LAPAROSCOPIC CHOLECYSTECTOMY DON J. SELZER, MD, AND KEITH D. LILLEMOE, MD

CHAPTER 130 LAPAROSCOPIC CHOLECYSTECTOMY DON J. SELZER, MD, AND KEITH D. LILLEMOE, MD Laparoscopic cholecystectomy, reported by Reddick in 1989, began a revolution in surgical practice. Improvements in video imaging and instrumentation, in addition to changing patient expectations, have fueled an explosion in the breadth, availability, and number of laparoscopic procedures. A videoscopic minimally invasive approach is available for treatment of diseases ranging from parathyroid adenoma to morbid obesity to varicose veins. Benefits of a laparoscopic approach over a traditional open technique include less pain, shorter hospital stay, faster return to activities of daily living, and improved cosmesis. Since the National Institutes of Health Consensus Statement in 1992, the laparoscopic approach has become the preferred technique for cholecystectomy. Laparoscopic cholecystectomy is now the most commonly performed elective abdominal procedure in the United States. During the last decade, significant experience gained in preoperative selection, surgical technique, and intraoperative decision making has dramatically improved results. However, complications continue to occur and controversies remain. Indications, surgical technique, and outcomes for laparoscopic cholecystectomy are reviewed. Indications and Evaluation Currently, the Centers for Disease Control and Prevention estimates 600,000 to 750,000 cholecystectomies are performed annually in the United States. Cholecystectomy is classically indicated to treat signs, symptoms, and complications of gallstones. Despite the relatively low risks associated with laparoscopic cholecystectomy, the procedure should be limited to symptomatic patients. These patients are at increased risk of developing complications including acute cholecystitis, common bile duct obstruction, cholangitis, and pancreatitis. Evidence exists that these complications seldom develop at initial presentation, so asymptomatic patients are generally treated with watchful waiting. Laparoscopic cholecystectomy is also indicated for patients without gallstones but typical biliary colic. These patients may have acalculous cholecystitis or biliary dyskinesia diagnoses made by quantitative gallbladder emptying or radio-nucleotide study. The quick recovery and excellent outcomes of laparoscopic cholecystectomy have reduced the reluctance of patients to undergo gallbladder surgery, leading to an increase in the number of cholecystectomies performed annually. During the 1990s, there was a 29% increase in the number of cholecystectomies performed, with over a 100% increase in cholecystectomy for acute acalculous cholecystitis and 300% increase for biliary dyskinesia. Although nonsurgical methods of gallstone removal, including pharmacologic dissolution, shock wave lithotripsy, and endoscopic laser ablation, were once considered alternatives to the traditional open surgical approach, widespread use of laparoscopic cholecystectomy with its increased patient acceptance, has generally lead to the elimination of these treatments as alternatives. Despite advances in radiologic methods, ultrasonography remains the mainstay of gallbladder imaging. Information obtained from a right upper quadrant sonogram (ie, including the presence of gallstones, gallbladder wall thickening, pericholecystic fluid, and common bile duct dilatation) surpasses other diagnostic studies at a fraction of the cost. Radioscintigraphy of the biliary tree has two indications. First, it confirms gallbladder uptake or cystic duct obstruction in the diagnosis of acute cholecystitis in patients with confounding symptoms, signs, and medical conditions. Second, a calculated gallbladder ejection fraction below 35% following administration of intravenous cholecystikinin during scintigraphy is used to diagnose biliary dyskinesia. In addition to radiologic tests, laboratory evaluations, including complete blood count, liver function tests, and serum amylase and lipase, help confirm disease processes and determine treatment plans. The choice of surgical treatment may be affected by a patient s medical comorbidities and presentation. Severely limiting cardiac and pulmonary disease processes may prevent a patient from withstanding the rigors of even laparoscopic surgical intervention. Creation of a pneumoperitoneum leads to multiple cardiovascular effects including decreased stroke volume, cardiac output, and venous return. Patients also develop increased systemic and pulmonary vascular resistance, mean arterial pressure, central venous pressure, and pulmonary artery wedge pressure. Most of these effects are directly related to the mechanical effects of increased intra-abdominal pressure, but sympathetic stimulation 748

