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Laparoscopic Cholecystectomy

AG Nande
 
Gall stones are the commonest digestive disease encountered by the General surgeon and thousands of patients undergo surgery for gall stones all over the world.
 
Historical Background

In 1882 Langenbuch performed the first cholecystectomy. He said that “the gall bladder should be removed not because it contains stones, but because it forms stones.”

Surgical removal of gall bladder thus became the gold standard for management of gall stones disease. Although open cholecystectomy had been performed with minimal mortality and morbidity, physicians continued to search for alternatives to what became known as success but often very painful means of treating gall bladder disease.

With the introduction of laparoscopic cholecystectomy, patients were given the option of a treatment that managed the disease definitively without the morbidity of surgical incision. The technique was accepted with such speed and energy that many have referred to it as a revolution. This revolution has stimulated a growth in new technologies that has been unprecedented in surgical history.

Dr. Erich Muhe of Germany is credited for performing the first procedure in September 1985. Phillipe Mouret and Francois DuBois performed their first procedure in 1987-88 in France. At approximately the same time Drs. Mckernan and Saye and Drs. Olsen and Reddick performed their first procedure in June and August 1988 respectively in the USA.

Indications

The indications for laparoscopic cholecystectomy are the same as for open cholecystectomy. They are:

Cholelithiasis and biliary colic or cholecystitis
Symptomatic gallbladder polyps
Gallstone pancreatitis
Symptomatic biliary dyskinesis
Calcified gallbladder wall
Large gallstones (> 2 cm)
Nonfunctioning gallbladder
Chronic typhoid carrier

Contraindications
Patients who are usually not the candidates for laparoscopic cholecystectomy includes those with generalized peritonitis, septic shock from cholangitis, severe acute pancreatitis, end stage cirrhosis of liver, gall bladder cancer, recent myocardial infarction coagulation disorders, inability to tolerate general anaesthesia and pregnant women in third trimester as there is a risk of injury to the uterus during operation.

Technique
General principles of laparoscopic cholecystectomy are not different than those established and followed for open operation.

1) Gaining safe access to abdominal cavity.
2) Ensuring adequate exposure before proceeding for operation.
3) Careful and meticulous dissection with proper haemostasis.
4) Positive identification of anatomy before any structure is ligated or divided.

Safe access
Two techniques are generally used for accessing the abdominal cavity. The first relies on the blind insertion of either a Veress needle or a trocar and the second relies on direct cut down under visual control. The open technique is generally safer of two procedures.


Adequate exposure
The exposure is facilitated to a great extent by the inherent 10x – 16x magnification of the laparoscope, the liberal use of angled scopes, appropriate positioning and familiarity of relevant anatomy.

Dissection and maintenance of haemostasis
Vigorous attention to haemostasis is paramount to good exposure because relatively small amount of bleeding can obscure the laparoscopic view. Electro-cautery, argon beam coagulation, bipolar coagulation and ultrasound (harmonic) scalpel are all forms of coagulation energy which have been used successfully during the procedure. The type of energy utilized by the surgeon is a personal choice and is determined by availability of technology.

Identification of anatomy
Variations of biliary anatomy are extremely common. Absolute identification of anatomy at porta hepatis and triangle of Calot before ligation of any structure is the only safe way to reduce the risk of injury to CBD.
With few exceptions most cases of symptomatic gall stones can be treated laparoscopically. Approximately 80% of cholecystectomies are performed in this manner all over the world. In the hands of experienced surgeon the conversion rate to open operation is between 2-5%.

Complications
The most feared complication of laparoscopic cholecystectomy is a bile duct injury. Before the laparoscopic era, cholecystectomy was associated with low rate of bile duct injury (0.1 – 0.2%). Laparoscopic cholecystectomy in contrast is associated with bile duct injury rate in the range of 0.2 to 2%. A ‘learning curve’ phenomenon is described with significant proportion of injuries occurring before a given surgeon’s 30th or even 100th case. The rate of bile duct injury has now come down drastically over a period of last 10 years and it appears that the peak incidents of bile duct injuries has come and gone.

