Development and implementation of laparascopic cholecystectomy is a milestone event in the sphere of gallbladder surgery, particularly in treatment of stones. Over a few years, laparascopic surgery gained recognition among the community of surgeons, and today the procedure is successfully incorporated in many German clinics.
Laparascopic cholecystectomy boasts a number of advantages versus laparotomy (involving dissection of the abdomen), such as shorter stays in hospital, lower risk of post-surgery aggravations and quick rehabilitation. Besides, laparoscopic gallbladder surgery has aesthetic benefits, since small incisions leave only minor scars.
It should be noted, however, that laparascopic cholecystectomy is a complex surgery that requires pinpoint accuracy and expertise in the topographic anatomy of the area and high-precision image-guided laparoscopic manipulation.
Laparoscopy indications are the same as laparotomy indications, since both pursue the universal goal of gallbladder removal. Chronic calculous cholecystitis is the key indication, and neither size nor number of concrements (gallstones), nor the length of the disease, should be regarded as major factors in choosing between traditional laparotomic and laparoscopic surgery.
- chronic calculous cholecystitis:
- cholesterosis and polyps;
- acute cholecystitis (the first 48 hours following the beginning of the onset);
- asymptomatic cholecystolithiasis (silent gallstones).
Indications for laparoscopic surgery in patients dealing with ‘silent cholecystolithiasis,’ particularly with small-size and large-size concrements, arise from the fact that weakness or absence of symptoms do not rule out the possibility of aggravations, such as migration of small-size stones to the cystic or choledochous bile duct or gallbladder wall necrosis caused by large stones.
Contraindications for laparoscopic cholecystectomy can be general and local.
General contraindications include diseases and conditions, which put the necessity of laparoscopic examination or operation to doubt in cases whereby they can cause serious aggravations, such as:
- pronounced cardiac and pulmonary disorders;
- incorrigible blood coagulation disorders;
- generalized peritonitis;
- late pregnancy;
- Class II and Class III obesity.
Local contraindications can be revealed both prior to and during a laparoscopic examination or surgery:
- intrahepatic problems
- pronounced cicatrical/infiltrative gallbladder neck and hepatoduodenal ligament abnormalities;
- mechanical jaundice and acute pancreatitis;
- gallbladder malignancy;
- history of upper abdominal surgeries.
Laparoscopy requires a thorough clinical examination, which should be as extensive as those performed prior to traditional gallbladder surgeries. Ultrasonic test is mandatory as long as it appears to be the most effective cholecystholithiasis diagnostic method.
Laparoscopic cholecystectomy stages.
Laparoscopic surgery comprises several phases:
- pumping gas into the abdominal cavity (carbon dioxide or nitrogen oxide);
- introduction of instruments into the abdominal cavity through trocars to examine abdominal organs;
- separation of adhesions, extraction of the elements of the hepatoduodenal ligament (gallbladder artery and duct), their dissection and closure (clipping);
- extraction of the gallbladder from the liver;
- extraction of the gallbladder from the abdominal cavity, final revision of abdominal organs and completion.
Post-surgical rehabilitation lasts one to two weeks depending on the type and intensity of professional and physical workload.