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Cholecystectomy
Aka: Cholecystectomy, Laparoscopic Cholecystectomy
- Epidemiology
- Laparoscopic Cholecystectomy is the most common abdominal surgery in Europe and U.S. (900,000 cases per year)
- Indications
- Biliary Colic
- Biliary Dyskinesia
- Calcified Gallbladder
- Acute Cholecystitis
- Urgently perform within 72 hours of onset
- Choledocholithiasis
- Perform after Common Bile Duct Stone is cleared with ERCP
- Gallstone Pancreatitis
- Perform after Pancreatitis resolves, before hospital discharge
- Contraindications: Laparoscopic Cholecystectomy
- Gallbladder cancer (absolute contraindication)
- Uncontrolled Coagulopathy (absolute contraindication)
- Advanced Cirrhosis or liver failure
- Coagulopathy
- Peritonitis
- Sepsis
- Advantages: Laparoscopic Cholecystectomy (preferred)
- Decreased pain and Disability
- Much earlier return to work time
- Shorter hospital stay (often outpatient)
- Lower mortality
- Laparoscopic: 8 to 16 per 10,000 patients
- Open: 66 to 74 per 10,000 patients
- Shea (1996) Ann Surg 224:609-20 [PubMed]
- Treatment cost slightly less than open Cholecystectomy
- Better cosmetic result
- Management: Timing of Surgery - Early surgery is safe and preferred
- Incidence of technical complications is the same
- Reduces total illness duration by 30 days
- Hospitalization time reduced by 5-7 days
- Direct medical cost savings reduced by > $2000
- Death rate slightly lower with early surgery
- References
- Stevens (2006) Am J Surg 192:756-61 [PubMed]
- Management: Antibiotic prophylaxis
- Indications: Patients at high risk of Wound Infection
- Age over 60 years old
- Diabetes Mellitus
- Acute Biliary Colic within 30 days of surgery
- Jaundice
- Acute Cholecystitis
- Ascending Cholangitis
- Protocol
- Cefazolin 1 g IV within one hour of skin incision for one dose
- Continue other antibiotics as indicated (e.g. Ascending Cholangitis)
- References
- Choudhary (2008) J Gastrointest Surg 12(11): 1847-53 [PubMed]
- Complications: Conversion from laparoscopy to open laparotomy
- Rates
- Uninflamed gallbladder: 2-15%
- Acute Cholecystitis: 6-35%
- Risk factors
- Male gender
- Over age 60 years
- History of upper abdominal surgery
- Ultrasound with thickened gallbladder wall
- Acute Cholecystitis
- References
- Tayeb (2005) J Postgrad Med 51(1): 17-20 [PubMed]
- Complications: Common Bile duct injury (Bile leak)
- Typically presents within 3 days of Laparoscopic Cholecystectomy
- Laparoscopic: 36 to 47 per 10,000 patients
- Open: 19 to 29 per 10,000 patients
- Shea (1996) Ann Surg 224:609-20 [PubMed]
- Diagnosis
- Ultrasound will show a free fluid collection around the biliary duct
- ERCP: Dye extravasates
- Ultrasound guided needle aspiration will reveal brown bile (as opposed to post-operative hematoma)
- References
- Weinstock in Majoewsky (2012) EM:RAP 12(3): 3
- Complications: Other
- Dropped Gallstone
- Gallstone drops during resection into the peritoneum
- Results in infection, forming an abscess or phlegmon
- References
- Abraham (2014) Am Fam Physician 89(10): 795-802 [PubMed]