Laparoscopic Cholecystectomy Surgery

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Dr. Manish Motwani

Posted By : Dr. Manish Motwani - M.S, M.D. and Diplomats, etc.

Posted On : Sep 18, 2009 (Views : 2966)

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What is Gall bladder?


The gallbladder is a pear-shaped organ that lies beneath the liver in the right-upper abdomen. The gallbladder is connected to the liver (which produces the bile) by the hepatic duct. Its function is to store bile. When food containing fat reaches the small intestine, a hormone called cholecystokinin is produced by cells in the intestinal wall and is carried to the gall bladder via the bloodstream. The hormone causes the gall bladder to contract, forcing bile into the common bile duct. A valve, which opens only when food is present in the intestine, allows bile to flow from the common bile duct into the duodenum (upper intestine) where it functions in the process of fat digestion.

What is cholecystitis?



Cholecystitis is an inflammation of the gallbladder wall and nearby abdominal lining. Cholecystitis can occur suddenly or gradually over many years. Acute cholecystitis is the sudden onset of inflammation of the gallbladder, resulting in severe, steady upper abdominal pain (biliary colic), which may occur repeatedly. Chronic cholecystitis is long-standing inflammation of the gallbladder characterized by repeated attacks of pain (gallbladder attacks) over a prolonged period.



At least 95% of people with acute cholecystitis have gallstones. Gallstones are stones which are formed in the gallbladder. The Gall Bladder stores and concentrates bile. Sometimes the substances contained in bile crystallize in the gall bladder, forming stones. These small, hard concretions are more common in persons over 40, especially in women and the obese. Rarely, acute cholecystitis occurs in a person without gallstones (acalculous cholecystitis). In these cases the cause can be any major injury, operation or burn, bacterial infection in the bile duct system, tumor of the pancreas or liver.



What are the symptoms of cholecystitis?



A gallbladder attack, whether in acute or chronic cholecystitis, begins as severe, steady abdominal pain (biliary colic). The person typically feels a sharp pain when a doctor presses on the upper right part of the abdomen. The pain may worsen when the person breathes deeply and often extends to the lower part of the right shoulder blade. The pain may become excruciating; and may be accompanied by nausea and vomiting. The pain usually lasts more than 12 hours. Within a few hours, the abdominal muscles on the right side become rigid. Fever occurs in about one third of people but is less likely in older people. The fever tends to be mild at first, and then rises gradually to above 100° F (38° C). Typically, an attack of cholecystitis subsides in 2 to 3 days and completely disappears in a week. If the attack persists, it may signal a serious complication. This disorder initially produces symptoms similar to those of indigestion, especially after a fatty meal is consumed. This may be accompanied by nausea and vomiting. But when a stone becomes lodged in the bile duct, it produces severe pain. Many people also remain asymptomatic. The symptoms of cholecystitis may resemble gastric pain but one must always consult their physician for a proper diagnosis.



How is it diagnosed?



Doctors diagnose cholecystitis, both acute and chronic, based on the person's symptoms and the results of tests that suggest gallbladder inflammation. The physician will perform a careful abdominal examination to confirm the diagnosis. The enlarged, tender gallbladder may be felt by the physician through the abdominal wall. Pressure in the upper right corner of the abdomen may cause the patient to stop breathing in, due to an increase in pain. This is called Murphy's sign. Besides this, few diagnostic procedures may be advised. They include:



   * Blood tests: Increased levels of white blood cells suggest inflammation or infection or both. There may also be increase in bilirubin levels.



   * Ultrasound (Also called sonography.) - A diagnostic imaging technique which uses high-frequency sound waves to create an image of the internal organs. Ultrasounds are used to view internal organs of the abdomen such as the liver spleen, and kidneys and to assess blood flow through various vessels. Ultrasound scans can also show thickening of the gallbladder wall, which is typical of chronic cholecystitis.



   * Hepatobiliary scintigraphy - Cholescintigraphy is an imaging technique that is useful when acute cholecystitis is difficult to diagnose. In this test, a radioactive tracer is injected intravenously and its movement from the liver through the biliary tract is followed. Images are taken of the liver, bile ducts, gallbladder, and upper part of the small intestine. If the tracer does not fill the gallbladder, it is presumed that the cystic duct is obstructed by a gallstone.



   * Cholangiography - x-ray examination of the bile ducts using an intravenous (IV) dye (contrast).



   * Endoscopic retrograde cholangiopancreatography (ERCP) - a procedure that allows the physician to diagnose and treat problems in the liver, gallbladder, bile ducts, and pancreas. The procedure combines x-ray and the use of an endoscope - a long, flexible, lighted tube. The scope is guided through the patient's mouth and throat, then through the oesophagus, stomach, and duodenum. The physician can examine the inside of these organs and detect any abnormalities. A tube is then passed through the scope, and a dye is injected which will allow the internal organs to appear on an x-ray.



   * Computed tomography scan (CT or CAT scan) - a diagnostic imaging procedure using a combination of x-rays and computer technology to produce cross-sectional images (often called slices), both horizontally and vertically, of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general x-rays.



How is cholecystitis treated?



The approach taken to treat cholecystitis depends upon :



   * Extent of the disease

   * Age, overall health, and medical history of the patient

   * Tolerance of specific medicines, procedures, or therapies

   * Expectations for the course of the disease

   * Patient's opinion or preference



For acute cholecystitis, initial treatment includes bowel rest, intravenous hydration, intravenous antibiotics and pain management. Whether it is acute or chronic cholecystitis, the physician then takes a step to identify the cause. If the cause is gallstones, then he may suggest the conventional solution in which the gall bladder itself is removed. And if the physician feels that it is best to remove the gall bladder, he may advice the patient to undergo Cholecystectomy after the acute phase subsides. Cholecystectomy merely means removal of the gallbladder. In acalculous cholecystitis, immediate surgery is necessary to remove the diseased gallbladder. Cholecystectomy again can be done by conventional method (also called open method) or by the laparoscopic method. We wish to provide our patients with complete information about the available treatments. So we are discussing (below) both the conventional and new methods.



The conventional method



The conventional method, also called open method was initially the only standard treatment. This was the common treatment offered both for gallstone removal or gallbladder removal. This procedure required a 3 to 7 day stay in the hospital and a 3 to 7 inch incision and scar on the abdomen. The surgeon makes an abdominal incision under the right side of the rib cage, which cuts through the skin and muscle. The gallbladder is then located and removed.


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