Laparoscopic Cholecystectomy / 749 and biochemical effects of the gas used to create the pneumoperitoneum add to the insult. Early in its development, some surgeons limited the use of laparoscopic approach, avoiding patients with acute cholecystitis, gallstone pancreatitis, choledocholithiasis, hepatitis or cirrhosis with portal hypertension, previous abdominal surgery, severe obesity, sepsis, and pregnancy. As surgeons have surpassed the learning curve, the relative contraindications to the laparoscopic approach have been reduced or eliminated. In fact, preoperative concern for gallbladder carcinoma remains the only absolute contraindication to laparoscopic cholecystectomy because of the risk of dissemination of cancer cells by the turbulent flow of gas in the pneumoperitoneum. Perioperative Care and Surgical Technique Patient preparation for laparoscopic cholecystectomy does not typically include a bowel cleansing regimen, but no oral intake is restricted a minimum of 6 hours prior to induction of general anesthesia. Preoperative prophylactic antibiotics are typically administered intravenously, ideally one half hour before surgical incision. Choice of antibacterial agent is commensurate with the spectrum of biliary infectious agents. Following induction of general anesthesia and preparation of the patient s abdomen with antibacterial agents, the procedure begins with insertion of a 10 mm diameter laparoscopic port at the umbilicus. Gas is delivered, or insufflated, through the port into the abdomen and a laparoscope with attached fiber optic video camera is introduced. Carbon dioxide is almost exclusively used to create the pneumoperitoneum, but other gases including air, helium, and nitrous oxide have been used. Intraabdominal pressures are limited to approximately 15 mm Hg because of the previously mentioned secondary hemodynamic and pulmonary effects created by the pneumoperitoneum. A brief laparoscopic examination of the abdomen is performed and 3 more laparoscopic ports, typically 5 mm in diameter, are introduced through small incisions in the epigastrium and right subcostal regions. Laparoscopic graspers allow manipulation of intraabdominal contents including the gallbladder. The dome of the gallbladder is elevated in a cephalad fashion to reveal Calot s triangle. Inflammation secondary to acute or chronic cholecystitis may lead to regional adhesions, limit exposure of Calot s triangle, and render the laparoscopic approach precarious. Dissection begins with stripping of the peritoneal lining from the gallbladder infundibulum and cystic duct. Absolute, positive identification of the cystic duct and cystic artery are essential to performing a safe and successful laparoscopic cholecystectomy. Strong evidence exists that misidentification of the common bile duct as the cystic duct leads to most major bile duct injuries, the so-called classic bile duct injury. Difficult identification of important anatomical landmarks requires the surgeon to maintain a low threshold to convert from the laparoscopic approach to an open cholecystectomy. Conversion to an open procedure for prevention of inadvertent injury is not considered a complication; it is considered good clinical judgment. Selective use of laparoscopic intraoperative cholangiography (IOC) can help to determine anatomical variants, diagnose choledocholithiasis, and identify inadvertent injuries. A normal cholangiogram is followed by ligation of the cystic duct and cystic artery with clips or sutures and separation of the gallbladder from its liver attachments. The gallbladder is removed from the peritoneal cavity through one of the laparoscopic port incisions, commonly the umbilical site. Hemostasis is confirmed and the gas is removed, or desufflated, from the abdomen. Duration of the procedure is dependent on regional inflammatory changes and patient anatomy. However, an elective laparoscopic cholecystectomy may be performed in < 1 hour on a routine basis. Although patients are routinely admitted for overnight observation following the procedure, outpatient laparoscopic cholecystectomies are becoming more common. A liquid diet is instituted immediately following surgery and the patients is instructed to advance to regular food as tolerated. Patients generally recover and return to normal activities in < 2 weeks after surgery. Although the surgical technique of laparoscopic cholecystectomy remains essentially unchanged since the early days of its development, technological refinements continue to provide improvements. Improved digital imaging provides better visualization and allows the use of smaller diameter equipment, smaller incisions, and fewer laparoscopic ports. Laparoscopic Cholecystectomy for Expanded Indications With growing experience, surgeons are now successful in performing laparoscopic cholecystectomy on the majority of patients regardless of presentation. However, several clinical scenarios continue to provide challenging settings for the laparoscopic technique and controversies with regard to methods of treatment. Acute cholecystitis, gallstone pancreatitis, choledocholithiasis, hepatitis or cirrhosis with portal hypertension, previous abdominal surgery, severe obesity, sepsis, and pregnancy are areas where dramatic improvements have occurred. Acute cholecystitis is no longer considered an absolute contraindication to laparoscopic cholecystectomy. Recent experience shows cholecystectomy should be performed within 24 to 48 hours of admission or 72 to 96 hours after development of symptoms. During this brief window,

