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P athophysiology ................................................................................................................................. 209
taken during chills are more likely to be positive. The
essentials of cholangitis are summarized in Table 7.5.
Biliary Pancreatitis
This topic is discussed in detail in Chapter 4.
Gallstone Ileus
Any gallstones that can pass into the duodenum through
the sphincter of Oddi are not large enough to obstruct the
bowel. Larger stones can cause small bowel obstruction by
entering the intestine through a cholecysto-enteric fistula.
This complication is seen most commonly in elderly
patients. Symptoms of acute cholecystitis may precede
symptoms of bowel obstruction, but acute intermittent
bowel obstruction is often the first symptom. The gallstone
causes intermittent obstruction as it travels down the intestine by lodging in narrowed segments of the small intestine
(e.g., duodenojejunal flexure, areas narrowed by adhesions) until it finally lodges in the ileocecal sphincter. Initial
proximal small bowel obstruction is followed by distal
small bowel obstruction. Colicky pain, vomiting, abdominal distension, and dehydration are the clinical features.
Imaging studies may show not only typical small bowel
obstruction but also gas in the biliary tract (Figure 7.11).
Rarely, a gallstone may enter the gastrointestinal tract
through either a cholecystogastric or cholecystocolic
fistula. The essentials of gallstone ileus are summarized in
Table 7.6.
Sclerosing Cholangitis
Primary sclerosing cholangitis may occur without any
identifiable cause or associated condition. Two-thirds of
cases, however, occur in association primarily with inflammatory bowel disease. Some cases are associated with systemic fibrosing conditions or with autoimmune disorders.
The incidence of sclerosing cholangitis in chronic ulcerative colitis is approximately 2.4% to 4%, with the highest
incidence occurring in pancolitis. The pathogenesis is
unknown. Autoimmune causes are most commonly
believed to be involved, but other factors that have been
considered include enterohepatic toxins and portal bacteremia, viral infections [e.g., cytomegalovirus (CMV)],
and Cryptococcus neoformans. A genetic component is sug-
gested by the familial occurrence of primary sclerosing
cholangitis and ulcerative colitis, and by the association of
the disease with certain human leukocyte histocompatibility antigens (B8 and DR3). Secondary sclerosing
cholangitis may be caused by toxic agents (e.g., formaldehyde, hypertonic saline injected into echinococcal cysts,
absolute alcohol), ischemia associated with allograft rejection, and even operative trauma.
The affected bile ducts are thickened and narrowed.
The thickening is due to fibrosis in the duct wall. The
disease is often segmental, but sometimes the entire CBD
may be affected. Occasionally, the gallbladder may be
involved. Extrahepatic disease is often associated with
intrahepatic sclerosing cholangitis. Cholangiography is
often diagnostic and shows multifocal stricture in both
extra- and intrahepatic ducts. The strictures are often
short, with more proximal dilatation causing a beaded
appearance (Figure 7.12). Complications of sclerosing
cholangitis include obstructive jaundice, biliary stones,
cholangitis, biliary cirrhosis, and cholangiocarcinoma.
The incidence of cholangiocarcinoma in sclerosing
cholangitis is about 4% to 10% and carries a particularly
poor prognosis. The essentials of sclerosing cholangitis are
summarized in Table 7.7.
