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Laparoscopic Cholecystectomy

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30/04/2006

Laparoscopic Gallbladder Surgery is one of the few laparoscopic operations to have caught on in the UK. Most patients go home the next day and resume full activity within weeks. Three or four tiny nicks (see below) replace a traditional scar (seen on the left) one through the tummy button, two under the ribs and one at the breastbone.

Certain conditions make surgery more difficult; obesity, previous surgery, recent acute infection and stones in the bile duct. It is necessary to convert to an open operation in about 0.5% of cases.

For patients operated on in the afternoon, we advise a light breakfast at 8am then water, black tea or coffee up until 1200. Under a general anaesthetic the laparoscope is inserted through the umbilicus. The gallbladder is mobilised with its connecting tubes to the bile duct and hepatic artery displayed.  In many cases we only use 3 puncture wounds (as shown). 

If the patient has elevated liver function tests, has been jaundiced or the bile duct looks dilated on ultrasound, an x-ray/ultrasound is performed to check for stones in the bile duct.

Any stones can usually be removed laparoscopicaly. However, it is sometimes not possible and the patient needs an ERCP in which a small cut is made at the bottom of the bile duct using an endoscope and the stones retrieved.

Once this x-ray/ultrasound has been done and the artery and cystic duct clipped/divided, the gallbladder is removed from the liver using diathermy and retrieved through the umbilical incision. The abdomen is washed with saline and a check made to exclude bleeding or leakage of bile. If the procedure was difficult or the gallbladder acutely inflamed or the bile duct explored, a small drain will be brought out through one of the holes (removed the next day). The wounds are infiltrated with local anaesthetic. Additional pain relief and anti nausea medication is provided as necessary. 9 out of 10 patients go home the following day, having had breakfast. 10% have problems with nausea. Most patients resume normal activities within two weeks.

Complications can and do occur. The most common is bleeding. Occasionally there can be delayed bleeding from the gallbladder bed. The patient feels faint, nauseated and the blood pressure falls. It usually occurs during the first night. It may be necessary to return to theatre, re-insert the laparoscope, wash-out the blood and then find/stop the bleeding. The second is leakage of bile from an accessory duct in the gallbladder bed of the liver. This does not usually require a repeat operation. If it becomes a problem, x-rays are taken to assess the volume and if necessary a small tube may be inserted under ultrasound control for drainage. Sometimes it is necessary to perform an ERCP and inset a small tube to relieve the pressure in the bile duct and allow the drainage to stop. Very rarely the common bile duct itself can be injured. If this happens it requires corrective surgery through an open operation. It is also possible to damage bowel/blood vessels. The above complications although potentially serious are uncommon occurring in approximately 4 per 5,000operations.

The most common symptom is nausea and shoulder pain. The latter is due to a combination of the gas used to distend the abdomen and the diathermy to the gallbladder bed. This can take up to a week to resolve.


Single port Cholecystectomy (SPA, SILS, LESS, ENOTES)


The technique of single port access (SPA) is as a recent development resulting from the search for innovative approaches in laparoscopic surgery. Through the use of a single incision, there is significantly less tissue trauma, pain and access-related complications, as well a better cosmetic result. 

BLA have treated 8 patients by single port laparoscopic cholecystectomy. We have used either the ASC TriPort system (from Advanced Surgical Concepts, Dublin, Ireland) or SILS (Covidien Healthcare) which are multichannel pathways allowing two instruments and one video laparoscope to enter simultaneously through only one incision.

Using the introducer, the inner ring of the TriPort is inserted through a transumbilical 2 cm long incision into the abdominal cavity. The inner ring is connected to two outer rings via a doubled over cylindrical plastic sleeve. The sleeve is then pulled outwards and put under tension by drawing the inner and the outer ring as close as possible together. This tension creates a pathway for the laparoscopic instruments through retracting of the incision. One 12mm and two 5 mm gateways consisting of a thermoplastic elastomer maintain the pneumoperitoneum during the surgical procedure.

We have tended to use a 5-mm rigid 30° video-laparoscope (EndoEye, Olympus Medical), so we could also use 10mm laparoscopic instruments such as clips.  In no cases were any additional incisions needed.

Results

All procedures were completed successfully without any perioperative complications, with all patients being very satisfied with the cosmetic result of a "perfect" scar within the umbilicus.  At 35 minutes, the time taken to carry out the operation is longer than that required for standard laparoscopic cholecystectomy.

The longer operative time is due to the limited space, itself the result of using only one access. point This means that the instruments, the telescope and the hands of both the surgeon and assistant can easily collide.

Given our positive experience with the system so far we are now using a transumbilical placed trocar at the start of every laparoscopic cholecystectomy.

Further Reading

Langwieler TE et al. Single-port access in laparoscopic cholecystectomy. Surg Endosc 2009; 23(5): 1138-41

Romanelli JR et al. Single Port Laparoscopic Cholecystectomy with the TriPort System: A Case Report. Surg Innov 2008; 15(3): 223-28

Gumbs AA et al. Totally Transumbilical Laparoscopic Cholecystectomy. J Gastrointest Surg 2008 Aug 16; [Epub ahead of print]

Rao PP et al. The feasibility of single port laparoscopic cholecystectomy: a pilot study of 20 cases. HPB (Oxford) 2008; 10(5):336-40


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SPIRE Hospital, Bristol. 
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Contact: Claire Trenberth - 0117 9804051
claire.TRENBERTH@spirehealthcare.com
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