Cholecystectomy - the laparoscopic approach

Of all surgical procedures for which laparoscopy is an option, cholecystectomy - gallbladder removal - is the most widely recognised and accepted.

A specialist trained in laparoscopic procedure will recognise any adjunct problems encountered, and be in a position to deal with them.

The following may help you advise your patients.

When to admit:

• if an attack hasn't settled after 12 hours.
• if there are complications such as jaundice, pancreatitis.
• if patient suffers recurrent pain or vomiting
• if patient suffers cholangitis.

Facts about gallbladder disease

Around 10% of the New Zealand population has gallstones. Most of these are "silent" but about 4% of patients with stones develop symptoms each year. For about half of them, the symptoms reoccur within 12 months.

The complication rate for silent stones that become symptomatic and for symptomatic stones is about the same, at around 5%. Hence it is quite safe to leave silent stones alone.

In adulthood, gallbladder stones are formed as a result of biochemical and secretory defects in bile metabolism. In childhood, they are almost always secondary to other problems, such as haemolytic anaemia or disease of terminal ilium.

Neither the number nor the size of stones is predictive of symptoms. 

Who is at risk

Recognisable risk factors for cholesterol stones are:

• Race.  
  In some countries this has been shown to be a factor, with Chileans and North American Indians having a high rate. 
• Gender.
  Women are most at risk.
• Drug use. 
  Clofibrate is known to contribute to formation of stones
• Type 2B and type 4 hyperlipidaemia.
• Multiparity.
• Pigment stones are usually associated with haemolytic anaemia, prosthetic heart valves, Far Eastern ancestry and cirrhosis.
• Prophylactic cholecystectomy.

Some situations justifying treating an asymptomatic gallbladder

• 'porcelain' (calcified) gallbladder, which has a 25% to 50% association with cancer of the gallbladder.
• when true gallbladder polyps, which are pre-malignant, are present. These are very rare, as distinct from inflammatory 'polyps' as described on ultrasound reports.
• carriers of Salmonella typhii.
• as a precaution, when the patient does not have ready access to medical care.

Is laparoscopy always advised?

There are very few instances when laparoscopic surgery is not preferable to conventional surgery for cholecystectomy. This is especially true when the surgical and nursing team is well experienced in the procedures and post-operative care.

The only real contraindication is if the anaesthetic risk is too high. Other, lsser contraindications - such as during the first trimester of pregnancy - need not pose a problem to the experienced laparoscopic surgeon. 

• Obesity - there are fewer post-operative complications with laparoscopic surgery.
• Previous surgery - adhesions can be dealt with successfully.
• Common bile duct stones can be removed by laparoscopy, or by ERCP.
• Severe cholecystitis is best dealt with acutely - one operation and recovery period - and can be done safely with laparoscopic   technique.

Doing the sums

The disposable instruments - used are more expensive but carry no risk of hepatitis or AIDS. There are hidden costs to using non-disposable intruments, in cleaning and handling.

Surgical skill speeds procedures and lessens time-related theatre and anaesthetic charges. The current average cost of 60 minutes theatre time is $733 - and for 65 minutes $836.

Fewer complications occur, a saving because they add to the expense, requiring more time off work, more medications and more time in hospital.

Routine use of x-ray adds costs to theatre time, also to equipment, radiographer, radiologists and chemicals.

An experienced laparoscopic nursing team - when staff are familiar with the equipment and procedures there will not be problems of inappropriate or unnecessary use of antibiotics or catheters.