Recurrent Pyogenic Cholangitis
Formerly referred to as Oriental cholangiohepatitis, this
disease is endemic in Asian countries. It is characterized
by intra- and extrahepatic bilirubin stones that cause
chronic obstruction and dilatation of the biliary tract with
recurrent attacks of septic cholangitis. The gallbladder is
usually free of disease. Recurrent pyogenic cholangitis is
being seen more and more in the U.S. in the migrant population from Southeast Asia. Several etiological hypotheses have been put forward, including parasitic infection
with Clonorchis sinensis, indolent bacterial infection, and
protein malnutrition. With recurrent sepsis, not only
biliary dilatation but also several focal strictures form. The
formation of intrahepatic stones is also a feature. Symptoms include chronic abdominal pain, intermittent
TABLE 7.5. Essentials: Cholangitis
Causes
䊏
Infection in obstructed bile ducts
䊏
Obstruction most commonly due to stones
Microorganisms
䊏
Aerobes
Gram-positive: Streptococcus faecalis, b-hemolytic
streptococcus, Staphylococcus aureus, Staphylococcus albus
Gram-negative: Escherichia coli, Pseudomonas aeruginosa,
Klebsiella, Proteus
䊏
Anaerobes
Gram-positive: Clostridium welchii, anaerobic streptococcus
Gram-negative: Bacteroides
Clinical features (Reynauld’s pentad)
䊏
Upper abdominal pain
䊏
Fever and chills
䊏
Jaundice
䊏
Mental obtundation
䊏
Septic shock
Principles of treatment
䊏
Intravenous broad-spectrum antibiotics (aminoglycoside,
cephalosporin, metronidazole or clindamycin)
䊏
Prompt removal of obstruction and common bile duct
drainage (via endoscope, radiology or surgery)
䊏
Definitive operative or endoscopic treatment electively
A
B
FIGURE 7.11. Gallstone ileus as manifest on CT scan. (A) Air in the biliary tree is a result of a cholecystoduodenal fistula due to a gallstone. (B) In the second scan, a gallstone (black arrow) partially
obstructs a jejunal loop of bowel; collapsed segments of bowel (small arrows) can be seen beyond the
site of obstruction. (Courtesy of Henry I. Goldberg, MD.)
210 .................................................................................................................................... Biliary T ract
TABLE 7.6. Essentials: Gallstone Ileus
Definition
Bowel obstruction due to passage of large stone into small
intestine through cholecystoduodenal fistula
Clinical picture
䊏
Intermittent attacks of small bowel obstruction preceding
complete obstruction of distal small intestine
䊏
Biliary tract symptoms may or may not be present
Radiologic diagnosis
䊏
Mechanical small bowel obstruction
䊏
Air in biliary tree
Treatment
䊏
Nasogastric suction and fluid and electrolyte resuscitation
䊏
Prompt operation
Removal of stone by enterotomy proximal to site of
obstruction
Search for other stones in transit
Closure of enterotomy
No attempt to take down fistula or perform
cholecystectomy
TABLE 7.7. Essentials: Sclerosing Cholangitis
Causes unknown
䊏
Two-thirds associated with IBD
䊏
Autoimmune
䊏
Enterohepatic toxins
䊏
Portal bacteremia, viremia
䊏
Genetic: Human histocompatibility; antigens (B8, DR3)
Pathology
䊏
Segmental fibrosis and stricture of bile ducts with dilatation
of intervening duct segment (beaded appearance)
䊏
May affect intra- as well as extrahepatic ducts
Complications
䊏
Obstructive jaundice
䊏
Biliary stones
䊏
Cholangitis
䊏
Biliary cirrhosis
䊏
Cholangiocarcinoma (4%–10%)
Treatment
䊏
Medical: immunosuppression (corticosteroids, azothyoprine)
䊏
Interventional: endoscopic/transhepatic stenting
䊏
Surgical
Resection of CBD and hepaticojejunostomy
Colectomy for associated ulcerative colitis
Abbreviations: CBD, common bile duct; IBD, inflammatory bowel disease.
A
B
FIGURE 7.12. Cholangiography is often diagnostic in primary sclerosing cholangitis. (A) The percutaneous THC shows a beaded appearance in the common bile duct (arrows). (B) The ERCP demonstrates
a normal caliber common duct but short strictures in intrahepatic ducts (arrows). (Courtesy of Henry I.
Goldberg, MD.)
