Overview
Definition:
Laparoscopic cholecystectomy (LC) is the gold standard surgical treatment for symptomatic cholelithiasis and acute cholecystitis, involving removal of the gallbladder through small abdominal incisions using a laparoscope and specialized instruments
The Tokyo Guidelines provide a framework for diagnosis, severity classification, and management of acute cholecystitis, emphasizing prompt surgical intervention.
Epidemiology:
Acute cholecystitis is a common surgical emergency, affecting approximately 10-20% of individuals with symptomatic gallstones
Incidence increases with age, obesity, and in women
It accounts for a significant proportion of emergency abdominal surgeries globally.
Clinical Significance:
Acute cholecystitis is a serious condition that can lead to severe complications such as gallbladder perforation, abscess formation, sepsis, and multi-organ failure
Prompt and appropriate management, guided by established criteria like the Tokyo Guidelines, is crucial to reduce morbidity and mortality, and LC offers a minimally invasive approach with faster recovery.
Clinical Presentation
Symptoms:
Right upper quadrant (RUQ) abdominal pain, often severe and constant
Pain may radiate to the right shoulder or back
Associated fever, often high grade
Nausea and vomiting
Sometimes jaundice, especially if a stone is in the common bile duct (choledocholithiasis)
History of similar, less severe episodes
Positive Murphy's sign on palpation of the RUQ.
Signs:
Fever (temperature > 38°C)
Tachycardia
Tenderness in the RUQ
Palpable, distended gallbladder in some cases
Jaundice (icterus) may be present
Signs of peritonitis if perforation occurs (rebound tenderness, guarding)
Possible abdominal distension.
Diagnostic Criteria:
The Tokyo Guidelines 2018 classify acute cholecystitis into three grades based on clinical, laboratory, and imaging findings: Grade I (Mild): No signs of systemic inflammation or organ dysfunction
Grade II (Moderate): Mild-moderate leukocytosis, palpable tender mass, duration of symptoms > 72 hours, or significant inflammation of the gallbladder
Grade III (Severe): Shock or circulatory collapse, myocardial insufficiency, impaired consciousness, renal dysfunction, coagulopathy, or severe local inflammation confirmed by imaging.
Diagnostic Approach
History Taking:
Detailed inquiry about the onset, character, severity, and radiation of abdominal pain
Associated symptoms like fever, nausea, vomiting, and changes in bowel habits
Past history of gallstones, biliary colic, or previous abdominal surgery
Risk factors: female, forty, fat, fertile
Any previous episodes of similar pain
Duration of symptoms is critical for grading.
Physical Examination:
General appearance: assess for signs of toxicity, jaundice, dehydration
Vital signs: temperature, pulse, respiratory rate, blood pressure
Abdominal examination: inspection for distension or scars
palpation for tenderness, masses, guarding, rebound tenderness
Palpation in the RUQ for tenderness (Murphy's sign)
Auscultation for bowel sounds.
Investigations:
Laboratory tests: Complete blood count (CBC) showing leukocytosis (WBC > 10,000/µL) with a left shift
Liver function tests (LFTs) may show elevated bilirubin and alkaline phosphatase if there is concurrent choledocholithiasis or cholangitis
Amylase/lipase to rule out pancreatitis
Urinalysis to rule out urinary tract infection
Imaging: Ultrasound (US) is the primary modality, demonstrating gallstones, thickened gallbladder wall (>4 mm), pericholecystic fluid, and positive sonographic Murphy's sign
CT scan or MRI can be used if US is inconclusive or for assessing complications
HIDA scan is useful in cases of suspected cystic duct obstruction or acalculous cholecystitis.
Differential Diagnosis:
Peptic ulcer disease
Biliary colic without inflammation
Acute pancreatitis
Hepatitis
Fitz-Hugh-Curtis syndrome
Pneumonia (right lower lobe)
Appendicitis (atypical presentation)
Renal colic
Myocardial infarction (atypical presentation)
Functional dyspepsia.
Management
Initial Management:
Fluid resuscitation with intravenous (IV) crystalloids
Analgesia, typically with IV opioids (e.g., morphine, fentanyl) or NSAIDs (e.g., ketorolac) if no contraindications
Antibiotics are crucial: broad-spectrum coverage targeting gut flora (e.g., ceftriaxone + metronidazole, or piperacillin-tazobactam for severe cases)
Nasogastric (NG) tube decompression if persistent vomiting or signs of obstruction
Bowel rest.
