Laparoscopy Surgery

PERSONALIZED PATIENT CARE

Laparoscopic Cholecystectomy Treatment

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.

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.

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.

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.
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, 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.

Laparoscopic Cholecystectomy is now the gold standard treatment and is the commonest operation performed laparoscopically worldwide. Gynaecologists have long used this technique to tie the Fallopian tubes and to inspect the female reproductive organs. Now the use of laparoscopy has been expanded to include removing a diseased gallbladder. The first documented laparoscopic Cholecystectomy was performed by Erich Mühe in Germany in 1985. Currently, over 90% of cholecystectomies are performed laparoscopically making it the most common procedure performed in general surgery practice.

It is a minimally invasive approach that involves specialized video equipment and instruments that allow a surgeon to remove the gallbladder through four tiny incisions, most of which are less than a half-centimetre in size.

After deciding upon the line of treatment of the case, the physician will explain the procedure to the patient. He will also give an opportunity to the patient and his relatives to ask any queries or doubts. In addition to a complete medical history, the physician may perform a physical examination to ensure that the patient is in good health. In an otherwise healthy person, little is required to prepare for surgery. Depending on the age, gender, and health problems, some routine blood tests, an EKG and a chest x-ray may be needed. In fit patients, the only investigations needed are ultrasound examination, hemoglobin estimation, and liver function tests. Blood is also collected for group determination and keeping a couple of bottles on the standby. Endoscopic retrograde cholangiopancreatography (ERCP) is performed when ductal stones are suspected on the basis of clinical, biochemical and ultra-sound criteria. The surgeon will also make note if there is any history of allergy to any medication or anesthetic agents. One should be very open with their surgeon and must let him know about all medications he is taking. In general, all blood thinners need to be stopped 3-5 days before surgery.

The physician fixes up the surgery date and the patient is given an outline of the schedule. The patient will be instructed to refrain from eating 8 hours before surgery. On the day of the surgery, the patient is required to sign a consent form. The patient is again thoroughly examined by the physician. Based upon the patient's medical condition, the physician may request the specific preparation. Gallbladder operations are performed under general anesthesia. An IV line will be placed in the arm for fluids and then the patient is brought into the operation room.

The anesthesiologist and nurses keep using monitors to check the heart rate and breathing rate during the procedure. These may include EKG leads, a blood pressure cuff and an oxygen mask. The patient is operated in the supine position with a steep head-up tilt. A nasogastric tube is inserted and the stomach aspirated. The tube is kept in the stomach during the operation but removed at the end of the procedure.

Laparoscopic cholecystectomy requires several small incisions in the abdomen to allow the insertion of surgical instruments and a small video camera. So, the surgeon makes a small incision at the navel o insert to a thin tube carrying the video camera. The camera sends a magnified image from inside the body to a video monitor, giving the surgeon a close-up view of the organs and tissues. The surgeon then inflates the abdomen with carbon dioxide, a harmless gas, for easier viewing and to provide room for the surgery to be performed. Next, two needles-like instruments are inserted at a different place. These instruments serve as tiny hands within the abdomen. They can pick up the gallbladder, move intestines around, and generally assist the surgeon. Finally, several different instruments are inserted to clip the gallbladder artery and bile duct, and to safely dissect and remove the gallbladder and stones. When the gallbladder is freed, it is then eased out of the tiny navel incision. The entire procedure normally takes 60 minutes. The three puncture wounds require no stitches and may leave very slight blemishes. The navel incision is barely visible.

After the procedure, the patient is taken to the recovery room for observation. The recovery process will vary depending upon the type of procedure performed and the type of anesthesia that is given. Once the blood pressure, pulse, and breathing are stable and the patient is alert, they are shifted to the hospital room. It is common to feel groggy and nauseated soon after surgery and medication is available to help with these discomforts.

Using advanced laparoscopic technology, it is now possible to remove the gallbladder through a tiny incision at the navel! With new video technology, the laparoscope has become a miniature television camera. Powerful magnification is now possible, showing the intestinal organs in great detail. It is an exciting development because it offers so much to the patient like :

  • Less postoperative pain because it does not require the abdominal muscles to be cut
  • Shortens hospital stay
  • May result in a quicker return to bowel function
  • Quicker return to normal activity
  • Better cosmetic results

But while the procedure seems very easy for the patient, it is still an abdominal surgery. In many instances, the surgeon may not recommend this procedure. To decide upon the technique, the surgeon has to carefully evaluate each case and weight the benefit for the patient against the risks. However, in the presence of infection, adhesions, or variations in anatomy, this method becomes dangerous and your surgeon may need to make the prudent decision to continue by making the traditional incision to safely complete the operation. This should not be seen as a failure, but as a wise decision by your surgeon to prevent dangerous complications. In about 5 to 10% of cases, the gallbladder cannot be safely removed by laparoscopy. In these cases, standard open abdominal surgery has to be the mode of treatment. The table given below compares the laparoscopic and open surgery.

LAPAROSCOPIC

  • Small Incisions (less than ½ an inch)
  • Hospital stay is 1 to 3 days
  • Patients usually return to work in 5 to 10 days
  • Lesser risk of Infection
  • Less painful
  • Less chance of hernias

OPEN

  • Large Incision
  • Hospital stay of about 5 days
  • Return to work in about 4 weeks
  • Greater risk of infection
  • More painful
  • More chance of hernias

An uncommon but potentially serious complication with the new procedure is injury to the common bile duct, which connects the gallbladder and liver. An injured bile duct can leak bile and cause a painful and potentially dangerous infection. Many cases of minor injury to the common bile duct can be managed non-surgically. Major injury to the bile duct, however, is a very serious problem and may require corrective surgery. At this time it is unclear whether these complications are more common following laparoscopic cholecystectomy than following standard cholecystectomy.

Once the patient is back at home, it is important to keep the incision clean and dry. The physician will give specific bathing instructions. If stitches or surgical staples are used, they will be removed during a follow-up office visit. If adhesive strips are used, they should be kept dry and generally will fall off within a few days.

The incision and the abdominal muscles may ache, especially after long periods of standing. Pain relievers for soreness can be taken as recommended by the physician. Aspirin or certain other pain medications may increase the chance of bleeding. Patients must ensure that they take only recommended medications. Walking and limited movement are generally encouraged, but strenuous activity should be avoided. The physician will give proper instructions about when the patient can return to work and resume normal activities.