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Laparoscopic Cholecystectomy

  1. Introduction

First Endoscopic Cholecystectomy was performed in 1985 by Erich Muhe of Boblingen, Germany. Shortly pioneers in France & USA coupled with a CCD video camera with a laparoscopy to allow entire surgical team to view the operative field.

  1. Indication for Cholecystectomy
  1. Symptomatic Cholelithiasis
  1. Biliary Colic
  2. Acute Cholecystitis

     2. Choledocholithiasis

      a) Gall Stone Pancreatitis

      b) Cholangitis or Obstuctive Jaundice

  1. Asymptomatic Cholelithiasis – Prophylatic Cholecystectomy for Asymptomatic Cholelithiasis can be justified in certain circumstances, such as

     

     

    1. With sickle cell disease : Pt. with sickle cell disease often have hepatic or vaso-occlesive crises that are difficult to differentiate from acute cholecystitis,
    2. Bariatric surgery, In bariatric pt. there is increase in possibility of development of gall stone due to rapid weight loss,
    3. Cholelithiasis with diabetes mellitus to avoid complications after acute attack
    4. Cholelithiasis with porcelline gall bladder – it’s a premalignant condition
  2. Acalculous Cholecystitis
  3. Gall Bladder Dyskinesia
  4. Gall Bladder Polyp – 10mm in diameter
  1. Symptoms

Biliary colic is typically a severe and episodic right upper abdomen or epigastric pain that can radiate to the back.

Attacks frequently occur post prandially or awakens patients from sleep. Post prandial pain is associated with high fat diet.

Once Patients has these symptoms, there are 80%  chance that they may have complications. Complication may result from obstruction of gall bladder outlet causing acute cholecystitis or migration of stone into CBD.

  1. Signs
  1. Tenderness in epigastrium and right hypochondrium.
  2. Icterus in care of obstructive jaundice.
  3. Fever
  1. Investigations
  1. Laboratory test of patient with biliary disease includes Total Bilirubin, Alkaline Phosphatase, Transaminase, Amylase, Lipase .
  2. Elevated liver function may suggest biliary obstruction.
  3. Elevated Amylase & Lipase suggest pancreatitis.
  4. The only diagnostic imaging study necessary prior to Laparoscopic Cholecystectomy is ultrasound of abdomen, which demonstrates size, number of stones, thickness of gall bladder, diameter CBD.
  5. When Ultrasound is negative despite typical biliary symptoms. CCK- stimulated HIDA scan demonstrating a low gall bladder ejection fraction with or without pain reproduction suggest of gall bladder dyskinesia.
  1. Contraindication of Laparoscopic Cholecystectomy
  1. Absolute

Patient not fit for anaesthesia

Refractory Coagulopathy

Diagnosed of gall bladder ca.

  1. Relative
  1. Previous upper abdomen surgery
  2. Cholangitis
  3. Diffuse peritonitis with hemadynamic compromise – This represents a surgical emergency in which attempting Laparoscopic Cholecystectomy is not prudent, because etiology in not clear or sure &  pheumoperitoneum may lead to vascular collapse.
  4. Cirrhosis / Portal Hypertension
  5. Chronic Obstructive Pulmonary Disease
  6. Cholecystrenteric Fistula
  7. Morbid Obesity
  8. Pregnancy
  1. Advantages & Disadvantages of Laparoscopic Cholecystectomy compared to Open Cholecystectomy

‚ÄčAdvantages

Limitations

  1. Less pain
  2. Smaller incision
  3. Better cosmesis
  4. Shorter hospitalization
  5. Earlier return to full activity
  6. Decreased costs
  1. Lack of depth perception
  2. Adhesion / Inflommation limit use
  3. More difficult to control haemorrhage
  4. Decreased tactile discrimination
  5. Potential co2 insufflation complications
  1. Complications
  • Bile duct injury
  • Bile leak
  • Retained stones
  • Wound infection
  • Incisional hernia
  • Preumoperitonium related

     I.   New Techniques to Perform Cholecystectomy

  1. Single Port Laparoscopic Surgery – All operative instruments & devices through a single skin incision, usually at the umbilicus
  2. Notes [Natural Orifice Translumenal Endoscopic Surgery] 
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