Cholecystectomy

Question 1

Define cholecystectomy.

Answer 1

Removal of the gall bladder

Question 2

What are the indications for cholecystectomy?

Answer 2

Symptomatic cholecystectomy:

• Biliary colic
• Acute cholecystitis - if diagnosed <72hours (NICE: 1 week) from onset can usually be done laparoscopically. Beyond this it should be done by open procedure due to inflammatory changes in surrounding tissue rendering dissection planes difficult.
• Biliary dyskinesia
• Gallstone pancreatitis - after symptoms resolve
• Gallbladder cancer - for patients with mucosal (T1a) disease and a negative cystic duct margin

Asymptomatic cholecystectomy (less common)

• Calculi >3 cm in diameter, in individuals from areas of high prevalence of gallbladder cancer
• Chronically obliterated cystic duct
• Nonfunctioning gallbladder
• Calcified (porcelain) gallbladder
• Gallbladder polyp >10 mm or showing a rapid increase in size
• Gallbladder trauma
• Anomalous junction of the pancreatic and biliary ducts
• Obesity - alongside RYGB

Question 3

What are the possible complications of cholecystectomy?

Answer 3

Laparoscopic cholecystectomyis safe - mortality of 0.22-0.4%. Major morbidity occurs in approximately 5% of patients. Complications include:

• Retained stones - intra or extrahepatic
• Biliary duct injury - CBD injury or stricture
• Infection - site or chest ; ascending cholangitis
• Haemorrhage - cystic/hepatic arteries
• Post-cholecystectomy syndrome - symptoms similar to those from gallstones after procedure
• Ileus
• Deep vein thrombosis
• Risks of general anaesthetic
• Abscess

Question 4

Which of these is associated with laparoscopic cholecystectomy (over open cholecystectomy)?

• Is associated with a shorter stay in hospital
• Has a lower mortality
• Has lower complication rate
• Has a quicker convalescence
• Has a shorter operative time.

Answer 4

No differences in mortality, complications, or operative time. There was however, clear evidence of a shorter stay in hospital with quicker convalescence. Complication rates are equivalent around 17% (using small incision group for open approach).

Question 5

If the patient is not fit for surgical cholecystectomy in acute cholecystitis, what is the alternative?

Answer 5

Percutaneous cholecystostomy - offer if there is a gallbladder empyema, surgery is contraindicated and conservative management is unsuccessful (gallbladder is punctured to relieve the pressure

Question 6

When can you return to work following cholecystectomy?

Answer 6

Laparoscopic = 2-3 weeks

Open = 3-5 weeks