2 Laparoscopic Cholecystectomy

Gallstone disease is one of the leading causes of gastrointestinal hospital admissions in the United States. Cholelithiasis affects 10–15% of the Western adult population, with 20% of those patients experiencing symptoms at some point in their life. Biliary colic is the most common gallstone pathology, characterized by temporary acute right upper quadrant abdominal pain due to intermittent obstruction of the cystic duct by gallstones. Patients with biliary colic require surgical removal of their gallbladder (cholecystectomy) to alleviate their recurring symptoms. Here we present the case of a young woman with recurrent episodes of biliary colic who undergoes a laparoscopic cholecystectomy. This article and associated video describe the natural history, preoperative evaluation, and operative steps.

Cholelithiasis is the presence of gallstones within the gallbladder. Approximately 10–15% of the Western adult population has gallstones, yet 80% of these people will remain asymptomatic throughout their lifetimes.¹ Between 1% and 4% of patients with gallstones will have an episode of biliary colic each year.² Biliary colic is often a harbinger of future gallstone complications, with 15% eventually developing cholecystitis or inflammation of the gallbladder.³ Females are twice as likely to develop gallstones as males. Additional risk factors include family history, obesity, rapid weight loss, and increasing age.⁴

Our patient is a 32-year-old female with a prior medical history significant only for irritable bowel syndrome. She had recently delivered a child one year prior and had been in good health until six months postpartum when she began to notice symptoms of biliary colic. She had experienced intermittent, nonradiating pain in her midepigastric region for the last six months. The pain would most frequently occur a few hours after eating a fatty or greasy meal. The duration of this pain would last on average for two hours. Nausea and vomiting were associated with these episodes of colic. The pain would occasionally wake her from sleep. Her symptoms improved somewhat upon changing to a low-fat diet. Prior to her referral, she underwent an abdominal ultrasound that revealed multiple gallstones within her gallbladder. Our patient then presented for surgical evaluation for gallbladder removal.

She had no prior abdominal surgical history other than a cesarean section one year prior. She takes no medications at this time and has an allergy to latex. She is a former smoker who previously smoked a quarter of a pack a day for ten years but quit five years prior to this evaluation. She has no relevant family history.

Physical exam revealed a healthy-appearing young lady with a pulse of 72 bpm and blood pressure of 122/84 mmHg. Her BMI is 25.8 kg/m². She had no scleral icterus, and neither cervical nor supraclavicular lymphadenopathy. Her lungs were clear to auscultation bilaterally, and her heart had a regular rate and rhythm without murmur. Her abdomen was soft, nontender, nondistended, and without any palpable masses, splenomegaly, hepatomegaly, or hernias. She had a negative Murphy’s exam. Her skin and extremities exams were without any focal abnormalities.

Our patient underwent an abdominal ultrasound that revealed numerous gallstones within the gallbladder. There was neither thickening of the gallbladder wall nor dilation of the cystic duct to suggest either acute cholecystitis or choledocholithiasis, respectively. No further imaging was necessary as these findings correlated with the patient’s clinical history and confirmed the diagnosis of biliary colic resulting from cholelithiasis.

Patients will often undergo imaging studies prior to their referral to a surgeon. The most common imaging modalities used are an abdominal ultrasound or an abdominal computed tomography (CT) scan. Both these modalities, when evaluated in context with the patient’s history and physical exam, provide useful adjuncts in surgical decision making. A right upper quadrant ultrasound, however, is often sufficient as it is the gold standard study diagnosing cholelithiasis.⁵ This modality is easy to interpret, inexpensive, and easily available.

