The surgical procedure of choice is minimally invasive laparoscopic cholecystectomy (CHE; CCE; gallbladder removal by laparoscopy). In this procedure, surgery is performed through small openings – the abdomen no longer needs to be cut open – which allows for a shorter hospital stay, a lower complication rate, and lower costs.
According to the current S3 guideline, to prevent complications in acute cholecystitis (gallbladder inflammation), laparoscopic cholecystectomy should be performed early, within 24 hours of hospital admission.
Cholecystectomy
Asymptomatic stone carriers should not usually be treated. Exceptions include certain forms of chronic cholecystitis (because of increased incidence of gallbladder carcinoma):
- Gallstones ≥ 3 cm,
- Shrinking gallbladder/porcelain gallbladder,
- Coincidence (“co-occurrence”) of cholecystolithiasis (gallstone disease) and gallbladder polyps > 1 cm.
In these cases, elective laparoscopic cholecystectomy (gallbladder removal by laparoscopy) should be performed.
The following procedures are available for laparoscopic cholecystectomy (CHE; CCE):
- (classic) laparoscopic CCE
- Single-port CCE (all work through one central access) [standard].
- Natural-orifice-transluminal-endoscopic-surgery(NOTES)-CCE/Operative technique in which the patient is operated on through approaches selected through natural orifices]
Furthermore, cholecystectomy should be performed when: Symptoms and complaints are so frequent and severe that they affect the general condition and performance of the patient or complications such as cholecystitis (gallbladder inflammation), pancreatitis (pancreatitis), etc. have already occurred.
Immediate surgery should be performed if:
- Risk of empyema (accumulation of pus in the gallbladder), perforation (rupture) and local peritonitis (inflammation of the peritoneum).
- Persistence of colic and occurrence of jaundice (jaundice) despite intensive spasmolytic therapy.
- Increase in signs of inflammation (leukocytosis (increase in the number of white blood cells), fever, defensive tension).
Choledocholithiasis and cholecystolithiasis
If there is simultaneous choledocho- and cholecystolithiasis, that is, if the gallbladder and bile ducts are affected by stones at the same time, therapy should be performed in two temporally separate steps:
- Stone extraction by endoscopic retrograde cholangiopancreaticography (ERCP; see ERCP below) or percutaneous (“through the skin“) bile duct sanitation.
- Cholecystectomy within 72 h after ERCP plus stone extraction.
This procedure safely prevents biliary (“affecting the gall bladder“) colic and acute cholecystitis, whereas the risks of this would increase significantly if cholecystectomy were performed later, after 6-8 weeks.
Further notes
- Asymptomatic bile duct stones resolve spontaneously in more than 20% of cases and less than 50% become symptomatic.
- A retrospective analysis of the Swedish GallRisk registry of 3,828 patients demonstrated that the complication rate (colic, cholangitis, pancreatitis) was 25% in patients whose asymptomatic bile duct stones were not removed (versus 13% after surgical removal). Similar results were demonstrated when small (< 4 mm) and medium-sized (4-8 mm) stones were analyzed separately. The new guideline therefore recommends that asymptomatic bile duct stones should also be treated.