212 .................................................................................................................................... Biliary T ract
IMAGING STUDIES OF THE
BILIARY TRACT
During the last 25 years, the most revolutionary advances
in imaging of the biliary tract have occurred, which have
significantly improved both diagnosis and interventional
approaches in biliary tract disease. During that period,
ultrasonography increasingly improved to become the
standard screening test for gallstone disease, virtually
cholecystogram, intravenous cholangiogram, and scintigraphy. In addition to ultrasonography, the most important
imaging studies include magnetic resonance cholangiopancreatography (MRC), endoscopic retrograde
cholangiopancreatography (ERCP), transhepatic cholangiography (THC), computed tomography (CT), and intraoperative cholangiography (IOC). The essentials of biliary
tract imaging are listed in Table 7.8.
Ultrasonography
Abdominal ultrasonography (Figure 7.13) is noninvasive
and has sensitivity and specificity rates of 90% to 95% in
the diagnosis of cholelithiasis. In this regard, it is superior
to CT. It is not as good, however, in demonstrating stones
in the common bile duct (CBD). It can accurately measure
the CBD diameter, which, on ultrasonography is normally
6 to 7mm, with anything larger indicating abnormal
dilatation. When a patient presents with typical signs and
symptoms of biliary colic or acute cholecystitis, ultrasound is often the only preoperative imaging study
required, unless jaundice is associated.
Ultrasonography is also possible via probes introduced
through endoscopes or laparoscopic trocars. Endoscopic
ultrasound is particularly useful in preoperative screening
of the CBD. Laparoscopic ultrasound is becoming increasingly useful for assessing the CBD during cholecystectomy
but has not replaced intraoperative cholangiography, particularly when the need arises to accurately demonstrate
bile duct anatomy during a difficult operation. Duplex
ultrasound is very useful in identifying masses and the
presence of neoplasms in the bile ducts or portal veins.
Magnetic Resonance
Cholangiopancreatography
Rapidly becoming one of the most important imaging
studies of the biliary tract, magnetic resonance cholangiopancreatography (MRC) is noninvasive, requires no
contrast, and poses no risk of radiation (Figure 7.14).
These properties make it the ideal study in pregnancy and
CLINICAL MANAGEMENT
TABLE 7.8. Essentials: Biliary Tract Imaging
Oral cholecystogram, intravenous cholangiogram
䊏
Of historic interest
Ultrasonography
䊏
Best initial study
䊏
Diagnostic in acute cholecystitis
䊏
Demonstrates bile duct dilatation
䊏
Can be used laparoscopically and endoscopically
Magnetic resonance cholangiography
䊏
Excellent evaluation of bile ducts and pancreatic duct
䊏
Diagnostic in bile duct tumors
䊏
Safe in pregnancy
Endoscopic retrograde cholangiopancreatography (ERCP)
䊏
Excellent evaluation of biliary and pancreatic systems
䊏
Most useful in pathology of distal common bile duct
䊏
Permits biopsy and brushing
䊏
Facilitates papillotomy, choledocholithotomy, stenting, and
nasobiliary drainage
䊏
0.5%–1.0% complication rate
Transhepatic cholangiography (THC)
䊏
Most useful in pathology of proximal common bile duct
䊏
Permits percutaneous biliary drainage, stenting, and biopsy
Computed tomography (CT)
䊏
Most useful in evaluation of tumors
䊏
Spiral CT provides three-dimensional image
Hepatic iminodiacetic acid (HIDA) scan
䊏
Useful in diagnosis of selected patients with acute
cholecystitis or CBD obstruction
obstructive jaundice, and, occasionally, frank septic
cholangitis. Because the cause is not understood, the treatment is to try to clear the common bile duct and prevent
further obstruction by creating a wide anastomosis
between the common duct and the GI tract, either with
choledochoduodenostomy or choledochojejunostomy.
Because recurrent obstruction is possible after either of
these procedures, easy subsequent access to the CBD
should be created for endoscopic or percutaneous inter-
vention. CBD obstruction after choledochoduodenostomy
can be managed endoscopically by introducing a basket
through the wide stoma. When the initial operative treatment is choledochojejunostomy, the distal end of the cut
jejunum is brought out on the abdominal wall as a stoma
and choledochojejunostomy is performed some 6 to 8
inches distally. This procedure allows access to the CBD
through the jejunal stones.
