Laparoscopic Cholecystectomy and Bile Duct Exploration
Cholecystectomy is perhaps the most common procedure performed by a general surgeon possibly second only to herniorrhaphy. Today the standard treatment for symptomatic gallstones is Laparoscopic Cholecystectomy, which is the performance of Cholecystectomy through small (1/4” - ˝”) incisions, aided by a special camera called a Laparoscope, which is designed to be introduced into the abdomen. Many specialized instruments are utilized in the performance of this surgery. The major advantage of this procedure as compared to the open procedure is in short post-operative recovery and rapid return to full function. Following Laparoscopic Cholecystectomy patients are typically discharged after an overnight stay and in some cases this procedure is done as an outpatient. Usually patients may return to work after two weeks of convalescence at home. This is compared to the usual 4 or 5 day hospitalization associated with open cholecystectomy and a convalescent period of 4 to 6 weeks.
Though most patients are good candidates for the laparoscopic approach, some are not. Patients with severe acute cholecystitis may be a very high risk for bile duct injury during laparoscopic cholecystectomy or may simply be too difficult to complete safely because of the severity of inflammation. This is particularly true for diabetic patients whose symptoms very typically do not correspond with the degree of pathology encountered at the time of surgery. Nevertheless, it is usual to begin this procedure laparoscopically with the understanding that if for any reason it is deemed unsafe to proceed in this manner, the procedure will be aborted and converted to an open procedure.
During Laparoscopic Cholecystectomy a cholangiogram may be performed for clarification of ductal anatomy or if there is the possibility of stones within the ductal system. Many surgeons elect to do a cholangiogram on an “as needed basis” while others do it routinely. The rationale for doing the cholangiogram for selected cases only is that it adds time and expense to the procedure and the vast majority will be normal studies since those patients who have had symptoms of choledocholithiasis will usually have had an ERCP pre-operatively.
Conversely, those surgeons who do the cholangiogram routinely site 2 reasons. First, the incidence of ductal injuries is lower in those patients who have had a cholangiogram during surgery because the anatomy is completely clarified and unusual variations in anatomy are delineated. Secondly, even those patients who have had no symptoms of common bile duct stones have a 10% chance of harboring such stones and may develop symptoms post-operatively. If these are recognized at the time of surgery, they may be dealt with via ERCP post-operatively, or with the laparoscopic techniques for bile duct surgery to be described below. Additionally, some stones may not be amenable to treatment with either the laparoscopic approach or with ERCP and conversion to an open procedure may be warranted.
I have made some mention of ductal injuries during laparoscopic cholecystectomy and I feel this issue warrants further discussion. When Laparoscopic Cholecystectomy was first becoming popular among surgeons around the USA and indeed throughout the world there was initially an increase in the incidence of common bile duct injuries during cholecystectomy via the laparoscopic approach as compared to the open procedure. This was associated with the “learning curve” of surgeons learning to do laparoscopic cholecystectomy. Today, the incidence of bile duct injuries during laparoscopic cholecystectomy as compared to open cholecystectomy is about equal though it is still slightly higher for the laparoscopic procedure. In many series this incidence is given as 1 - 3%. This is old data and the current incidence is under 1%. Nevertheless, this unfortunately is still a concern when performing cholecystectomy either laparoscopically or open. Though the hazard is certainly greater with the laparoscopic technique, increased awareness and vigilance on the part of surgeons performing this procedure have enabled it to be performed safely with a very low risk, approximating that of the open procedure.
New techniques are continuously evolving in the management of common bile duct stones. A common bile duct exploration involves making an incision in the common bile duct and passing a variety of devices into the bile duct in an effort to evaluate if any stones are present, and if so, to remove them. Until recently, the presence of documented common bile duct stones that were not treatable via ERCP often precluded laparoscopic surgery. It is now possible to perform a common bile duct exploration with laparoscopic technology. Various balloons are used to dilate the cystic duct where it enters the common bile duct. Special catheters or “baskets” can then be passed in an attempt to extract stones. A choledochoscope may be used to visualize the inside of the common bile duct with this image appearing simultaneously on the video monitor along with the laparoscopic image. When stones are visualized they are then extracted utilizing specially designed “baskets” that are passed through the choledochoscope. If necessary, an incision can be made in the common bile duct under laparoscopic visualization to facilitate any of these maneuvers. A special drain called a T-tube can then be placed into the common bile duct as the duct is sutured with laparoscopic suturing techniques. The T-tube is removed 4 - 6 weeks after surgery in the office after an X-ray confirms that no stones are any longer present. If there are stones at this time, a radiologist specially trained in interventional techniques may be able to remove them through the T-tube tract.
Though I have attempted to keep the language of these pages appropriate for the lay person, I understand that the issues discussed herein may be complicated and confusing at times. Please visit the section entitled Gallstones and Gallbladder Disease in the Education Section where I hope you will find answers to questions you may have.
As always, I am more than happy to answer questions via phone or E-mail.