 3 to 4 days after the percutaneous cholecystostomy) resulted in a considerable decrease in the hospital stay compared with delayed laparoscopic cholecystectomy. It is not possible, however, to assess the effect of percutaneous cholecystostomy alone from this trial. It appears that percutaneous cholecystostomy with early laparoscopic cholecystectomy is an effective option in patients who are temporarily unwell because of gallbladder sepsis. The only trial that assessed whether percutaneous cholecystostomy in addition to antibiotic therapy (but without early laparoscopic cholecystectomy) was of any benefit in high-risk surgical individuals showed that there was no benefit in performing percutaneous cholecystostomy in patients with acute choleystitis. This study, however, was not powered to measure the difference in mortality, which was 9.1% in the percutaneous cholecystostomy group and 17.7% in the antibiotics-alone group. Further studies are necessary to assess the role of percutaneous cholecystostomy as a temporary measure in the treatment of high-risk surgical individuals with acute cholecystitis. In patients who are at high risk of surgery because of comorbidities that will not improve with the treatment of sepsis, surgery cannot be recommended (grade B).
Cirrhotic
There are few studies that report the natural history of gallstones in cirrhotic patients. The frequency of symptoms or complications does not appear to be any different from other groups of patients with gallstones. When patients develop complications, however, they can be more severe. Cholecystectomy is recommended for symptomatic gallstones (grade B). There are no differences in the timing of surgery for various indications between compensated cirrhotic patients and other patients with symptomatic gallstones. For compensated cirrhotic patients with symptomatic gallstones, laparoscopic cholecystectomy appears better than open cholecystectomy, as randomized controlled trials have shown that the laparoscopic cholecystectomy has similar morbidity as open cholecystectomy but results in lower blood loss, transfusion requirements, and hospital stay. The overall morbidity and mortality after cholecystectomy, however, are higher in cirrhotic patients than in noncirrhotic patients.
Pregnancy
Most pregnant women with gallstones remain asymptomatic during their pregnancy, and there is no indication for cholecystectomy. Patients with symptomatic gallstones present a great dilemma, however. Traditionally, cholecystectomy was performed only in the presence of severe or nonresolution of symptoms. This is because of the risk of perioperative fetal complications. A recent large retrospective case–control study on pregnant women requiring admission with biliary disease or biliary pancreatitis compared those pregnant women (with biliary disease or biliary pancreatitis) who underwent cholecystectomy with those pregnant women (with biliary disease or biliary pancreatitis) who did not undergo surgery. Over a 10-year period, 36,929 pregnant women with biliary disease or biliary pancreatitis were admitted in the hospital. Of these, 9714 (26%) women underwent cholecystectomy. Of these 9714 women, about 5% underwent endoscopic retrograde cholangiopancreatography; about 3% underwent common bile duct exploration, and 0.1% had placement of a percutaneous cholecystostomy tube in addition to cholecystectomy. The remaining women did not undergo surgery. Patients who underwent surgery had significantly lower maternal complication rates (4.3% vs 16.5%) and fetal complication rates (5.8% vs 16.5%) compared with those who did not undergo surgery. The overall hospital mortality in the surgical group was 0.05%. The cause for mortality was not stated. The hospital mortality in the nonsurgical group was not stated but is likely to be zero. There is likely to be a large selection bias in this study. Patients are more likely to be offered cholecystectomy during pregnancy if the biliary disease or biliary pancreatitis is severe. Many patients who underwent cholecystectomy would have been treated conservatively first before they would have been offered cholecystectomy. Thus the complications in this group of patients who had failed conservative treatment would have been included under the surgery group rather than the nonsurgery group (ie, a treatment-received analysis that can only favor the non-surgery group was performed). The proportion of patients who presented in each trimester and the outcomes of patients stratified by the trimester of presentation were not reported. It is possible that a significant proportion of patients treated conservatively presented in the third trimester, and a significant proportion of patients treated surgically presented in the second trimester, resulting in an apparent but not true benefit of surgery over conservative management. In another study of 63 women, surgical management was compared with nonsurgical management in pregnant women with symptomatic gallstones. The authors of this study recommend surgical management because of the higher risk of fetal and maternal complications in the nonsurgical group. The time of presentation of the pregnant women stratified by the trimester of pregnancy was not reported in this study also. In another study of 126 pregnant women with symptomatic gallstones, the patients were treated conservatively, and surgical management was offered only in patients in whom conservative management failed. Medical management failed in 57% of patients. These patients underwent surgical management without maternal or fetal complications. In this study, only second trimester patients were offered laparoscopic cholecystectomy, while the patients in the first and third trimesters were offered percutaneous gallbladder aspiration. Thus it appears that surgical management by cholecystectomy is safe in selected patients and should be considered in pregnant women with symptomatic cholelithiasis who require hospital admission for symptomatic gallstones or other complications at least in the second trimester of pregnancy (grade B).
The long-term effect of cholecystectomy in pregnant women on fetal and child development has not been reported. Carbon dioxide pneumoperitoneum at 15 mm Hg pressure causes fetal hypercarbia in pregnant ewes. However, another study, a randomized controlled trial of 15 mm Hg pneumoperitoneum in pregnant ewes, did not demonstrate any effect of pneumoperitoneum on fetal acidosis. Thus, it is unlikely that pneumoperitoneum has any effects on fetal acid–base balance. The safety of anesthesia during early pregnancy, however, has not been established. So, it is best to avoid surgery during the first trimester of pregnancy if possible. Another issue of laparoscopic surgery in pregnant women is to gain access without causing injury to the enlarged uterus, particularly in the third trimester. Because of this, a significant proportion of the operations may have to be performed by open cholecystectomy. Thus, the second trimester appears to be the best time for performing cholecystectomy in pregnant women (grade B).
In the study including 9714 pregnant women who underwent cholecystectomy, patients who underwent laparoscopic cholecystectomy had lower surgical morbidity, fewer maternal complications (hysterectomy, caesarean section, and dilation, and curettage), fewer fetal complications (fetal death, loss, or distress), and shorter hospital stay compared with those who underwent open cholecystectomy. There is likely to be a selection bias favoring laparoscopic cholecystectomy however, as surgeons are more likely to opt for the open approach in the presence of complications such as severe inflammation or empyema, particularly if this is during the third trimester. Other studies have shown that laparoscopic cholecystectomy can be done safely with similar morbidity as open cholecystectomy during pregnancy.
The overall surgery-related morbidity and hospital stay were higher in the pregnant women undergoing cholecystectomy as compared with nonpregnant women undergoing cholecystectomy. Both maternal and fetal outcomes should be considered in relation to the management of gallstones during pregnancy and further studies are required on the risks and benefits of cholecystectomy.
With certain reservations about obtaining access in the third trimester and the safety of anesthesia and pneumoperitoneum in the first trimester, laparoscopic cholecystectomy appears to be the preferred route for cholecystectomy in pregnant women in the second trimester of pregnancy (grade B).
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