Cholecystectomy

Preparation for operation

After appropriate history taking and assessment of the patient’s fitness for the procedure, which will include investi­gation of the cardiovascular and respiratory systems if history suggests these to be a risk factor, a full blood count and biochemical profile are done to exclude abnormal liver function tests or anaemia. Blood coagulation is checked if there is a history of jaundice. The patient is given prophylactic anti­biotics either with the premedication intramuscularly, or intravenously at the time of induction. A second-generation cephalosporin is appropriate. Subcutaneous heparin or antiembolus stockings are prescribed. A consent form is signed ensuring that the patient is fully aware of the procedure being undertaken, the risks involved and complications that may occur.

Laparotomy

A short right upper transverse incision is made centred over the lateral border of the rectus muscle. A full laparotomy, inspecting all abdominal organs, is undertaken and the diagnosis of gallstones confirmed. The gall bladder is appropriately exposed and packs are placed on the hepatic flexure of the colon, the duodenum and the lesser omentum to ensure a clear view of the anatomy of the porta hepatis. These packs may be retracted using the hand of the assistant (‘It is the left hand of the assistant that does all the work’ —Moynihan) or a stabilised ring retractor used to keep the packs in position (Fig. 54.37). An artery forceps is placed on the infundibulum of the gall bladder and the peritoneum overlying Calot’s triangle is placed on a stretch. The peritoneum is then divided close to the wall of the gall bladder and the fat in the triangle of Calot carefully dissected away to expose the cystic artery and the cystic duct. The cystic duct is cleaned down to the common bile duct whose position is clearly ascertained. The cystic artery is tied and divided. The whole of the triangle of Calot is displayed to ensure that the anatomy of the ducts is clear and the cystic duct is then divided between ligatures. The gall bladder is then dissected away from the gall-bladder bed.

Some golden rules in case of difficulty.

  When the anatomy of the triangle of Cálot is unclear, blind dissection should stop.

  Bleeding adjacent to the triangle of Calot should be controlled by pressure and not by blind clipping or clamping.

  When there is doubt about the anatomy a ‘fundus-flrst’ cholecystectomy dissecting on the gall-bladder wall down to the cystic duct can be helpful.

  If the cystic duct is densely adherent to the common bile duct and there is the possibility of a Mirizzi syndrome (the stone ulcerating through into the common duct), the infundibulum of the gall bladder should be opened, the stone removed and the infundibulum oversewn.

  A cholecystostomy is almost never indicated, but if it has to be done as many stones as possible should be extracted and a large Foley catheter (14 French) placed in the fundus of the gall bladder with a direct track externally. By so doing, should stones be left behind in the gall bladder, these can be extracted with a choledochoscope.

The technique of open cholecystectomy has largely been superseded by laparoscopic cholecystectomy. Nevertheless, no surgeon undertaking laparoscopic cholecystectomy should lose the different technique of undertaking an open cholecystectomy as this may be required when difficulties are encountered laparoscopically.

Laparoscopic cholecystectomy

The preparation and indications for cholecystectomy are the same whether it is performed by laparoscopy or by open techniques. However, a laparoscopic cholecystectomy should only be performed by a surgeon who is frequently undertaking laparoscopic procedures as the skills are different from those required in undertaking an open cholecystectomy.

The patient is positioned either in a Lloyd-Davies position or flat on the table depending on whether the French or American approach is used by the surgeon. A pneumoperitoneum is created and four ports are placed in the abdomen, usually at the umbilicus and the epigastrium, with two 5-mm ports laterally. The triangle of Calot is laid widely open by dividing the peritoneum on the posterior and on the anterior aspect. The cystic duct is carefully defined as is the cystic artery which is divided. Once the triangle of Calot has been laid widely open the cystic duct is clipped and divided. The gall bladder is then removed from the gall bladder bed and once free removed via the umbilicus (Fig. 54.40).

Indications for choledochotomy

In an environment where the modern diagnostic armamen­tarium described at the beginning of this chapter is not available and neither is peroperative cholangiography, it is well to rehearse the traditional indications for choledochotomy, which are: (1) palpable duct stones; (2) there is jaundice or a history of jaundice or cholangitis; (3) the common bile duct is dilated; and (4) the liver function tests are abnormal, in particular, the alkaline phosphatase is raised.

In centres where adequate facilities are available it is probably inadvisable to do a choledochotomy laparoscopically, but rather to rely on endoscopic techniques unless particular expertise has been achieved in laparoscopic exploration of the bile duct. The incidence of symptomatic stones in the bile duct varies from 5 to 8 pet cent. These can, in the main, be dealt with endoscopically without resort to opening the duct. However, current trials suggest that in experienced hands the morbidity of the two techniques is identical.

Symptoms persisting after cholecystectomy

In 15 per cent of patients cholecystectomy fails to relieve the symptoms for which the operation was performed. Such patients may be considered to have a ‘postcholecystectomy’ syndrome. However, such problems are usually related to the preoperative symptoms and are merely a continuation of those symptoms. Full investigation should be undertaken to exclude the presence of a stone in the bile duct, a stone in the cystic duct stump or operative damage to the biliary tree. This is best performed by an MRCP or an ERCP which has the added advantage that if a stone remains it can be removed.