Gallstones

Laparoscopic Gallbladder Surgery.

The gallbladder is an important organ, but it is not essential for life. Therefore, the standard treatment for symptomatic patients who suffer from gallstones or acute/chronic cholecystitis is to surgically remove the gallbladder and the gallstones.

For over 100 years the cholecystectomy technique evolved little and required a generous abdominal incision, but with the advent of laparoscopy, the laparoscopic cholecystectomy has become the “gold standard” in the treatment of gallbladder disease and more than 90% are done using this minimally invasive approach with very low risks and a fast recovery.

Even at present times, the technique continues evolving and improving, looking for better recovery times with less pain and better aesthetical results, an example of this continuous evolution is the Single Port Access Surgery or the mini-laparoscopic surgery where instruments of 2 millimeters of diameter are used.

GALLBLADDER DISEASES
DIAGNOSIS & TREATMENT
LAPAROSCOPIC VS OPEN SURGERY
SURGICAL TECHNIQUE

  • GALLSTONES (CHOLELITHIASIS)

Gallstones are a widespread condition, arising in approximately 10 to 36% of the adult population in the United States and, as such, pose a significant public health problem. The factors that contribute to the development of this disease are:

  • Female sex
  • Obesity (BMI* over 30)
  • Pregnancy
  • Fatty foods
  • Crohn´s disease
  • Gastric surgery
  • Rapid weight loss
  • First degree relatives with gallstones

Symptoms can be summarised in biliary colic which refers to the presence of moderate intermittent right upper quadrant and epigastric pain (top right and central areas of the abdomen) that may radiate to the back or below right scapula, it usually begins abruptly and subsides gradually lasting for minutes to hours.

Complications related to gallstones include acute cholecystitis, choledocholithiasis with or without cholangitis, gallstone pancreatitis, gallstone ileus, and gallbladder carcinoma.

  • ACUTE/CHRONIC CHOLECYSTITIS

Ongoing inflammation with recurrent episodes of biliary colic or pain is referred to as chronic cholecystitis, about 66% of patients with gallstones present these repeated attacks which lead to scarring and alteration of the normal function of the gallbladder.

 

Symptoms:

Abdominal Pain*

Nausea or vomiting

Bloating

Belching

Fever (not always present)

 

*The attack of abdominal pain, in these case, usually last for more than 1 hour but subsides by 24 hours; if pain persists longer than one day, acute cholecystitis is likely the underlying cause.

DIAGNOSIS

It relies on the clinical presentation and evidence of gallstones on diagnostic imaging. An abdominal ultrasound is the standard diagnostic exam for gallstones and acute or chronic cholecystitis.

 

TREATMENT/INDICATIONS

Laparoscopic cholecystectomy, there is no other medical treatment that definitely and permanently solves gallbladder diseases. It offers excellent long-term results making all symptoms disappear.

 

  • Indications for laparoscopic cholecystectomy:
  • Symptomatic patients with gallstones or disease of the gallbladder (e.g., acute or chronic cholecystitis)
  • People with diabetes should receive treatment promptly because of the higher risk for complications
  • Pregnant women with symptomatic gallstones who fail expectant management can safely undergo surgery during the second trimester.
  • Biliary dyskinesia
  • Gallbladder wall calcification (“porcelain gallbladder”)
  • Gallstone larger than 2 cm, even if asymptomatic

 

  • Contraindications:
  • Patient unable to tolerate general anaesthesia
  • Pregnancy, first or third trimester.
  • Elevated Bleeding Risk

 

 

LAPAROSCOPIC VS OPEN SURGERY

 

ADVANTAGES OF LAPAROSCOPIC SURGERY

  • Fast recovery time (one-night hospital stay)
  • Minimal postoperative pain
  • Lower morbidity rate
  • Lower hospital stay
  • Return to normal activity and return to work in a shorter period of time (complete recovery in 5 to 7 days)
  • Decreased risk of wound infection and hernia formation
  • Minimal scarring

 

COMPLICATIONS (ALL RARE IN EXPERIENCED HANDS)

  • Wound infection 1 to 4%
  • Bleeding <1%
  • Pancreatitis <0.3%
  • Bile leak 0.7%
  • Retained common duct stone <5%
  • Bile duct injury 0.4%
  • Conversion to open surgery less than 5%. **

 

**Conversion should never be considered as a failure, but as a tool, when Dr. Rosales decides that the laparoscopic approach might lead to unnecessary complications. Factors that contribute to the need to convert to an open procedure are:

  • Increased patient age
  • Elevated American Society of Anesthesiologists (ASA) Class
  • Extreme Obesity
  • Thickened gallbladder wall

SURGICAL TECHNIQUE (SIMPLIFIED EXPLANATION)

Under general anesthesia, a 10 mm incision is made at the navel or umbilicus, CO2 is introduced to the cavity, then 3 more incisions are made in the abdomen (one of 10 mm and 2 of 5mm) to introduce the rest of the instruments, the gallbladder and the structures that attach it to the body are dissected, stapled and cut, then the gallbladder is extracted through one of the incisions, which are closed with suture and the procedure is completed.

 

Incisions For Laparoscopic Gallbladder Surgery

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