Laparoscopic Cholecystectomy- Minimally Invasive Gallbladder Surgery

The surgical removal of the gallbladder is called cholecystectomy. Gallbladder problems are usually caused by the presence of gall stones, which are small hard masses consisting of cholesterol or bile salts that form in the gallbladder or in the bile duct.  A problem may arise when one or more gallstones block the flow of bile out of the gallbladder.  This may cause swelling, abdominal pain, vomiting, indigestion, and fever.  If a gallstone blocks the common bile duct (the larger bile duct which drains into the small intestine), jaundice may occur.  Removal of the gallbladder is one of the most commonly performed surgical procedures in the United States.  For the past twenty years, gallbladder surgery has been performed laparoscopically.  The medical name for this procedure is laparoscopic cholecystectomy.

Laparoscopic surgery is performed with the assistance of a video camera encased by a long thin tube. During a laparoscopic procedure, small incisions are made and plastic tubes called ports are placed through these incisions. The video camera and small thin instruments are then introduced through the ports, which allow access to the inside of the patient. The camera transmits an image of the organs inside the abdomen onto a television screen, which allows the surgeon to see into the patient’s body and perform the surgery.

Because laparoscopic cholecystectomy does not require the abdominal muscles to be cut, there is less pain, quicker healing, improved cosmetic results, and fewer complications such as infection and adhesions.  Most patients can be discharged on the same or following day, and can return to work in about a week.  With over twenty years of experience, laparoscopic cholecystectomy should be and is a very safe operation.  The overall complication rate is less than 2% when performed by a properly trained surgeon.  

Complications of laparoscopic cholecystectomy are rare, and can include bleeding, infection, pneumonia, blood clots, or heart problems.  Unintended surgical injury to adjacent structures such as the common bile duct, the first part of the small intestine called the duodenum, or other parts of the small bowel may occur and may require another surgical procedure to repair them.  Bile leakage into the abdomen from damaged bile ducts can cause a painful and potentially dangerous infection. Many cases of minor injury to the common bile duct can be managed non-surgically.  Major injury to the bile duct, however, is a very serious problem and may require corrective surgery. This surgery should be performed by an experienced biliary surgeon 

Because laparoscopic cholecystectomy was considered a new procedure in the late 1980s and 90s, what was called a “learning curve” was created to explain complications that did occur.  By observing the learning curve for laparoscopic skills during those early procedures, and applying what was learned to the training of future surgeons during their residency programs, it was believed future injuries could be avoided. Numerous studies concluded that surgeons truly dedicated and interested in learning new laparoscopic procedures needed to set aside a substantial amount of time to acquire the skills needed. Practice in animate and inanimate models, repeated observation with the opportunity to ask questions and the presence of an instructor during the first ten cases were essential

A 2005 article in the journal Surgical Endoscopy entitled “Laparoscopic cholecystectomy after the learning curve: what should we expect?” addressed the issue of the increasing common bile duct (CBD) injuries, which started in the late 1980s.   They did a retrospective analysis of laparoscopic cholecystectomies performed at a single institution from that time to the present, and found that eventually they had decreased the complication rate to zero CBD injuries in 1,674 consecutive procedures.  They concluded that injuries of the CBD can be avoided by performing an extensive dissection and by developing a critical view of the operative field to ensure the patient's safety.   It appears that unlike the late 1980s and 90s, the 21st century finds laparoscopic cholecystectomy to be a mature and safe surgical procedure.  

Though there are certain acceptable risks associated with any kind of operation, the vast majority of laparoscopic gallbladder patients experience extremely few or no complications and quickly return to normal activities.  It is important to remember that before undergoing any type of surgery, whether laparoscopic or open, one must ask his or her surgeon about his or her training and experience in performing laparoscopic cholecystectomy.  Absent unusual circumstances, life altering complications are no longer acceptable in today’s modern practice of laparoscopic cholecystectomy.