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.
The indications for laparoscopic cholecystectomy are the same as for open cholecystectomy. They are:
Cholelithiasis and biliary colic or cholecystitis
Symptomatic gallbladder polyps
Symptomatic biliary dyskinesis
Calcified gallbladder wall
Large gallstones (> 2 cm)
Chronic typhoid carrier
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.
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.
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.
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%.
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.
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.
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