Conclusion
Laparoscopic chlecystectomy incurs the same risk as conventional cholecystectomy in addition to risk associated with laparoscopy. It must be accepted that its complications have been highly scrutinized. Some patients undoubtedly suffered as technology advances to help the masses. For indivisual surgeon however the learning curve should have nothing to do with safety and soundness of procedure, for these are absolute and never to be compromised. There are some areas in which there is some potential for further improvement. Gasless laparoscopic surgery using mechanical abdominal wall retractors to reduce or to minimize the ill effects of CO2 pneumoperitoneum, development of three dimensional optics, narrower ports and instruments, and multi-jointed instruments have been introduced. The use of robotic surgery to minimize human tremors and to facilitate long distance surgery is also some of the exciting new developments in this field.

References

  1. Downs SH et al. Systematic review of the effectiveness and safety of laparoscopic cholecystectomy. Ann R Coll Surg 1996; 78 : 241-324.
  2. Darzi A, Gould S. Minimally invasive surgery. In: Johnson CD, Taylor I (eds) Recent advances in Surgery 22. Churchill Livingston 1999; 63-72.
  3. Chitre VV, Studley JGN. Audit of methods of laparoscopic cholecystectomy. Br J Surg 1999; 86 : 185-8.
  4. Cuschieri A. How I do it: Laparoscopic cholecystectomy. J R Coll Surg Ed 1999; 44 : 187-92.
  5. Geoghegan JG, Keane FB. Laparoscopic management of complicated gallstone disease. Br J Surg 1999; 86 : 145-6.
  6. Indar AA, Beckingham IJ. Acute cholecystitis. Br Med J 2002; 325 : 639-43.
  7. Kiviluoto T, Siren J, Luukkonen, Kivilaakso E. Randomized trial of laparoscopic versus open cholecystectomy for acute and gangrenous cholecystitis. Lancet 1998; 351: 321-5.
  8. Lomas DJ, Gimson A. Magnetic resonance cholangiopancreatography. Hosp Med 2000; 61 : 395-9.
  9. Parks RW. Biliary tract emergencies. Hosp Med 2002; 63 : 226-9.
  10. Perrisat J. Management of bile duct stones in the era of laparoscopic cholecystectomy. Br J Surg 1994; 81 : 799-810.
  11. Paterson-Brown S. Emergency laparoscopic surgery. Br J Surg 1993; 80 : 279-81.
  12. Svanvik J. Laparoscopic cholecystectomy for acute cholecystitis. Eur J Surg 2000; 166 (Suppl 585) : 16-7.
  13. Tait N, Little JM. The treatment of gall stones. Br Med J 1995; 311 : 99-105.

 

DOCTORS TO CONSIDER SCRUBS TO REDUCE INFECTION

Doctors’ representatives have criticised the government for failing to act sufficiently swiftly to control the rise of hospital acquired infections in the United Kingdom. They called for new resources to tackle factors that they saw as contributing to the problem - in particular, high bed occupancy and the contracting-out of hospital cleaning services.

Representatives at the annual meeting of the BMA in Manchester this week also called for controls to be set for visitors to hospitals to help stem the spread of infections. They also agreed to consider the introduction of scrubs for all healthcare professionals and students working in hospitals.
Geoffrey Lewis, a member of BMA Council who proposed the motion on cleanliness in hospitals, told the conference that despite the government’s pledge to halve the number of cases methicillin resistant Staphylococcus aureus (MRSA) in the next three years, the problem of hospital acquired infections was getting worse.

The incidence of MRSA in England and Wales has risen by 600% in the past 10 years, he told representatives. In 2003, there were 7647 cases of MRSA in England and Wales, a rise of 4% on the previous year, and 955 deaths. This compared with 481 deaths in 1999. Dr Lewis added that the UK had two of the most virulent strains of MRSA in existence.

He said that a second year medical student in the Midlands had recently reported that patients in the area were scared to go to hospital because they were concerned of what they could catch there.

BMJ, 2005; 331 : 9.

Sander V Van Zanten, Lancet, 2005; 365 : 2163-4.


QUETIAPINE AND RIVASTIGMINE MAY NOT WORK FOR DEMENTIA

An atypical antipsychotic, quetiapine, and a central cholinesterase inhibitor, rivastigmine, may not be effective for treating agitation in people with dementia in institutional care. In a randomised double blind placebo controlled trial including 93 patients with Alzheimer’s disease, Ballard and colleagues found that both of these drugs failed to reduce agitation or ameliorate the decline of cognition after six weeks and after 26 weeks of folllow-up. In these patients, quetiapine was associated with accelerated cognitive decline.

BMJ, 2005; 330 : 874.

Honorary Consultant Surgeon, Bombay Hospital, Mumbai.
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