FIGURE 7.13. Abdominal ultrasonography is the most useful screening study for biliary tract disease,
especially in stone disease. The ultrasonogram shows several stones (arrow) in the dependent portion
of the gallbladder in a patient with clinical features of an early cholecystitis. The gallbladder wall is
not yet thickened as in Figure 7.9. (Courtesy of Henry I. Goldberg, MD.)
FIGURE 7.14. The magnetic resonance cholangiopancreatography (MRC) scan shows a stricture of the common bile duct (large
arrow) with a normal distal common duct (arrowhead). The bile
ducts proximal to this malignant stricture are dilated. Abbrevia-
tion: GB, gallbladder. (Courtesy of Henry I. Goldberg, MD.)
in clinical situations where use of contrast increases the
risk of renal failure. Because fluid (e.g., bile, pancreatic
juice) shows as white, MRC images of the biliary tract and
pancreatic duct are as good or nearly as good as those
obtained with ERCP or transhepatic cholangiography.
Magnetic resonance can also be used to perform angiography in the evaluation of complex disease or for planning
surgery. Magnetic resonance angiography (MRA) is
extremely fast, enabling 3D imaging and excellent visualization of strictures in both the arterial and venous phases.
It is likely that in the future, MRC and MRA may replace
the other imaging studies now in greater use.
Endoscopic Retrograde
Cholangiopancreatography
Endoscopic retrograde cholangiopancreatography (ERCP)
has represented a major advance in diagnosis and therapy
of the biliary tract and has had significant impact on the
treatment of choledocholithiasis and cholangitis (Figure
7.15). Its major advantage over other imaging studies is
that treatment (e.g., papillotomy, choledocholithotomy,
stenting) can be provided at the same time. It is an invasive procedure with complications of perforation and pancreatitis of 0.5% to 1%.
ERCP is most important in the management of
retained stones (Figure 7.16), ampullary and distal CBD
tumors, cholangitis, and biliary pancreatitis. Retained
stones can be extracted after papillotomy. In ampullary
C linical M anagement .......................................................................................................................... 213
FIGURE 7.15. This endoscopic retrograde cholangiopancreatography (ERCP) scan demonstrates a
normal common bile duct (large arrow), cystic duct (small arrow) and gallbladder (GB). (Courtesy of
Henry I. Goldberg, MD.)
A
B
FIGURE 7.16. (A) Normal endoscopic retrograde cholangiopancreatography (ERCP) scan shows the
biliary tree and pancreatic duct in a patient who previously underwent cholecystectomy. (B) The ERCP
scan in another patient shows a dilated common bile duct containing a large stone. (Courtesy of John
P. Cello, MD.)
214 .................................................................................................................................... Biliary T ract
and distal CBD tumors, tissue for histological diagnosis
can be obtained by biopsy or brushing. In suppurative
cholangitis, ERCP can be used to rapidly decompress the
CBD by papillotomy or by the placement of nasobiliary
drain. It converts a life-threatening condition that once
required emergency surgery to one that can be treated by
elective operation. In severe biliary pancreatitis, early
ERCP and sphincterotomy have been shown to reduce
mortality tenfold.
3
In the future, it is likely that MRC will
replace ERCP as the most common diagnostic imaging
study for the CBD, but ERCP will continue to be important as an interventional therapeutic procedure.
Transhepatic Cholangiography
Excellent imaging of both the intra- and extrahepatic
biliary tract can be obtained with percutaneous transhepatic injection of dye into a biliary radical in the liver
(Figure 7.17). Transhepatic cholangiography (THC) and
ERCP are complementary in imaging the CBD, with THC
being more useful for proximal lesions and ERCP for distal
lesions. While these therapeutic uses of the transhepatic
approach will continue to be important, MRC is increasingly replacing THC as the diagnostic imaging study in
hilar lesions.
