A cholecystectomy is the surgical removal of the gallbladder. The two basic types of this procedure are open cholecystectomy and the laparoscopic approach. It is estimated that the laparoscopic procedure is currently used for approximately 80% of cases.
A cholecystectomy is performed to treat cholelithiasis and cholecystitis. In cholelithiasis, gallstones of varying shapes and sizes form from the solid components of bile. The presence of these stones, often referred to as gallbladder disease, may produce symptoms of excruciating right upper abdominal pain radiating to the right shoulder. The gallbladder may become the site of acute infection and inflammation, resulting in symptoms of upper right abdominal pain, nausea, and vomiting. This condition is referred to as cholecystitis. The surgical removal of the gallbladder can provide relief of these symptoms. Cholecystectomy is used to treat both acute and chronic cholecystitis when there are significant pain symptoms. The typical composition of gallstones is predominately cholesterol, or a compound called calcium bilirubinate.
Cholecystitis is an inflammation of the gallbladder, both acute and chronic, that results after the development of gallstones in some individuals. The most common symptoms and physical findings associated with cholecystitis include:
- pain and tenderness in the upper right quadrant of the abdomen
- history of pain after eating large, high-fat meals
In a laparoscopic cholecystectomy, four small incisions are made in the abdomen (A). The abdomen is filled with carbon dioxide, and the surgeon views internal structures with a video monitor (B). The gallbladder is located and cut with laparoscopic scissors (C). It is then removed through an incision (D). (Illustration by GGS Inc.)
Overall, cholelithasis is found in about 20,000,000 Americans. An overwhelming majority of these individuals do not ever develop symptoms. Overall, about 500,000 to 600,000 (2–3%) are treated with cholecystectomies every year. Typically, the incidence of cholelithasis increases with age. The greatest incidence occurs in individuals between the ages of 40 and 60 years. The following groups are at an increased risk for developing choleliathiasis:
- pregnant women
- female sex
- family history of gallstones
- certain types of intestinal disease
- age greater than 40 years
- oral contraceptive use
- diabetes mellitus
- estrogen replacement therapy
- rapid weight loss
Overall, patients with cholelathiasis have about a 20% chance of developing biliary colic (the extremely painful complication that usually requires surgery) over a 20-year period. Acute cholecystitis develops most commonly in women between the ages of 40 and 60 years. Some ethnic groups such as Native Americans have a dramatically higher incidence of cholecystitis.
Most patients have elevated leukocyte (white blood cells) levels. Leukocyte levels are determined using laboratory analysis of blood samples. Traditional x rays are not particularly useful in diagnosing cholecystitis. Ultrasonography of the gallbladder usually provides evidence of gallstones, if they are present. Ultrasonography can also help identify inflammation of the gallbladder. Nuclear imaging may also be used. This type of imaging cannot identify gallstones, but it can provide evidence of obstruction of the cystic and common bile ducts.
Cholelithiasis is initially diagnosed based on the following signs and symptoms:
- history of biliary colic or jaundice
- sudden onset of extreme pain in the upper right quadrant of the abdomen
Laboratory blood analysis often finds evidence of elevated bilirubin, alkaline phosphatase, or aminotransferase levels. Ultrasonography, computed tomography (CT) scanning, and radionuclide imaging are able to detect the impaired functioning of bile flow and of the bile ducts.
As with any surgical procedure, the patient will be required to sign a consent form after the procedure is explained thoroughly. Food and fluids will be prohibited after midnight before the procedure. Enemas may be ordered to clean out the bowel. If nausea or vomiting are present, a suction tube to empty the stomach may be used, and for laparoscopic procedures, a urinary drainage catheter will also be used to decrease the risk of accidental puncture of the stomach or bladder with insertion of the trocar (a sharp, pointed instrument).
The prognosis for cholecystitis and cholelithaisis patients who receive cholecystectomy is generally good. Overall, cholecystectomy relieves symptoms in about 95% of cases.
Morbidity and mortality rates
The complication rate is less than 0.5% with open cholecystectomy and about 1% with laparoscopic cholecystectomy. The primary complication with the open technique is infection, whereas bile leak and hemorrhage are the most common complications associated with the laparoscopic technique. The overall mortality rate associated with cholecystectomy is less than 1%. However, the rate of mortality in the elderly is higher.
In a small minority of cases, symptoms will persist in patients who receive cholecystectomy. This has been named the post-cholecystectomy syndrome and usually results from functional bowel disorder, errors in diagnosis, technical errors, overlooked common bile duct stones, recurrence of common bile duct stones, or the spasm of a structure called the sphincter of Oddi.
Acute cholecystitis usually improves following conservative therapy in most patients. This conservative therapy involves the withholding of oral feedings, the use of intravenous feedings, and the administration of antibiotics and analgesics . This is only a short-term alternative in hospitalized patients. Most of these patients should receive cholecystectomy within a few days to prevent recurrent attacks. In the short-term, patients often receive narcotic analgesics such as meperidine to relieve the intense pain associated with this condition. Patients who have evidence of gallbladder perforation or gangrene need to have an immediate cholecystectomy.
In patients with cholelithasis who are deemed unfit for surgery, alternative treatments are sometimes effective. These individuals often have symptom improvement after lifestyle changes and medical therapy. Lifestyle changes include dietary avoidance of foods high in polyunsaturated fats and gradual weight loss in obese individuals. Medical therapy includes the administration of oral bile salts. Patients with three or fewer gallstones of cholesterol composition and with a gallstone diameter less than 0.6 in (15 mm) are more likely to receive medical therapy and have positive results. The primary requirements for receiving medical therapy include the presence of a functioning gallbladder and the absence of calcification on computed tomography (CT) scans. Other non-surgical alternatives include using a solvent to dissolve the stones and using sound waves to breakup small stones. A major drawback to medical therapy is the high recurrence rate of stones in those treated.
WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?
Cholecystectomy, including the laparoscopic approach, is usually performed by a general surgeon who has completed a five-year residency training program in all components of general surgery and in particular proper techniques involving the use of the laparoscope. If surgery is being considered, it is a good idea to find out how many laparoscopic cholecystectomies the surgeon performs on a yearly basis. Laparoscopic cholecystectomies are often performed in the specialized department of a general hospital, but they are also performed in specialized gastrointestinal clinics or institutes for gastrointestinal disorders.