Cholecystectomy

Cholecystectomy is the surgical removal of the

gallbladder. Cholecystectomy is a common treatment Cholecystectomy
of symptomatic gallstones and other gallbladder
conditions.[1] In 2011, cholecystectomy was the eighth
most common operating room procedure performed in
hospitals in the United States.[2] Cholecystectomy can
be performed either laparoscopically, or via an open
surgical technique.[3]

The surgery is usually successful in relieving

symptoms, but up to 10 percent of people may
continue to experience similar symptoms after A US Navy general surgeon and an operating
cholecystectomy, a condition called room nurse performing a laparoscopic
[4] cholecystectomy
postcholecystectomy syndrome. Complications of
cholecystectomy include bile duct injury, wound Pronunciation /ˌkɒləsɪsˈtɛktəmi/
infection, bleeding, vasculobiliary injury, retained Specialty General surgery
gallstones, liver abscess formation and stenosis
ICD-9-CM 575.0 ([Link]
(narrowing) of the bile duct.[5][4]
[Link]/[Link]?srchtype=pro
cs&srchtext=575.0&Submit=S
earch&action=search)
Medical use MeSH D002763
Pain and complications caused by gallstones are the CPT 47562
most common reasons for removal of the
gallbladder.[6] The gallbladder can also be removed in
order to treat biliary dyskinesia or gallbladder cancer.[7]

Gallstones are very common but 50–80% of people

with gallstones are asymptomatic and do not need
surgery; their stones are noticed incidentally on
imaging tests of the abdomen (such as ultrasound or
CT) done for some other reason.[8] The traditional risk
factors for gallstones are the four “F's: female, fat,
forty, and fertile.[9] Of the more than 20 million people
in the US with gallstones, only about 30% will
eventually require cholecystectomy to relieve
Gallbladder anatomy
symptoms (pain) or treat complications.[10]

Biliary colic
Biliary colic, or pain caused by gallstones, occurs when a gallstone temporarily blocks the bile duct that
drains the gallbladder.[11] Typically, pain from biliary colic is felt in the right upper part of the abdomen,
is moderate to severe, and goes away on its own after a few hours when the stone dislodges.[12] Biliary
colic usually occurs after meals when the gallbladder contracts to push bile out into the digestive tract.
After a first attack of biliary colic, more than 90% of people will have a repeat attack in the next 10
years.[1] Repeated attacks of biliary colic are the most common reason for removing the gallbladder, and
lead to about 300,000 cholecystectomies in the US each year.[10][13]

Acute cholecystitis
Cholecystitis, or inflammation of the gallbladder caused by interruption in the normal flow of bile, is
another reason for cholecystectomy.[14] It is the most common complication of gallstones; 90–95% of
acute cholecystitis is caused by gallstones blocking drainage of the gallbladder.[15] If the blockage is
incomplete and the stone passes quickly, the person experiences biliary colic. If the gallbladder is
completely blocked and remains so for a prolonged period, the person develops acute cholecystitis.[16]

Pain in cholecystitis is similar to that of biliary colic, but lasts longer than six hours and occurs together
with signs of infection such as fever, chills, or an elevated white blood cell count.[1] People with
cholecystitis will also usually have a positive Murphy sign on physical exam – meaning that when a
doctor asks the patient to take a deep breath and then pushes down on the upper right side of their
abdomen, the patient stops their inhalation due to pain from the pressure on their inflamed gallbladder.[1]

Five to ten percent of acute cholecystitis occurs in people without gallstones, and for this reason, is called
acalculous cholecystitis. It usually develops in people who have abnormal bile drainage secondary to a
serious illness, such as people with multi-organ failure, serious trauma, recent major surgery, or following
a long stay in the intensive care unit.[16]

People with repeat episodes of acute cholecystitis can develop chronic cholecystitis from changes in the
normal anatomy of the gallbladder.[16] This can also be an indication for cholecystectomy if the person
has ongoing pain.