Medical Management:
Antibiotic therapy as per local resistance patterns and severity of illness
Continuation of IV fluids and analgesia
Symptomatic relief of nausea and vomiting with antiemetics
Close monitoring of vital signs and urine output
Management of comorbidities.
Surgical Management:
Laparoscopic cholecystectomy is indicated for most cases of acute cholecystitis, especially those classified as Grade I and II by Tokyo Guidelines
Early LC (within 24-72 hours of symptom onset) is preferred to minimize complications
For Grade III cases, initial medical stabilization is paramount, followed by urgent surgery
Laparoscopic approach involves port placement, dissection of Calot's triangle, identification and clipping of cystic artery and duct, and removal of the gallbladder
Conversion to open cholecystectomy may be necessary due to severe inflammation, adhesions, difficult anatomy, or intraoperative complications.
Supportive Care:
Continuous monitoring of vital signs, fluid balance, and pain control
Regular laboratory monitoring of inflammatory markers and LFTs
Nutritional support, often starting with clear liquids and advancing as tolerated postoperatively
Early mobilization to prevent deep vein thrombosis and pneumonia
Wound care and pain management post-surgery.
Complications
Early Complications:
Bleeding from cystic artery or liver bed
Bile leak from cystic duct stump or aberrant bile ducts
Injury to common bile duct or other abdominal organs
Retained common bile duct stones
Post-cholecystectomy syndrome (biliary pain, pancreatitis)
Wound infection
Intra-abdominal abscess
Deep vein thrombosis (DVT) and pulmonary embolism (PE).
Late Complications:
Bile duct strictures
Adhesions and bowel obstruction
Chronic abdominal pain
Incisional hernia
Diarrhea.
Prevention Strategies:
Meticulous surgical technique, especially in dissection of Calot's triangle, ensuring clear visualization before clipping and dividing cystic duct and artery
Judicious use of intraoperative cholangiography if common bile duct stones are suspected
Prompt conversion to open surgery when necessary
Appropriate antibiotic prophylaxis
Postoperative prophylactic measures for DVT/PE
Careful patient selection and preoperative optimization.
Prognosis
Factors Affecting Prognosis:
Severity of cholecystitis (Tokyo Grade)
Presence of comorbidities
Delay in diagnosis and treatment
Surgical expertise and experience
Occurrence of complications
Age and overall health of the patient.
Outcomes:
For uncomplicated acute cholecystitis treated with early LC, outcomes are generally excellent with high success rates and low morbidity
Mortality is low, especially in younger, healthier patients
Complications and delayed treatment are associated with poorer outcomes and increased mortality, particularly in severe (Grade III) cases.
Follow Up:
Routine follow-up is typically not required for uncomplicated LC
Patients should be advised to report any new or persistent abdominal pain, fever, jaundice, or signs of infection
If complications arose, follow-up will be guided by the specific issue (e.g., for bile leaks, strictures, or retained stones)
Long-term dietary adjustments may be recommended, though most patients resume a normal diet.
Key Points
Exam Focus:
Tokyo Guidelines classification (Grade I, II, III) is crucial
Early laparoscopic cholecystectomy is the cornerstone of management for Grade I and II
Initial medical stabilization followed by urgent surgery for Grade III
Common complications of LC and their management are high-yield
Role of ultrasound in diagnosis
Antibiotic regimens for acute cholecystitis.
Clinical Pearls:
Always consider Murphy's sign, but its absence does not rule out acute cholecystitis
A thickened gallbladder wall (>4mm) on ultrasound is highly suggestive
If severe inflammation or a distended gallbladder obscures Calot's triangle, do not force dissection
consider subtotal cholecystectomy or conversion to open surgery
Consider intraoperative cholangiography if dilated CBD or deranged LFTs
Early post-op mobilization is vital
Beware of bile leak symptoms (pain, fever, jaundice, RUQ tenderness).
Common Mistakes:
Delaying surgery in favorable cases, leading to complications
Aggressive dissection in a severely inflamed gallbladder, risking bile duct injury
Neglecting to adequately treat choledocholithiasis or cholangitis concurrently
Inadequate antibiotic coverage
Failing to recognize signs of gallbladder perforation or sepsis
Not converting to open surgery when technically necessary, leading to increased intraoperative morbidity.