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.
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