Cholangitis and gallstone pancreatitis

Cholangitis and gallstone pancreatitis are rarer and more serious complications from gallstone disease.
Both can occur if gallstones leave the gallbladder, pass through the cystic duct, and get stuck in the
common bile duct. The common bile duct drains the liver and pancreas, and a blockage there can lead to
inflammation and infection in both the pancreas and biliary system. While cholecystectomy is not usually
the immediate treatment choice for either of these conditions, it is often recommended to prevent repeat
episodes from additional gallstones getting stuck.[14]: 940, 1017

Gallbladder cancer
Gallbladder cancer (also called carcinoma of the gallbladder) is a rare indication for cholecystectomy. In
cases where cancer is suspected, the open technique for cholecystectomy is usually performed.[13]

Liver transplantation
In living donor liver transplantation between adults, a cholecystectomy is performed in the donor because
the gallbladder interferes with removal of the right (lateral) lobe of the liver and to prevent the formation
of gallstones in the recipient.[17][18] The gallbladder is not removed in pediatric transplantations as the
left lobe of the liver is used instead.[19]

Contraindications
There are no specific contraindications for cholecystectomy, and in general it is considered a low-risk
surgery. However, anyone who cannot tolerate surgery under general anesthesia should not undergo
cholecystectomy. People can be split into high and low risk groups using a tool such as the ASA physical
status classification system. In this system, people who are ASA categories III, IV, and V are considered
high risk for cholecystectomy. Typically this includes very elderly people and people with co-existing
illness, such as end-stage liver disease with portal hypertension and whose blood does not clot
properly.[7] Alternatives to surgery are briefly mentioned below.

Risks
All surgery carries risk of serious complications including damage to nearby structures, bleeding,
infection,[20] or even death. The operative death rate in cholecystectomy is about 0.1% in people under
age 50 and about 0.5% in people over age 50.[10] The greatest risk of death comes from co-existing
illness like cardiac or pulmonary disease.[21]

Biliary injury
A serious complication of cholecystectomy is biliary injury, or damage to the bile ducts.[22] Laparoscopic
cholecystectomy has a higher risk of bile duct injury than the open approach, with injury to bile ducts
occurring in 0.3% to 0.5% of laparoscopic cases and 0.1% to 0.2% of open cases.[23] In laparoscopic
cholecystectomy, approximately 25–30% of biliary injuries are identified during the operation; the rest
become apparent in the early post-operative period.[3]

Damage to the bile ducts is very serious because it causes leakage of bile into the abdomen. Signs and
symptoms of a bile leak include abdominal pain, tenderness, fever and signs of sepsis several days
following surgery, or through laboratory studies as rising total bilirubin and alkaline phosphatase.[22]
Complications from a bile leak can follow a person for years and can lead to death. Bile leak should
always be considered in any patient who is not recovering as expected after cholecystectomy.[22] Most
bile injuries require repair by a surgeon with special training in biliary reconstruction. If biliary injuries
are properly treated and repaired, more than 90% of patients can have a long-term successful recovery.[23]

Injury of the bile ducts can be prevented and treated by routinely using X-ray investigation of the bile
ducts (intraoperative cholangiography (IOC)).[24] This method was assessed by the Swedish SBU and
routine use deemed to decrease risk of injury and morbidity following unaddressed injury while only
increasing cancer rates due to radiation exposure by a lesser fraction.[24]

Other complications
A review of safety data in laparoscopic cholecystectomy found the following complications to be most
common:

Rates of complications other than bile duct injury after

laparoscopic cholecystectomy[25]
Complication Prevalence

Wound infection 1.25%

Urinary retention 0.90%

Bleeding 0.79%

Retained stone in the common bile duct 0.50%

Respiratory 0.48%
Cardiac 0.36%

Intra-abdominal abscess 0.34%

Hernia 0.21%

The same study found the prevalence of bowel injury, sepsis, pancreatitis, and deep vein
thrombosis/pulmonary embolism to be around 0.15% each.[25]

Leakage from the stump of the cystic duct is a complication that is more common with the laparoscopic
approach than the open approach but is still rare, occurring in less than 1% of procedures; it is treated by
drainage followed by insertion of a bile duct stent.[26]