More advanced imaging may be necessary if the ultrasound is inconclusive or if there is a concern for variant pathology. Both an abdominal CT scan or a hepatobiliary iminodiacetic acid (HIDA) scan are possibilities if the ultrasound is inconclusive. A CT scan would be able to demonstrate the gallstones within the gallbladder. A HIDA scan would only be beneficial if the gallstone were still impacting the cystic duct, meaning that the patient would likely still be symptomatic at the time of the exam.⁶ Magnetic resonance imaging (MRI) is typically reserved for patients with concern for choledocholithiasis, in which a magnetic resonance cholangiopancreatogram (MRCP) is performed to ascertain if there is obstruction of the common bile duct (CBD).⁷

Gallstones can be classified by their composition and are distinguished as either cholesterol stones or pigmented stones. Cholesterol stones are the predominant variant and develop as a result of the imbalance of concentrations of cholesterol and bile salts within the gallbladder. When the concentration of bile salts decreases, cholesterol can precipitate out of the bile salt-lecithin-cholesterol micelles to generate cholesterol stones.⁸ Pigmented stones can be further subdivided into black or brown pigment stones.⁹ Black pigment stones form in patients with increased concentrations of unconjugated bilirubin, most commonly due to hemolytic blood dyscrasias, or in patients with bile stasis from hypoactivity of the gallbladder, often seen in patients dependent on total parenteral nutrition.^9, 10 Brown pigment stones typically form on account of infected bile that results in elevated calcium concentrations within the bile, ultimately precipitating and resulting in stone formation. Brown stones typically form within the intrahepatic or extrahepatic ducts rather than within the gallbladder.^9, 11

The clinical manifestations of biliary colic occur when a gallstone temporarily obstructs the cystic duct of the gallbladder. This blockage results in colic or pain of the right upper quadrant.¹² The pain is severe and will typically last at least 1–2 hours and can recur at unpredictable intervals. Contraction of the gallbladder to release bile typically occurs following a meal, and it is the contraction against an obstructed cystic duct, the outflow tract of the gallbladder, that results in visceral pain.¹³ This is why biliary colic most frequently occurs after ingesting a fatty or greasy meal.

Patients with biliary colic require surgical removal of their gallbladder to alleviate their recurring symptoms. Nevertheless, patients may require optimization prior to surgery. Nausea and vomiting associated with biliary colic can result in fluid imbalance or electrolyte abnormalities. These should be corrected prior to surgery. Pain should also be controlled, preferably with nonsteroidal anti-inflammatory drugs (NSAIDs) rather than opioids.¹⁴ Should patients have severe enough pain that results in a presentation to the emergency department, they should be admitted with a plan to operate within 72 hours. Recent studies have suggested that early gallbladder removal at the time of presentation is preferable to delayed removal in order to decrease the risk of recurrent attacks or representation with more advanced disease.^15, 16

Our patient has had recurrent symptoms for the past six months; therefore, surgical removal of her gallbladder is the best option to relieve her recurrent pain and prevent future development of acute cholecystitis. The procedure of choice is a laparoscopic cholecystectomy given that she had no contraindications to laparoscopic surgery and her only prior operation was a cesarean section.

The above treatment recommendations are for biliary colic and apply in most situations for acute cholecystitis. Nevertheless, there are various gallbladder pathologies, many of which require adjustments to this workup. These include, but are not limited to, the following: biliary dyskinesia, choledocholithiasis, Mirizzi syndrome, gallstone pancreatitis, gallstone ileus, gallbladder polyps, hydrops, or emphysematous cholecystitis.

Please refer to an alternate reference if your patient has one of these other pathologies.

Here we present the case of a 32-year-old female with recurrent biliary colic. She underwent an uncomplicated laparoscopic cholecystectomy and recovered well without any additional complications. She has had no recurrent attacks of abdominal pain similar to what she had experienced prior. Final pathology revealed a normal gallbladder with numerous gallstones within it.

At the conclusion of this procedure, patients often return home the same day. Nevertheless, there is a low threshold to have the patient remain in the hospital for one night should they be experiencing notable pain or have significant nausea precluding them from ingesting adequate oral intake.

Patient diet should be slowly advanced as tolerated. Most begin with thin liquids but can usually tolerate solid food within 24 hours after surgery. This operation results in no postoperative dietary restrictions. In the absence of explicit complications, we usually provide routine restrictions after surgery including avoiding heavy lifting for 4 to 6 weeks after surgery. Patients will return to the clinic for follow-up either 2 or 3 weeks after surgery. No follow-up laboratory tests or imaging is required.