Computed Tomography
The most important use of computed tomography (CT)
in biliary tract disease is in the evaluation of tumors and
biliary pancreatitis. As indicated earlier, ultrasound provides cheaper, noninvasive, and more accurate assessment
of stone disease. CT is superior, however, in the diagnosis
and staging of neoplasms in the biliary tract. Spiral CT has
significantly improved the usefulness of the study (Figure
7.18).
Hepatobiliary Scintigraphy
The most useful application of hepatobiliary scintigraphy
is to ascertain biliary tree patency. Radionuclide agents
99m
(e.g.,
Te) administered intravenously are excreted by the
FIGURE 7.17. Transhepatic cholangiography (THC) of the bile
duct. THC is useful for imaging the common bile duct and proximal lesions of the biliary tract, inserting drains or stents, and for
biopsy of lesions. This cholangiogram shows a normal unobstructed biliary tract. (Courtesy of Henry I. Goldberg, MD.)
hepatocytes into the biliary tract. Failure of the GB to
opacify some 60 minutes after injection provides strong
presumptive evidence that the cystic duct is obstructed
and, in the presence of relevant clinical symptoms,
strongly suggests the diagnosis of acute cholecystitis.
Hepatic iminodiacetic acid (HIDA) scanning diagnoses
acute cholecystitis with 98% accuracy (Figure 7.19). When
obstruction at the distal CBD is present, the biliary tract
and the GB may be visualized without any opacification of
the duodenum.
C linical M anagement .......................................................................................................................... 215
FIGURE 7.18. Spiral CT is superior to ultrasound in diagnosis and staging of neoplasms in the biliary
tree. This CT scan shows dilated intrahepatic bile ducts radiating to the proximal common hepatic
duct, which is abruptly cut off (arrow). A subtle cholangiocarcinoma is present. (Courtesy of Henry I.
Goldberg, MD.)
FIGURE 7.19. This HIDA scan was taken 60 minutes after injection of the radionuclide. The common
hepatic and bile ducts are shown (arrows), but no filling of the gallbladder (GB) has occurred. HIDA
has entered the small bowel (B) and refluxed into the stomach (S). (Courtesy of Henry I. Goldberg,
MD.)
216 .................................................................................................................................... Biliary T ract
C linical D isorders.............................................................................................................................. 217
CLINICAL DISORDERS
ASYMPTOMATIC CHOLELITHIASIS
Silent gallstones may be discovered incidentally during
imaging studies or abdominal exploration. Long-term followup studies show that only 10% to 20% of individuals
with silent gallstones develop symptoms, most commonly
biliary colic.
4
Fewer than 3% develop acute cholecystitis,
and fewer than 1% die from gallstone complications.
4
A
study comparing prophylactic cholecystectomy with no
treatment showed that surgery decreased expected survival
slightly.
1
It is now generally agreed that asymptomatic gallstones should be managed conservatively, even in diabetic
individuals, who seem to have an increased risk for developing symptoms. It is prudent, however, to perform cholecystectomy in most patients with asymptomatic gallstones
in the course of abdominal surgery for other indications.
This recommendation is particularly important in patients
who have diabetes, large stones, or calcified gallbladder,
because they all have a slightly increased risk of complications from asymptomatic gallstones.
BILIARY COLIC
Typically, pain in biliary colic is felt in the right upper
quadrant (RUQ) of the abdomen and often radiates to the
back in the right infrascapular region. The pain may last
from minutes to hours and often follows ingestion of a
meal, particularly one with a large fat content. Nausea and
vomiting may be present, but fever and abdominal tenderness are not.
Investigations
Abdominal ultrasound is the simplest and best diagnostic
tool and shows stones in the gallbladder, usually with
minimal gallbladder wall thickening or pericholecystic
fluid. Fever or leukocytosis are absent in most cases. Liver
function tests and serum amylase are usually normal.