Another complication singular to the laparoscopic procedure is the phenomenon of the "spilled gallstone"
which complicates 0.08–0.3% of cases.[27] Here a stone escapes the resected gallbladder into the
abdomen where it can become a focus for infection if it is not identified and removed.[28] Some reports
exist of spilled stones lying unnoticed for up to 20 years before eventually causing an abscess to form.[29]

Conversion to open cholecystectomy

Experts agree that many biliary injuries in laparoscopic cases are caused by difficulties seeing and
identifying the anatomy clearly. If the surgeon has problems identifying anatomical structures, they might
need to convert from laparoscopic to open cholecystectomy.[30]

Peroperative Endoscopic Retrograde Cholangio-Pancreaticography (ERCP)/

Laparo-endoscopic rendezvous (LERV) technique
CBDS are found in 10–15% of patients during cholecystectomy when intraoperative cholangiography
(IOC) is routinely performed.[31] [32] There are several strategies to manage choledocholithiasis but the
optimal method as well as the timing of treatment is still under debate.[33]

In recent years the LERV technique, in which access to the common bile duct by ERCP is facilitated by
an antegrade guidewire, which is intraoperatively introduced during fluoroscopy and is advanced through
the cystic duct to the duodenum, has been established as an alternative to treat common bile duct stones
discovered during laparoscopic cholecystectomy. This technique was first described in 1993 by
Deslandres et al.[34] and has, in several studies, been shown to have a high rate of CBD stones clearance
and a reduced number of complications, particularly post-ERCP pancreatitis, in comparison with
conventional ERCP.[35] [36] This is probably due to the facilitated access to the common bile duct with a
lesser degree of manipulation and trauma to the papilla Vateri. In a study by Swahn et al. the rendezvous
method was shown to reduce the risk of PEP from 3.6 to 2.2% compared with conventional biliary
cannulation.[37] The success rate of passing the transcystic guidewire into the duodenum has been
reported to be over 80%.[38]

Procedure

Pre-operative preparation
Before surgery, a complete blood count and liver function tests are
usually obtained.[39] Prophylactic treatment is given to prevent
deep vein thrombosis.[39] Use of prophylactic antibiotics is
controversial; however, a dose may be given prior to surgery to
prevent infection in certain people at high risk.[40][41] Gas may be
removed from the stomach with an OG or NG tube.[39] A Foley
Abdomen of a 45-year-old male
catheter may be used to empty the patient's bladder.[39]
approximately one month after a
laparoscopic cholecystectomy.
Laparoscopic cholecystectomy Surgical incision points are
highlighted; the point at top right is
Laparoscopic cholecystectomy uses several (usually 4) small barely visible. The gall bladder was
incisions in the abdomen to allow the insertion of operating ports, removed via the incision at the
small cylindrical tubes approximately 5 to 10 mm in diameter, navel. There is a fourth incision (not
through which surgical instruments are placed into the abdominal shown) on the person's right lower
flank, used for draining. All incisions
cavity. The laparoscope, an instrument with a video camera and
have healed well and the most
light source at the end, illuminates the abdominal cavity and sends
visible remaining effect of surgery is
a magnified image from inside the abdomen to a video screen, from the pre-operative hair removal.
giving the surgeon a clear view of the organs and tissues. The
cystic duct and cystic artery are identified and dissected, then
ligated with clips and cut in order to remove the gallbladder. The gallbladder is then removed through one
of the ports.[42]

As of 2008, 90% of cholecystectomies in the United States were done laparoscopically.[43] Laparoscopic
surgery is thought to have fewer complications, shorter hospital stay, and quicker recovery than open
cholecystectomy.[44]

Single incision
Single incision laparoscopic surgery (SILS) or laparoendoscopic single site surgery (LESS) is a technique
in which a single incision is made through the navel, instead of the 3-4 four small different incisions used
in standard laparoscopy. There appears to be a cosmetic benefit over conventional four-hole laparoscopic
cholecystectomy, and no advantage in postoperative pain and
hospital stay compared with standard laparoscopic procedures.[45]
There is no scientific consensus regarding risk for bile duct injury
with SILS versus traditional laparoscopic cholecystectomy.[45]