Since the 1990s, laparoscopic cholecystectomy has superseded the open cholecystectomy and become the standard operative procedure for gallstone disease.¹⁷ The principal advantages of a laparoscopic approach include decreased morbidity, shorter patient recovery, and shorter hospital length of stay. Among patients undergoing laparoscopic cholecystectomy, 5–10% are converted to open.¹⁸ The decision to convert the operation to open should not be judged as a complication but rather a demonstration of safe judgment in appropriate situations.

While the principles of an open cholecystectomy are the same, there are some fundamental differences inherent to the approach. The gallbladder is best accessed through a right subcostal incision. While the laparoscopic method used a “neck-to-fundus” removal of the gallbladder, the open exposure best allows for a “fundus-down” approach. By dissecting the fundus off of the liver first, this creates a new plane separate from the densest inflammation that allows for a reduced rate of inadvertent injury with the subsequent exposure of the cystic duct and artery.

The morbidity of an open cholecystectomy is 5–15%, yet the overall mortality is low at 0.1–0.5%.¹⁹ The most significant complication of either laparoscopic or open cholecystectomy is a bile duct injury. The incidence of bile duct injury is 0.2%–0.8% in laparoscopic cholecystectomy and 0.1%–0.2% in open cholecystectomy.¹⁹ Bile duct injury most commonly results from the misidentification of the hepatic duct or the common bile duct for the cystic duct, resulting in improper transection. Anatomic variations or extensive adhesions that are incompletely dissected are the most common reasons for this misidentification. Variations of the arterial anatomy can also be present and place the patient at risk for vascular injury. Injury to the right hepatic artery occurs when it is misidentified as the cystic artery.

The best way to reduce the risk of either a bile duct injury or vascular injury is to obtain the Critical View of Safety (CVS).²⁰ These criteria should be obtained in every case, regardless of approach, prior to the clipping and transecting of the cystic duct and artery. The CVS, published by Strasberg in 1995, includes the following:

1. The hepatocystic triangle is cleared of surrounding adhesions, fibrous tissue, and fat. 
   • The hepatocystic triangle is the triangle delineated by the cystic duct, the common hepatic duct, and the inferior edge of the liver. The common bile duct and common hepatic duct are not required to be exposed.
2. The lower one third of the gallbladder is separated from the liver to expose the cystic plate.
   • The cystic plate is also known as the liver bed of the gallbladder and lies in the gallbladder fossa.
3. Only two structures should be visualized entering the gallbladder.

A common tool that was not indicated in the case presented but is nevertheless useful is an intraoperative cholangiogram (IOC). This technique is most helpful in cases where the ductal anatomy may be uncertain. The use of IOC can also elucidate unidentified gallstones within the biliary tree and provide a modality for their removal.²¹ Most surgeons use this tool selectively for difficult cases in which there is a concern for either a ductal injury or a retained stone within the duct.

There are additional approaches for the treatment of advanced gallbladder disease, including subtotal cholecystectomy and cholecystostomy tube. These techniques are suited for more complicated cases of acute cholecystitis rather than general biliary colic and, therefore, would not have been considered for the patient presented in this case. A subtotal cholecystectomy, as the name suggests, only removes a portion of the gallbladder.²² The anterior wall of the gallbladder is removed distal to the cystic duct. The posterior wall is left in contact with the liver; however, the mucosal layer is removed via electrocautery or curettage. The opening of the cystic duct is then stitched closed. This technique is only used in cases where Calot’s triangle cannot be safely identified or in emergent situations such as excessive bleeding or patient instability that require quick termination of the case. The placement of a cholecystostomy tube is an alternative to surgery, usually reserved for high-risk surgical patients.²³ A cholecystostomy tube is placed percutaneously and results in immediate biliary decompression that can serve as either a temporizing measure or a definitive treatment.

Biliary colic is one of the most prevalent gastrointestinal pathologies. Laparoscopic cholecystectomy is a safe and effective procedure to alleviate symptoms.

No special equipment was used in this case.

Nothing to disclose.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.