Cholecystectomy – Traditional Laparoscopic and Open Techniques (pp. 29-50)
Authors: (Shiva Seetahal, Dilip Dan, Vijay Naraynsingh, Howard University Hospital, Washington, DC, USA, and others)
Abstract: Removal of the gallbladder has been long recognized as the best treatment for
symptomatic gallstones. Incisions have evolved from laparotomy and extended Kocher‘s
incision to ―minilap‖ cholecystectomy. The revolutionary era of multi-port laparoscopic
surgery in the 1980‘s- 90‘s saw transformation in the approach with much improved
outcomes to the patient especially in terms of recovery. This is currently accepted as the
standard operation for gallbladder disease. We are now witnessing another change that is
not yet accepted as standard. Single port laparoscopy is ―in vogue‖ and is still trying to
prove itself as a sustainable alternative to multi- port laparoscopy. The obvious benefit is
cosmesis but the long-term issues with hernia and pain are still to be discerned. Natural
orifice cholecystectomy is still investigational and the advantages unproven.
In open cholecystectomy, a right subcostal incision is preferred. The ―dome down‖
technique is utilized with careful dissection performed from the gallbladder fundus
towards the neck. Along this path, the cystic artery must be identified and ligated. The
cystic duct must be identified with absolute certainty prior to ligation. The incision must
be carefully closed to avoid future hernia.
Laparoscopic Cholecystectomy possesses more versatility. The multiple incision
approach involves placing a 12mm port peri-umbilically, a 5mm port in the right
abdomen for gallbladder retraction and 2 left abdominal operating ports (5-10mm). The
single incision approach involves a larger umbilical incision and specialized port that
allows for 3 instruments. In either technique the gallbladder can be approached from a
―dome down‖ perspective, similar to open surgery, or by exposing the ―critical view‖.
The latter entails retracting the gallbladder cranio-laterally to expose Calot‘s triangle and
identifying the cystic duct and artery carefully before ligation. Various energy sources
can then be utilized to dissect the gallbladder off of its bed and gain hemostasis.
Specialized retrieval devices aid extraction of the organ from the umbilical incision.
Injury to the common bile duct (CBD) remains the most feared pitfall of gallbladder
surgery. The 1990’s saw a wave of high laparoscopic CBD injuries but with time, this has
settled to be on par with open cholecystectomy. Proponents of intra-op cholangiography
argue that it reduces the incidence, but this is unproven. Minor injuries may be repaired
primarily with the support of a T-tube but larger injuries usually require
hepaticojejunostomy for definitive repair. Additionally, repair should only be attempted
by experienced surgeons. The morbidity associated with CBD injuries is significant.
Other potential complications include retention of calculi within the biliary system,
bleeding, hernias and infection. As with all procedures, complication rates decrease with
as the surgeon gains experience.