Cholecystectomy is a surgical procedure to remove the gallbladder, which can be used primarily for symptomatic cholecystolithiasis (gallstone disease with the appearance of symptoms). Cholecystectomy can be performed laparoscopically (minimally invasive surgical procedure in which an endoscope and surgical instruments are inserted into the abdomen through openings in the abdominal wall) or openly, with the laparoscopic method used in more than 90% of surgeries. Only 25% of people with gallstones develop symptoms or complications over the course of 25 years, so if they are symptom-free, there is usually no indication for treatment.
Indications (areas of application)
- Cholecystolithiasis (gallstone disease).
- The presence of cholecystolithiasis with complications represents an absolute surgical indication, whereas exclusively symptomatic cholecystolithiasis represents a relative surgical indication.
- Common complications of cholecystolithiasis include recurrent colic. Acute cholecystitis (gallbladder inflammation) or obstruction of the bile ducts may also occur as a result of cholecystolithiasis.
- Asymptomatic gallbladder stones are usually not an indication for cholecystectomy. Exceptions are the presence of a porcelain gallbladder, major oncologic surgery with lymphadenectomy (removal of lymph nodes), or major surgery on the small intestine.
- Gallbladder stones with a diameter of more than 3 cm and gallbladder polyps with a size of 1 cm or more are a relative indication for surgery despite the absence of symptoms.Asymptomatic stones in the bile ducts, usually so-called brown pigment stones, can also be removed.
- Stone perforation – When stone perforation occurs, gallstones migrate into adjacent organs. If they migrate into the intestinal tract, there may be obstruction (complete closure) of the small intestine with gallstone ileus (mechanical obstruction with stasis of intestinal contents). Furthermore, there is a possibility of perforation into the abdomen (the abdominal cavity), resulting in peritonitis (inflammation of the peritoneum). In addition to cholecystectomy, other therapeutic measures are necessary.
- Chronic recurrent cholecystitis – In the course of chronic inflammation of the gallbladder, a shrunken gallbladder or a porcelain gallbladder may develop. A porcelain gallbladder is characterized by a hardening of the wall structures due to an increased amount of connective tissue. Due to the increased risk of carcinoma, there is an absolute indication for cholecystectomy even in the absence of symptoms of cholecystitis.
- Gallbladder carcinoma (gallbladder cancer) – Cholecystolithiasis and chronic gallbladder inflammation are the main risk factors for the development of a tumor of the gallbladder. Cholecystectomy is sufficient only in case of accidentally discovered early stage of the tumor. In the advanced stage, it is indispensable to check beforehand whether surgical curative therapy (with complete cure) is feasible.
Contraindications
Relative contraindications
- Acute pancreatitis (inflammation of the pancreas).
Absolute contraindication
- Blood clotting disorder
- Severe general illness
Before surgery
- History and Diagnosis – Cholecystolithiasis is sometimes difficult to diagnose because different conditions cause similar symptoms. In particular, pancreatitis (inflammation of the pancreas) is an important differential diagnosis because it can also occur as a complication of cholecystolithiasis and requires prompt treatment. The most sensitive and rapid detection method is sonography (ultrasound).
- Discontinuation of anticoagulants (anticoagulants) – Discontinuation of, for example, acetylsalicylic acid (ASA) or Marcumar should be done in consultation with the treating physician. Discontinuing medication for a short period of time significantly minimizes the risk of secondary bleeding without a significant increase in risk to the patient. If diseases are present that can influence the blood coagulation system and are known to the patient, this must be communicated to the attending physician.
The operation procedures
Cholecystectomy allows complete removal of all gallstones present. Furthermore, the use of the surgical procedure leads to a minimization of the risk of recurrence (risk of recurrence). Types of cholecystectomy
- Laparoscopic cholecystectomy – In laparoscopic surgery, different types of procedures can be distinguished. Transumbilical (via the belly button) single-port cholecystectomy can be mentioned as a new standard operation, which, in contrast to other laparoscopic procedures, requires only one access to the abdominal cavity. The procedure can be used for both acute and chronic bile duct processes. In other laparoscopic procedures, after making an incision in the skin – above or below the navel – the laparoscope (endoscope) is inserted into the abdomen. Cutting and grasping instruments are inserted through another access point. Depending on the procedure, the number of accesses varies. To remove the gallbladder, it is placed in a salvage bag and removed.Another – not common – procedure is the “natural-orifice-transluminal-endoscopic-surgery(NOTES)-CCE/Operation technique”, in which the patient is operated on through accesses selected through natural body orifices.
- Open cholecystectomy – The use of open access allows manual palpation (palpation examination) by the surgeon. Furthermore, the choice of surgical instruments is greater because there is no size limitation due to the access. Nevertheless, the procedure is very rarely used today because of its particularly high invasiveness (penetrating or injurious procedure), which is less tolerated, especially by older patients. Removal of the gallbladder is performed after making a skin incision at the costal arch, through which the organ structures are subsequently visualized.
Possible complications
- Postcholecystectomy syndrome – this is the occurrence of upper abdominal pain after surgery has been performed, which may be due to, for example, an overlooked stenosis (narrowing) or the presence of calculi (stones) in the choledochal duct (from Latin ductus “duct”, choledochus “receiving bile”; also common bile duct).
- Hematoma (bruise) in the surgical area.
- Surgical scars
- Postoperative inflammatory reactions/wound infections (1.3-1.8%)
- Postoperative bleeding (0.2-1.4%)
- Biliary leakage (leak, ductus cysticus/aberrant bile duct) (0.4-1.3%)
- Bile duct injuries (0.2-0.4%).
- Mortality (death rate): 0.4% (Germany; period. 2009-2013).
Further notes
- Determination of bladder wall thickness by ultrasound reflects expired inflammatory and/or fibrotic processes. According to one study, wall thickness is associated with the duration of surgery or the number of intraoperative complications:
- Wall thickness <3 mm: surgery completed after a median of 84 minutes.
- Wall thickness 3-7 mm: operation completed after median 94
- Wall thickness > 7 mm: operation completed after median 110 minutes
Bladder wall thickness also correlated with length of hospital stay.