Natural orifice transluminal

Natural orifice transluminal endoscopic surgery (NOTES) is an
experimental technique where the laparoscope is inserted through
natural orifices and internal incisions, rather than skin incisions, to
access to the abdominal cavity.[46] This offers the potential to
eliminate visible scars.[47] Since 2007, cholecystectomy by
NOTES has been performed anecdotally via transgastric and
transvaginal routes.[46] As of 2009 the risk of gastrointestinal leak,
difficulty visualizing the abdominal cavity and other technical
limitations limited further adoption of NOTES for
cholecystectomy.[47]

Open cholecystectomy
In open cholecystectomy, a surgical incision of around 8 to 12 cm
is made below the edge of the right rib cage and the gallbladder is
removed through this large opening, typically using
electrocautery.[42] Open cholecystectomy is often done if
difficulties arise during a laparoscopic cholecystectomy, for
example, the patient has unusual anatomy, the surgeon cannot see
well enough through the camera, or the patient is found to have
cancer.[42] It can also be done if the patient has severe
cholecystitis, emphysematous gallbladder, fistulization of
gallbladder and gallstone ileus, cholangitis, cirrhosis or portal
hypertension, and blood dyscrasias.[42]

Biopsy
After removal, the gallbladder should be sent for pathological
Steps of a cholecystectomy, as seen
examination to confirm the diagnosis and look for any incidental
through a laparoscope
cancer. Incidental cancer of the gallbladder is found in
approximately 1% of cholecystectomies.[14]: 1019 If cancer is
present in the gallbladder, it is usually necessary to re-operate to remove parts of the liver and lymph
nodes and test them for additional cancer.[48]

Post-operative management
After surgery, most patients are admitted to the hospital for routine
monitoring. For uncomplicated laparoscopic cholecystectomies,
people may be discharged on the day of surgery after adequate
control of pain and nausea.[41] Patients who were high-risk, those
who required emergency surgery, and/or those undergoing open
cholecystectomy usually need to stay in the hospital several days
after surgery.[21]

Subtotal Cholecystectomy The 1-week-old incisions of a post-

operative laparoscopic
Intra-operative decisions, with patient safety at the forefront, cholecystectomy as indicated by red
sometimes call for, what is known in surgical education as, "bail- arrows. The 3 abdominal incisions
out" procedures. This is usually due to the surgical team making a are approximately 6mm, while the
clinical decision in the operating room to not proceed with the fourth incision near the umbilicus is
18mm, each closed with dissolvable
intended cholecystectomy, due to issues such as adherent bowel or
sutures. Minor inflammation can be
colon, inability to properly identify anatomical planes from
seen surrounding each site due to
previously formed scar-tissue. If there is an inability to safely skin irritation caused by removal of
isolate the structures needed to isolate for cholecystectomy (the Tegaderm dressings.
cystic duct and the cystic artery) for whatever reason (many times
patients have part of the small bowel or colon stuck to the
gallbladder, which make it dangerous to pull off without making an accidental hole in the small bowel),
the surgical team may elect to do a subtotal cholecystectomy; either a fenestrated or reconstituting
type.[49] Essentially, only part of the gallbladder is removed and a drain is left in place for several days.
Complications include continued output from drain, which may result in the need for ERCP stent
placement to stop drainage.

Long-term prognosis
In 95% of people undergoing cholecystectomy as treatment for simple biliary colic, removing the
gallbladder completely resolves their symptoms.[10]

Up to 10% of people who undergo cholecystectomy develop a condition called postcholecystectomy

syndrome.[4] Symptoms are typically similar to the pain and discomfort of biliary colic with persistent
pain in the upper right abdomen and commonly include gastrointestinal distress (dyspepsia).[4]

Some people following cholecystectomy may develop diarrhea.[7] The cause is unclear, but is presumed
to be due to disturbances in the biliary system that speed up enterohepatic recycling of bile salts. The
terminal ileum, the portion of the intestine where these salts are normally reabsorbed, becomes
overwhelmed, does not absorb everything, and the person develops diarrhea.[7] Most cases resolve within
weeks or a few months, though in rare cases the condition can last for years. It can be controlled with
medication such as cholestyramine.