Treatment
The standard treatment is early laparoscopic cholecystectomy. Once surgery is scheduled, the patient is advised to
adhere to a low-fat diet. Analgesia is required only during
the acute attack. In early pregnancy, conservative management with a low-fat diet is appropriate, and this approach
may succeed in postponing cholecystectomy until after
delivery. Otherwise, cholecystectomy may be required and
performed safely during the second half of the second
trimester or in the third trimester if symptoms worsen or
if acute cholecystitis develops.
ACUTE CHOLECYSTITIS
The characteristic symptoms are RUQ pain, nausea, vomiting with mild fever, and leukocytosis. The pain typically
radiates to the right infrascapular region in the back.
Abdominal examination elicits RUQ tenderness, perhaps
guarding, and sometimes a mass due to omentum surrounding an inflamed gallbladder. A positive Murphy’s
sign is typically elicited: Palpation in the subhepatic region
at the time of deep inspiration causes arrest of inspiration
as the inflamed gallbladder and surrounding tissue
descend to the examiner’s touch. Clinical jaundice is rarely
present. If the patient appears toxic and has a high fever,
a complication must be suspected, either gangrenous
cholecystitis, perforation of the gallbladder, or empyema.
Investigations
Hemogram shows low-grade leukocytosis with a shift to
the left. Liver function tests are usually normal but may
sometimes show low-grade elevation of the bilirubin
(<2 mg%) and even minor elevation in liver enzymes.
Serum amylase is typically normal. Ultrasound is the best
way to confirm the diagnosis (Figure 7.9A). The typical
findings are: (1) stones in the gallbladder (Figure 7.13), (2)
thickening of the gallbladder wall, and (3) pericholecystic
fluid collection. The ultrasonographer is also able to elicit
Murphy’s sign by pressing the transducer into the RUQ.
Treatment
The diagnosis is usually readily confirmed. The patient
requires analgesia. A nasogastric tube should be inserted if
the patient is vomiting. The patient should be hydrated
quickly and broad-spectrum antibiotics should be administered intravenously. Laparoscopic cholecystectomy
should be performed without too much delay. In the past,
patients with acute cholecystitis were treated conservatively until inflammation resolved, and then elective
cholecystectomy was performed. Six randomized trials
have compared this delayed treatment with prompt cholecystectomy within 1 to 10 days in 1019 patients.
5
Complication rates were 21.0% for early and 16.5% for late
cholecystectomy. The corresponding mortality rates were
0.2% and 1.8%, respectively. As a result of these studies, it
is now recommended that cholecystectomy be performed
within 24 to 48 h of establishing the diagnosis. The early
treatment strategy returns patients to their normal lives
much more quickly, particularly if the cholecystectomy is
done laparoscopically.
When cholecystectomy for acute cholecystitis becomes
technically difficult because of severe inflammation, excessive bleeding, or difficulty in safely identifying the cystic
and bile ducts, the preferred procedure is tube cholecys-
218 .................................................................................................................................... Biliary T ract
tostomy and drainage of the right upper quadrant. All the
stones in the gallbladder should be removed if possible.
The patient usually recovers rapidly, and elective cholecystectomy can be scheduled in 3 to 6 months. In the very
elderly patient, if cholangiogram through the cholecystostomy tube shows no residual stones either in the gallbladder or in the CBD and dye flows freely through the
cystic duct, no further surgery may be required. Such decisions must be highly individualized.
CHRONIC CHOLECYSTITIS
Chronic cholecystitis is difficult to diagnose. The symptoms are vague abdominal pain, often occurring postprandially. When the course is punctuated with clear-cut
episodes of biliary colic, the diagnosis is easier. Ultrasonography shows cholelithiasis without evidence of acute
inflammation. If other conditions can be excluded, the
treatment is laparoscopic cholecystectomy. It must be
pointed out that some 10% to 15% of these patients
develop postcholecystectomy syndrome.