750 / Advanced Therapy in Gastroenterology and Liver Disease pericholecystic fluid and edema aid surgical dissection. After this period has passed, this edema leads to dense fibrosis and impedes or even prevents safe completion of the cholecystectomy. Laparoscopic cholecystectomy performed during the initial 72 hours after presentation has a conversion rate of approximately 25%; whereas procedures performed > 3 days after initial presentation lead to conversion in 30 to 60% of cases. The method of cooling down acute cholecystitis with interval cholecystectomy 6 weeks later has fallen out of favor, because the residual chronic inflammation often makes dissection difficult. Complication rates in patients with acute cholecystitis are similar for the laparoscopic and open approach. However, conversion from the laparoscopic approach to an open technique occurs in < 5% of patients undergoing elective laparoscopic cholecystectomy compared with the higher conversion rates noted previously for patients with acute cholecystitis. Judicious conversion to an open approach has limited inadvertent biliary injuries in patients with acute cholecystitis and prevented other major complications. Patients that undergo successful laparoscopic cholecystectomy for acute cholecystitis frequently experience the same rapid recovery as elective procedures. However, with the addition of the preoperative hospital stay and a brief postoperative observation period, total length of the hospital stay is generally longer for patients with acute cholecystitis. Gallstone pancreatitis, once considered a contraindication for the minimally invasive approach, is now successfully treated with laparoscopic cholecystectomy on a regular basis. Timing of cholecystectomy remains controversial and is determined by severity of the pancreatitis. Recovery from an attack of mild acute pancreatitis is signaled by normalization of white blood cell count, serum amylase and lipase, and resolution of pain. Long delay in removing the gallbladder leads to recurrent attacks and raises risk of severe necrotizing pancreatitis. Therefore, laparoscopic cholecystectomy and IOC performed during the same hospital admission and immediately following resolution of signs and symptoms is the recommended course of treatment. In the presence of pancreatitis, persistent signs of biliary obstruction and choledocholithiasis typically lead to endoscopic intervention with endoscopic retrograde pancreatography (ERCP), endoscopic sphincterotomy (ES), and stone removal prior to considering laparoscopic cholecystectomy. Successful preoperative ERCP with ES has not shown to significantly increase morbidity. In fact, early ERCP with duct clearance appears to benefit patients. Despite this evidence, most surgeons do not routinely employ preoperative ERCP in mild, self-limited gallstone pancreatitis, because stones have frequently passed and patients are exposed to the risk of the ERCP with ES and needlessly experience a longer hospital stay. Following resolution of pancreatitis, laparoscopic cholecystectomy exhibits the same low rates of morbidity and mortality and rapid surgical recovery as seen in other patients. Minimally invasive methods of treating choledocholithiasis have advanced dramatically. IOC during open cholecystectomy with common bile duct exploration and stone removal as indicated was considered the standard of care. Increasing use of ERCP with ES and stone removal has experienced great success. However, ERCP is associated with recognized morbidity. Postprocedure pancreatitis occurs in 0.5 to 2% of elective ERCPs, but therapeutic ERCP may cause pancreatitis in as many as 26% of cases. Duodenal perforation following sphincterotomy occurs in approximately 1% percent of patients. Therefore, use of preoperative ERCP should be limited to clinical scenarios with high likelihood for common bile duct stones, including jaundice and cholangitis. Unfortunately, attempts to identify statistically significant predictive signs for choledocholithiasis have been unsuccessful, including abnormal liver function tests and ultrasound findings. Therefore, a more common approach now includes laparoscopic cholecystectomy with IOC and laparoscopic common bile duct exploration with a transcystic duct or transcholedochal approach. Attempts to clear the common bile duct laparoscopically include administration of glucagon, infusion of saline, fluoroscopic guided insertion of stone retrieval wire baskets, or placement of a flexible choledochoscope for common bile duct exploration via the cystic or common bile duct. Laparoscopic common bile duct exploration is a complicated and technically demanding procedure practiced by few surgeons on a regular basis. Failure to clear the common bile duct of stones during