A systematic review and meta analysis of eighteen studies on the association between cholecystectomy
and the risk of development of colorectal cancer concluded that cholecystecomy has no effect on the risk
of colorectal cancer overall, but does have a harmful effect on the risk of right-sided colon cancer.[50] A
nationwide cohort study in Korea reported a significantly increased total cancer risk, including increased
risk of several different specific types of cancer, after cholecystectomy.[51]

Considerations

Pregnancy
It is generally safe for pregnant women to undergo laparoscopic cholecystectomy during any trimester of
pregnancy.[8] Early elective surgery is recommended for women with symptomatic gallstones to decrease
the risk of spontaneous abortion and pre-term delivery.[8] Without cholecystectomy, more than half of
such women will have recurrent symptoms during their pregnancy, and nearly one in four will develop a
complication, such as acute cholecystitis, that requires urgent surgery.[8] Acute cholecystitis is the second
most common cause of acute abdomen in pregnant women after appendectomy.[16]

Porcelain gallbladder
Porcelain gallbladder (PGB), a condition where the gallbladder wall shows calcification on imaging tests,
was previously considered a reason to remove the gallbladder because it was thought that people with this
condition had a high risk of developing gallbladder cancer.[1] However, recent studies have shown that
there is no strong association between gallbladder cancer and porcelain gallbladder, and that PGB alone is
not a strong enough indication for a prophylactic cholecystectomy.[8]

Alternatives to surgery
There are several alternatives to cholecystectomy for people who do not want surgery, or in whom the
benefits of surgery would not outweigh the risks.

Conservative management
Conservative management for biliary colic involves a "watch and wait" approach—treating symptoms as-
needed with oral medications. Experts agree that this is the preferred treatment for people with gallstones
but no symptoms.[8] Conservative management may also be appropriate for people with mild biliary
colic, as the pain from colic can be managed with pain medications like NSAIDs (ex: ketorolac) or
opioids.[1]

Conservative management for acute cholecystitis involves treating the infection without surgery. It is
usually only considered in patients at very high risk for surgery or other interventions listed below. It
consists of treatment with intravenous antibiotics and fluids.[52]

ERCP
ERCP, short for endoscopic retrograde cholangiopancreatography, is an endoscopic procedure that can
remove gallstones or prevent blockages by widening parts of the bile duct where gallstones frequently get
stuck. ERCP is often used to retrieve stones stuck in the common bile duct in patients with gallstone
pancreatitis or cholangitis. In this procedure, an endoscope, or small, long thin tube with a camera on the
end, is passed through the mouth and down the esophagus. The
doctor advances the camera through the stomach and into the first
part of the small intestine to reach the opening of the bile duct.
The doctor can inject a special, radiopaque dye through the
endoscope into the bile duct to see stones or other blockages on x-
ray.[53] ERCP does not require general anaesthesia and can be
done outside of the operating room. While ERCP can be used to
remove a specific stone that is causing a blockage to allow
drainage, it cannot remove all stones in the gallbladder. Thus, it is
not considered a definitive treatment and people with recurrent
In ERCP, the endoscope enters
complications from stones will still likely need a cholecystectomy.
through the mouth and passes
through the stomach and start of the
small intestine to reach the bile
Cholecystostomy
ducts.
Cholecystostomy is the drainage of the gallbladder via insertion of
a small tube through the abdominal wall. This is usually done
using guidance from imaging scans to find the right place to insert
the tube. Cholecystostomy can be used for people who need
immediate drainage of the gallbladder but have a high risk of
complications from surgery under general anaesthesia, such as
elderly people and those with co-existing illnesses.[52] Draining
pus and infected material through the tube reduces inflammation
in and around the gallbladder. It can be a lifesaving procedure,
without requiring that the person undergo emergency surgery.[54]

