Overview
Definition:
Cholecystectomy is the surgical removal of the gallbladder, most commonly performed for symptomatic gallstones (cholelithiasis) or gallbladder inflammation (cholecystitis)
It is one of the most frequent elective surgical procedures worldwide
Critical safety aspects focus on minimizing operative risks and ensuring optimal patient outcomes.
Epidemiology:
Gallstones affect approximately 10-20% of the adult population
Cholecystectomy is performed in millions of patients annually
Laparoscopic cholecystectomy (LC) is now the gold standard, accounting for over 90% of procedures
Open cholecystectomy (OC) is reserved for specific indications or when LC is not feasible.
Clinical Significance:
While generally safe, cholecystectomy carries potential risks that can impact patient morbidity and mortality
A thorough understanding of safety protocols, risk factors, and complication management is paramount for surgeons preparing for DNB and NEET SS examinations, ensuring they can deliver evidence-based and safe surgical care.
Indications
Symptomatic Cholelithiasis:
Recurrent biliary colic
Biliary pain associated with gallstones
Gallstones in patients with certain conditions (e.g., sickle cell disease, immunocompromised state).
Acute Cholecystitis:
Inflammation of the gallbladder, typically due to cystic duct obstruction
Usually requires prompt surgical intervention.
Chronic Cholecystitis:
Repeated episodes of gallbladder inflammation leading to fibrosis and thickening of the gallbladder wall.
Gallbladder Polyps:
Polyps larger than 1 cm, or multiple polyps, especially in the absence of stones, warrant consideration for cholecystectomy due to malignant potential.
Biliary Dyskinesia:
Disorder of gallbladder motility causing biliary pain without evidence of stones or inflammation.
Preoperative Preparation
Patient Assessment:
Detailed history including comorbidities (cardiac, pulmonary, renal)
Physical examination focusing on abdominal tenderness, guarding, and signs of jaundice
Assessment of risk factors for anesthesia and surgery.
Laboratory Investigations:
Complete blood count (CBC) for anemia and infection
Liver function tests (LFTs) to assess biliary patency and hepatic function
Renal function tests (RFTs)
Coagulation profile (PT/INR, aPTT) to assess hemostatic status.
Imaging:
Abdominal ultrasonography is the primary imaging modality to diagnose gallstones, assess gallbladder wall thickness, and evaluate bile ducts
CT scan or MRI may be used in select cases for better visualization of anatomy or complications.
Informed Consent:
Thorough discussion of the procedure, expected benefits, potential risks (including bile duct injury, bleeding, infection, port site hernia), alternatives, and the possibility of conversion from laparoscopic to open surgery
Documentation of consent is crucial.
Surgical Management
Laparoscopic Cholecystectomy:
Preferred approach
Typically involves 3-4 port sites
Dissection of the cystic duct and artery, followed by detachment of the gallbladder from the liver bed
Techniques include critical view of safety (CVS) for dissection.
Open Cholecystectomy:
Performed via a subcostal or midline incision
Indications include severe inflammation, adhesions, acute pancreatitis, previous abdominal surgery, suspected malignancy, or intraoperative conversion from LC due to difficulty.
Critical View Of Safety:
A mnemonic and technique emphasizing clear identification of the cystic duct and artery before clipping or cutting
Achieved by retracting the gallbladder superiorly and laterally, and dissecting the peritoneum from the gallbladder to expose Calot's triangle structures without ambiguity
Essential for preventing bile duct injury.
Intraoperative Imaging:
Intraoperative cholangiography (IOC) or intraoperative ultrasound (IOUS) may be used to identify common bile duct stones or anatomical anomalies, reducing the risk of missed stones and potential injuries.
Biliary Drainage:
Placement of drains may be considered in cases of severe inflammation or suspected bile leak, though routine drainage is not universally recommended.
Complications
Early Complications:
Bile duct injury (BDI): Can range from minor leaks to complete transection
Bleeding: From cystic artery, liver bed, or port sites
Infection: Wound infection, intra-abdominal abscess
Retained common bile duct stones
Pancreatitis: Post-IOC or manipulation
Bowel or organ injury.
Late Complications:
Post-cholecystectomy syndrome (persistent abdominal pain)
Biliary strictures
Bile leaks
Port site hernias
Adhesions
Residual gallstones in the common bile duct.
Prevention Strategies:
Meticulous adherence to Critical View of Safety (CVS)
Use of intraoperative cholangiography or ultrasound judiciously
Careful dissection and identification of anatomical structures
Proper ligation of cystic duct and artery
Avoiding blind clipping
Prompt recognition and management of suspected injuries.
Postoperative Care
Pain Management:
Adequate analgesia is crucial
Multimodal approaches including IV or oral analgesics, NSAIDs
Patient-controlled analgesia (PCA) may be used for severe pain.
Mobilization And Diet:
Early mobilization to prevent deep vein thrombosis (DVT) and pneumonia
Gradual reintroduction of oral diet as tolerated, starting with clear liquids and progressing to a regular diet
Low-fat diet may be recommended initially.
Monitoring:
Vital signs monitoring for signs of infection or hemodynamic instability
Monitoring for abdominal distension, nausea, vomiting
Observation for signs of bile leak (e.g., abdominal pain, fever, jaundice, drainage).
Discharge Planning:
Patient education on wound care, activity restrictions, diet, and warning signs of complications
Prescription of appropriate medications
Follow-up appointment scheduled typically within 1-2 weeks.
Key Points
Exam Focus:
The Critical View of Safety (CVS) for preventing bile duct injury is a high-yield concept
Understanding the different types of bile duct injuries and their management is crucial
Recognition of risk factors for complications is important.
Clinical Pearls:
Always confirm the cystic duct and artery before clipping
If anatomy is unclear, do not proceed with dissection – consider IOC, IOUS, or conversion to open surgery
Promptly address any suspicion of bile leak or BDI.
Common Mistakes:
Failure to achieve CVS leading to inadvertent clipping/cutting of the common bile duct
Inadequate dissection causing injury to adjacent structures
Over-reliance on laparoscopic technique in complex cases, delaying conversion to open
Inadequate postoperative pain control leading to delayed mobilization.