Cholecystectomy

Aka: Cholecystectomy, Laparoscopic Cholecystectomy

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