Laparoscopic cholecystectomy Indications ■ Same as for open procedure ■ One of the most important indications is that the surgeon be adequately trained to perform the procedure ■ All manifestations of symptomatic gallstones – biliary colic, history of jaundice, chronic cholecystitis and acute cholecystitis ■ Gallstone pancreatitis ■ Acalculous cholecystitis ■ Large gallbladder polyps Contraindications ■ There are no absolute contraindications to laparoscopic cholecystectomy ■ Relative contraindications include cirrhosis and portal hypertension, bleeding diathesis, pregnancy ■ Technical modifications can be made to suit these three problems

Preoperative Investigation and Preparation for the Procedure Preoperative investigations include liver function tests and typically an ultrasound examination. If the laparoscopic cholecystectomy is being performed for acalculous cholecystitis, patients may have had nuclear studies to assess gallbladder function. If there is the suspicion of gallbladder cancer or big polyps, a CT scan is required. There is no place for routine preoperative endoscopic retrograde cholangiopancreatography (ERCP) in laparoscopic cholecystectomy. The patient should have prophylactic antibiotics on induction and appropriate anti-thromboembolic measures.

The procedure should be performed on a table allowing operative cholangiography. There is no routine need for a nasogastric tube or Foley catheter. Typically there is no requirement for invasive anesthetic monitoring. Patients are placed supine, legs together with a slight reverse Trendelenburg position. There is little to gain by using a steep reverse Trendelenburg position. Safe access: Open insertion of a Hasson cannula through a transumbilical incision. Eversion of the umbilicus creates access via the gap in the linea alba at the base of the umbilicus. The Hasson cannula can be sat directly in the peritoneal cavity. There is no need for stay sutures nor to suture the port in place. A 30° telescope is used; insufflation pressures are set at 15mmHg. Placement of other access parts is as shown in the figure.

Complications Bleeding The major intraoperative complication is bleeding. This is typically from a very short cystic artery or from the right hepatic artery itself. Bleeding from the portal vein is very rare, but in contrast to hepatic and cystic artery bleeding, it is always torrential and the patient must be opened. Bile Duct Injury Proper retraction, careful dissection, steady control of hemorrhage and recognition of an appropriate time to convert to open cholecystectomy should minimize the chance of the most feared intraoperative complication – bile duct injury or bile duct resection. If a duct injury is recognized the surgeon should just stop, collect his or her thoughts, and ring a hepatobiliary colleague immediately. Postoperative Complications Most bile leaks are low volume and will settle spontaneously. A high volume bile leak is suggestive that the clip has come off the cystic duct or there is a major unrecognized duct injury. ERCP will determine this, allowing appropriate management. Subphrenic collection may require percutaneous drainage. Pneumonia – best treated with physiotherapy and antibiotics. Jaundice suggests major duct obstruction or excision – ERCP or referral to a hepatobiliary specialist.