the laparoscopic procedure leads to either postoperative ERCP or conversion to an open common bile duct exploration. Success of ERCP in this setting is excellent and preserves the benefits of minimally invasive procedures. The availability of skilled ERCP technicians or radiologic interventionalists has lead many surgeons to complete the cholecystectomy laparoscopically and allow duct clearance to be performed by one of these alternative minimally invasive approaches. Unsuccessful ERCP or percutaneous transhepatic stone removal leading to another surgical procedure with open common bile duct exploration is an infrequent occurrence. Patients with cirrhosis and portal hypertension remain a challenge for the surgeon to perform any surgical procedure. However, laparoscopic cholecystectomy can be performed safely and effectively in patients with Child s A or B cirrhosis. In addition, increased experience with laparoscopic lysis of adhesions allows surgeons to successfully complete laparoscopic cholecystectomy in patients who have had previous surgical procedures. Obesity is no longer considered a contraindication to the laparoscopic approach. Successful completion of the laparoscopic cholecystectomy in the morbidly obese patient may require insertion of addi-

Laparoscopic Cholecystectomy / 751 tional ports for retraction of adipose tissue or use of longer laparoscopic trochars, and is clearly associated with an increased risk for conversion to open approach. Although bedside diagnostic laparoscopy is performed in septic patients at some centers, percutaneous cholecystostomy or traditional open cholecystectomy are preferred forms of therapy in hemodynamically unstable patients with acute calculous or acalculous cholecystitis. Gasless laparoscopy or pneumoperitoneum laparoscopy performed with an alternative gas, like helium, that does not cause acidosis or other hemodynamic effects of carbon dioxide, are also options in this patient group. Finally, pregnancy remains a controversial setting to treat symptomatic gallstones. Conservative nonsurgical therapy is frequently considered in mild cases of biliary colic or acute cholecystitis to reduce risk to the patient and fetus. Although, laparoscopic cholecystectomy is a safe procedure in all three trimesters, the second trimester remains the preferred timing for any elective surgical intervention. A lower risk of spontaneous abortion during the first trimester and lower risk of preterm labor during the third trimester favor the laparoscopic approach over the open technique, if surgery is indicated during those time periods. Complications and Outcomes During the early development of laparoscopic cholecystectomy, controversy raged over the dramatically increased risks of complications associated with the new procedure and credentialing of practicing surgeons in this technique. Many at academic institutions initially dismissed this apparently radical and potentially dangerous approach. The result was that many surgeons gained their initial experience with the procedure through short animal courses with limited clinical proctoring. Therefore, an understandably steep learning curve was associated with frequent complications. Fortunately, with the passage of time and wide acceptance of the procedure, laparoscopic cholecystectomy is now performed safely and acquisition of surgical skills is no longer a problem. Although controlled trials, necessary to demonstrate the procedure s worth to academia, lagged behind the overwhelming public support, large retrospective reviews have eventually confirmed the safety and efficacy of laparoscopic cholecystectomy. Elective laparoscopic cholecystectomy for calculous disease is a safe and successful procedure with a morbidity of < 5% and a mortality of<0.25%. Greater than 90% of patients with a classic presentation of right upper quadrant pain and ultrasonographic diagnosis of gallstones experience relief of symptoms following laparoscopic cholecystectomy. Although elective laparoscopic cholecystectomy for uncomplicated symptomatic cholelithiasis may have a conversion rate of< 2 or 3% in skilled hands, the majority of reported series have demonstrated a consistent conversion ratio of 5 to 6% over the last decade. The most common predictive factors for conversion to an open approach include surgeon s experience, morbid obesity, acute cholecystitis, chronic cholecystitis with thickened gallbladder wall on preoperative ultrasound, previous surgical procedures, and patients with multiple medical comorbidities. As previously mentioned, patients with acute cholecystitis may experience a conversion rate as high as 25%.Patients with acalculous disease and atypical symptoms have not experienced the same results following laparoscopic cholecystectomy. As previously mentioned, acute acalculous cholecystitis frequently occurs in clinical scenarios limiting the role of surgical intervention. Hemodynamically unstable patients who are unable to tolerate general anesthesia are frequently treated with percutaneous ultrasound guided