ACALCULOUS CHOLECYSTITIS
Because acalculous cholecystitis (AC) most often occurs in
the setting of critical illness or postoperatively, the diagnosis may be difficult. Undiagnosed and untreated, AC has
a high mortality rate. The clinical signs are right upper
quadrant pain, tenderness, and fever, but they are not
always present. Pain and/or tenderness are seen in only
70% and fever in less than 66% of patients. Tenderness
may be present more diffusely in the upper abdomen
rather than localized to the right upper quadrant.
Investigations
Laboratory Tests
Leukocytosis with a shift to the left is found in approximately 85% of patients. Liver function test results are
abnormal in approximately 80% of cases.
Imaging Studies
Abdominal ultrasound is the best initial imaging study and
should be performed whenever the diagnosis is suspected.
The three major diagnostic criteria are: (1) thickening of
the gallbladder wall exceeding 3 to 5mm, (2) distention
(hydrops) of the gallbladder, and (3) presence of sludge
within the gallbladder.
Other secondary diagnostic criteria include subserosal
edema, pericholecystic fluid, and positive ultrasonographic Murphy’s sign. Ultrasound has more than 90%
sensitivity and specificity. CT examination is necessary
only if ultrasonography is negative. HIDA scan has a 30%
to 50% false–positive error rate. The error rate is reduced
somehow by the use of morphine cholecystography, in
which intravenous morphine is used to contract the
sphincter of Oddi to promote gallbladder filling. The
gallium or
111
Indium leukocyte scan is used infrequently.
A positive test shows a doughnut pattern of uptake in the
inflamed GB wall.
Treatment
Early diagnosis and early treatment are essential to reduce
mortality. Open cholecystectomy in these very ill patients
is associated with a 30% mortality rate.
6
This observation
led to the introduction of percutaneous cholecystostomy
or percutaneous transhepatic cholecystostomy, both of
which lead to rapid improvement in most patients. The
problem arises when the gallbladder wall is gangrenous or
when a complication of the procedure (e.g., hemorrhage,
bile leak) occurs. At present, the optimum treatment is
laparoscopic cholecystostomy or cholecystectomy. In the
desperately ill patient without gangrenous cholecystitis,
laparoscopic cholecystostomy is preferred. When the
patient is not so critically ill or when gangrene is present,
laparoscopic cholecystectomy is the treatment of choice.
TECHNIQUES OF
GALLBLADDER SURGERY
Laparoscopic Cholecystectomy
Laparoscopic cholecystectomy (LC) is now the standard
procedure for calculous gallbladder disease. This minimally invasive approach has dramatically reduced postoperative pain, length of hospital stay, and the patient’s
return to active life. The mortality rate is less than 0.2%
and similar to that of open cholecystectomy.
7
The morbidity rate at over 7% and bile duct injury rate at about
0% to 4% are higher than for open cholecystectomy.
7
Relative contraindications for LC include previous
upper abdominal surgery, severe obesity, pregnancy, and
acute cholecystitis. As LC has become established, none of
these conditions absolutely contraindicate performing LC.
On the other hand, significantly greater technical difficulty
may be encountered, and the surgeon should have low
resistance to converting the procedure to open surgery.
Mean conversion rate for all LC is almost 5% but can be
as high as 7% to 10% in the above circumstances.
LC is performed under general anesthesia. A nasogastric tube and bladder catheter are introduced. Pneumoperitoneum is created using a Veress needle or a Hassan
cannula. Trocar placement for performing LC is shown
in Figure 7.20. After adequate insufflation is achieved to
18 cm of water using nitrous oxide, a periumbilical trocar
is placed for the introduction of the laparoscope. Then,
three other trocars are placed while the site of peritoneal
puncture done with each trocar is directly viewed through
the laparoscope. The assistant stands on the right of the
patient, the surgeon on the left, and the camera operator
between the patient’s legs.
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