Laparoscopic cholecystectomy

"Cholecystectomy" is the complete removal of the gall-bladder together with any gallstones contained within it. "Laparoscopy" is often called the "key-hole" method of performing this operation, as opposed to the conventional or "open" method, which requires a cut to be made under the ribs.

How the operation is performed?

A 1cm (less than 1/2 inch) telescope is inserted via the umbilicus (belly button) and carbon dioxide gas introduced to separate the organs and provide space in which to work.  A further 1cm incision is made just under the breastbone to allow insertion of the main operating instruments and two tiny (0.5cm) incisions in the right flank for the passage of holding instruments (as pictured).

A general examination is made of the inside of the abdomen before the gallbladder is identified, lying underneath the liver.  The crucial part of the operation is to correctly identify the ducts (pipes) connecting the gallbladder to the liver and intestine.  Once the duct has been secured, the gallbladder can be removed from its bed in the liver by electro-cautery or laser.

The gallbladder is extricated from the abdomen via either the umbilical or top-most port and sent for pathological examination.  The wounds are generally closed with dissolving sutures or paper strips, neither of which requires removal.

Potential complications

The crucial part of the operation is to identify correctly the delicate individual ducts that make up the bile drainage system.  Serious damage occurs if the main duct between liver and bowel is misidentified and severed instead of the duct leading to the gallbladder.  Such an injury usually requires further surgery and is associated with long-term health problems.  The incidence of this type of injury is between 1 in 1000 and 1 in 10,000 cases.

The other most common type of injury associated with this kind of surgery occurs when the ports are inserted into the abdomen when a stab injury to the bowel or a blood vessel may occur.  Beyond this, the complications of any type of surgery apply, in particular, bleeding and infection.

How are risks minimised?

From the surgeon's point of view, the most important factor is meticulous technique.  Both surgeon and patient must appreciate that there are limitations to the keyhole technique and if difficulty occurs, the surgeon may need to convert to the conventional or "open" operation.  The open operation proceeds via an incision under the ribs and conversion may be expected to occur in between 5 and 10% of keyhole procedures, depending on the surgeon's experience.  Conversion should never be seen as a "failure", it is better to be safe than sorry.

The factors likely to result in conversion are:  A history of recent inflammation of the gallbladder, obesity, numerous previous abdominal operations, difficulty or unusual anatomy and being male.

What is the recovery?

There is usually surprisingly little discomfort. Residual gas in the abdomen can cause pain typically felt in the shoulder. It is possible to take fluids almost straight away and food within a few hours. Most patients are able to move out of bed in the evening and the usual length of hospital stay is about 2 days.

Patients in whom conversion to the open procedure has taken place can expect to be in hospital 5 -7 days.

It is common to feel very tired on returning home, it is easy to underestimate the magnitude of the surgery that has taken place when there is very little to see on the outside.

Patients are normally safe to drive after about 7 days and ready to return to office-type duties in 2 to 3 weeks.

Are there any long-term sequelae?

Very few. The function of the gallbladder is to store bile produced by the liver between meals and release it during mealtime. The absence of a gallbladder allows a constant drip of bile into the intestine. In practice, in most patients, the diseased gallbladder has long-since ceased to function and its removal does not alter the digestive balance in any way. A few patients will notice a very slight increase in the frequency at which they open their bowels.

Tower of video equipment required

Biliary anatomy

Operation in progress

Laparoscopic instruments