The Baltimore experience with laparoscopic management of acute cholecystitis

Article Abstract:

The most effective treatment for gallbladder disease is cholecystectomy (removal of the gallbladder); 500,000 such operations are performed annually. Traditional open cholecystectomy is performed through a large abdominal incision, is associated with significant pain and discomfort after surgery, and requires three to seven days in the hospital and three to six weeks convalescence. Laparoscopic cholecystectomy is a recently developed, minimally invasive procedure that eliminates many of the disadvantages of open cholecystectomy. It is carried out through several small (1/2 inch or smaller) abdominal incisions. Under laparoscopic visualization (images from the illuminated optic instrument are displayed on a video monitor), the gallbladder is manipulated and removed. This laparoscopic procedure has generally been limited to elective surgery; acute cholecystitis (inflammation of the gallbladder) was considered a contraindication. A report is presented of 15 patients with the preoperative diagnosis of acute cholecystitis on whom emergency laparoscopic cholecystectomy was attempted. In each case, the procedure was performed within 72 hours of admission. Five patients required conversion of the laparoscopic procedure to open abdominal surgery, the traditional technique for cholecystectomy. One of these five patients had an abscess, and the other four had extensive edema (fluid retention) and inflammation that complicated safe removal of abdominal structures. Cholangiography (X-ray examination of the bile ducts), performed in 14 patients, was found to be helpful. Patients remained in the hospital an average of 2.7 days after the procedure. It is concluded that laparoscopic cholecystectomy may be performed safely on patients with acute cholecystitis. The procedure should be performed by surgeons experienced in the technique, and it should be converted to open abdominal surgery if the anatomy of the ducts and blood vessels cannot be clearly identified through the laparoscope. (Consumer Summary produced by Reliance Medical Information, Inc.)

Abdomen, Laparotomy, Cholecystitis, Surgical technology, Bile ducts

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Traditional versus laparoscopic cholecystectomy

Article Abstract:

Laparoscopic cholecystectomy is a minimally-invasive method of removing the gallbladder. It is performed through four small incisions made into the abdomen; a laparoscope and trocars (sharply pointed instruments), which are fitted with surgical instruments, are inserted. The abdomen is viewed through the laparoscope, and the instruments manipulate and finally remove the gallbladder. This procedure differs in many ways from the traditional cholecystectomy which uses a major abdominal incision providing direct view of the gallbladder, and is performed with hand-held instruments and direct touch. Patient selection for the laparoscopic procedure is especially important. Acute cholecystitis (gallbladder inflammation) is not generally considered an indication for the laparoscopic procedure. If complications of cholecystitis and advanced disease are present, the traditional cholecystectomy is the preferred method. Some conditions for which the laparoscopic technique is not recommended include sepsis (body-wide infection), peritonitis (inflammation of the peritoneal lining of the abdomen), bowel distention, and pregnancy. Laparoscopic cholecystectomy takes longer to perform than the traditional procedure, but the operating time decreases as the surgeon's experience increases. Morbidity with laparoscopic technique is low, but there is concern of possible injury to the bile ducts. Mortality is low and comparable to the traditional procedure. Laparoscopic cholecystectomy requires a short (two day) hospital stay; the patient is able to return to normal activities within seven days. Another advantage is a significant reduction in hospital costs compared with the traditional procedure. (Consumer Summary produced by Reliance Medical Information, Inc.)

Equipment and supplies

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Laparoscopic guided cholecystectomy

Article Abstract:

The most effective treatment for cholelithiasis (gallstones) is cholecystectomy (complete removal of the gallbladder). The usual surgical approach includes an incision in the upper right abdomen. An alternative technique is to remove the gallbladder using laparoscopic guidance. Laparoscopic cholecystectomy is performed by making three or four small incisions in the abdomen. Trochars, fitted with forceps and other instruments, are inserted into the abdomen under video control using a laparoscope inserted into the abdominal cavity. Trochars are used to manipulate and to finally remove the gallbladder. Results are reported of 100 patients with cholelithiasis who underwent laparoscopic cholecystectomy. Five patients needed to have the procedure extended to an open laparotomy (open abdominal surgery). Two of these five complications were due to injury to the ductal system, which occurred early in the study. Of the 95 patients who had successful laparoscopic cholecystectomy, 93 left the hospital within 24 hours of surgery, and 94 returned to normal activities within a week of surgery. The few contraindications to laparoscopic cholecystectomy include acute cholangitis, abdominal infection, major bleeding disorders, and pregnancy. Stones located in the common bile duct cannot be extracted laparoscopically, and when possible this condition should be determined before surgery. The results of this study indicate that laparoscopic guided cholecystectomy has many advantages to the patient and also reduces the costs of treating cholelithiasis. To avoid complications, adequate training in the technique is essential. (Consumer Summary produced by Reliance Medical Information, Inc.)

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