placement of a cholecystostomy tube or urgent open cholecystectomy. Patients with biliary dyskinesia, experience only an 80% relief of symptoms following laparoscopic cholecystectomy. Common complications following laparoscopic cholecystectomy include those seen with operations of any type including bleeding, infection, and risks of general anesthesia, and those complications specific for the laparoscopic cholecystectomy, including conversion to an open procedure, bile duct injury, injury to surrounding organs, and bile or gallstone spillage into the peritoneal cavity. Although considered a complication by patients and many physicians, conversion to an open procedure more often demonstrates good clinical and technical judgment rather than surgical misadventure. Persistence with a laparoscopic approach despite difficulty with visualization and identification of anatomical landmarks may lead to other more severe complications like bile duct injury. Inadvertent bile duct injury is an uncommon but devastating complication that fortunately occurs less frequently with growing surgical experience. Common bile duct injury occurs in 0.5% of laparoscopic cholecystectomies. Suspicion of a biliary injury based on unclear anatomy, bile leak, or demonstration on IOC, requires immediate conversion to an open procedure to delineate the injury and repair it or reconstruct with a bilioenteric drainage procedure. Unfortunately, most bile duct injuries are missed at the initial laparoscopic cholecystectomy and remain undiagnosed until several days after surgery. This leads to the need for additional radiologic, endoscopic, or surgical drainage procedures, and a reoperation for eventual bilioenteric anastomosis. Although specific clinical scenarios, errors in skill, or lapses in judgment may lead to increased risk of injury, misperception appears to be the most common culprit. Recent surgical literature promotes regular use of IOC to help identify and perhaps reduce inadvertent biliary tree injuries. Although considered devastating and clearly associated with significant pain, suffering, and short term disability, long term results following reconstruction are good. Repair of a bile duct injury is

752 / Advanced Therapy in Gastroenterology and Liver Disease associated with an overall success rate of 90% and an excellent quality of life. Bleeding during laparoscopic cholecystectomy may occur from avulsion of the cystic artery or a tear in the liver. These are typically controlled successfully with ligation and cautery respectively. An inexperienced surgeon, when faced with persistent bleeding from the cystic artery stump, may rashly place superfluous metallic clips and cause inadvertent injury to other vascular structures or the remaining extrahepatic biliary tree. Errant introduction of the initial laparoscopic trochar has lead to injury of the mesenteric vessels, or more seriously, the iliac vessels. Injury to a major vascular structure including the portal vein, inferior vena cava, or hepatic artery is an extremely uncommon occurrence in only 0.11% of procedures, but it requires conversion to a laparotomy for immediate repair. Injury can occur to internal structures, including the intestine or mesentery, during insertion of laparoscopic ports, retraction of the liver or duodenum, or application of cautery to bleeding foci. Immediately identified injuries are repaired with laparoscopic or open surgical techniques. The most troublesome intestinal injury occurs from errant transmission of electrical cautery arcing to other inserted instruments or breakdown in the insulation of the electrical current applicator. These injuries may go unnoticed until 2 to 3 days have passed and peritonitis is present. Injuries are avoided by judicious use of electrical cautery under direct visualization. Bile spillage happens frequently during cholecystectomy. Inflammation alters surgical dissection planes and creates a friable and easily torn gallbladder wall. Bile is easily irrigated and aspirated with little residual effects. On the other hand, gallstones spilled into the peritoneal cavity should be located and removed to reduce infectious foci and possible complications. Wound infection, an infrequent occurrence, is limited by extraction of the gallbladder from the peritoneal cavity with a plastic pouch. Conclusion Time has provided surgeons with experience to surpass the learning curve associated with laparoscopic cholecystectomy. The surgical technique has changed little during the last several years. However, improved technology and growing experience have allowed surgeons to offer the laparoscopic approach to patients who were once considered to have relative contraindications with similar low rates of morbidity and mortality. Routine use of IOC and preoperative ERCP remain controversial issues. The greatest changes have occurred with increasing push to perform laparoscopic cholecystectomy early in the chronology of the disease process and in acalculous disease. 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