The procedure does come with significant risks and complications This is a cholangiogram, an x-ray of
—in one retrospective study of patients who received the bile ducts using contrast
percutaneous cholecystostomy for acute cholecystitis, 44% medium to make the bile ducts
developed choledocholithiasis (one or more stones stuck in the visible. 1 – Duodenum. 2 – Common
common bile duct), 27% had tube dislodgment, and 23% bile duct. 3 – Cystic duct. 4 –
Hepatic duct. The gallbladder is not
developed postoperative abscess.[54]
seen as the cystic duct is occluded
by a surgical instrument.
For some people, drainage with cholecystostomy is enough and
they do not need to have the gallbladder removed later. For others,
percutaneous cholecystostomy allows them to improve enough in the short term that they can get surgery
at a later time.[52] There is no clear evidence one way or another to indicate that surgical removal after
cholecystostomy is best for high-risk surgical patients with acute cholecystitis.[52]

Frequency of use
About 600,000 people receive a cholecystectomy in the United States each year.[14]: 855

In a study of Medicaid-covered and uninsured U.S. hospital stays in 2012, cholecystectomy was the most
common operating room procedure.[55]
Gallstones affect approximately 10-15% of the global adult population, with the incidence rising with age
and more commonly affecting women. As a result, cholecystectomy is one of the most common
abdominal surgeries performed worldwide.[56]

History
Carl Langenbuch performed the first successful cholecystectomy
at the Lazarus hospital in Berlin on July 15, 1882.[57] Before this,
surgical therapy for symptomatic gallstones was limited to
cholecystostomy, or gallstone removal.[57] Langenbuch's rationale
for developing the new technique stemmed from 17th century
studies in dogs that demonstrated the gallbladder to be
nonessential and medical opinion among his colleagues that
gallstones formed in the gallbladder.[57] Although the technique
was initially controversial, cholecystectomy became established as
a lower mortality procedure than cholecystostomy by the 20th
century.[57]

Laparoscopic technique
Erich Mühe performed the first laparoscopic cholecystectomy on
September 12, 1985, in Böblingen, Germany.[58] Mühe was
inspired to develop a technique for laparoscopic cholecystectomy Carl Langenbuch performed the first
successful cholecystectomy in 1882.
by the first laparoscopic appendectomy, performed by
gynecologist Kurt Semm in 1980.[59] He subsequently designed an
optical laparoscope with a working channel large enough to fit a distended gallbladder.[59] Mühe
presented his technique to the Congress of the German Surgical Society in 1986, claiming reduced
postoperative pain and shorter hospitalization.[60] His work was met with strong resistance by the
German surgical establishment and he had difficulty communicating it in English. It was consequently
ignored.[59] Mühe's work was further disparaged in 1987, when he was charged with manslaughter for a
postoperative patient death that was mistakenly attributed to his innovative technique.[61] He was
exonerated in 1990 after further investigation.[61] His pioneering work was eventually recognized by the
German Surgical Society Congress in 1992.[59]

Philippe Mouret performed laparoscopic cholecystectomy on March 17, 1987, in Lyon, France.[59] His
technique was rapidly adopted and improved in France.[59] It was subsequently introduced to the rest of
the world over the next three years.[59] Driven by popularity among patients, the laparoscopic technique
became preferred over open surgery and noninvasive treatments for gallstones.[59]

By 2013, laparoscopic cholecystectomy had replaced open cholecystectomy as the first-choice of

treatment for people with uncomplicated gallstones and acute cholecystitis.[42][62]

By 2014 laparoscopic cholecystectomy had become the gold standard for the treatment of symptomatic
gallstones.[39][63]
Laparoscopic cholecystectomy can be a challenging procedure and surgeons must be trained with
advanced laparoscopic skills to complete the operation with safety and effectiveness.[64]

See also
List of surgeries by type
List of -ectomies
Waltman Walter syndrome

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Further reading
"Operation Brochures for Patients: Cholecystectomy" ([Link]
1005339/[Link]
American College of Surgeons. Archived from the original ([Link]
s/education/patient%20ed/[Link]) on 2019-08-01. Retrieved 2018-03-20.
"Gallbladder removal" ([Link] NHS. 23
October 2017. Retrieved 4 January 2020.

Retrieved from "[Link]