Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy was first performed in France in 1987, and was rapidly adopted by patients and physicians. The procedure is now the standard of care for the treatment of symptomatic cholelithiasis and its complications. There have been few randomized, controlled trials comparing laparoscopic with open cholecystectomy, but prospective case series examining results in several thousand patients have shown that laparoscopic cholecys-tectomy is safe and effective. Compared with open chole-cystectomy, the laparoscopic approach produces shorter hospital stays with more rapid return to normal activities and fewer complications. Overall mortality appears to be similar to or even less than with open cholecystectomy.

Cholecystectomy can be performed laparoscopically in most patients. The only absolute contraindications to a laparoscopic approach are an inability to tolerate general anesthesia and uncontrollable coagulopathy. Even in patients with prior abdominal surgery or peritonitis, the laparoscopic approach can still be attempted, although conversion to an open procedure may be required. Experienced surgeons can often perform the procedure in obese or anticoagulated patients, those with recent cholecystitis, or pregnant women.

The mortality rate with laparoscopic cholecystectomy is low and is < 0.5%, with morbidity rates around 5% in most series (MacFayden et al, 1998). This is comparable to the mortality and morbidity rates seen with open cholecystectomy. Most complications are relatively minor, such as urinary retention or infections, wound infections or seromas. Complications related directly to cholecystectomy include bile duct injury, bile leak, and acute pancreatitis. Of these, bile duct injury is the most serious, but relatively uncommon (< 1% of cases). Nevertheless, bile duct injuries can be difficult to repair and lead to biliary strictures. Bile duct injuries are commonly the result of unrecognized variations in bile duct anatomy or problems in identifying normal anatomy. Other factors influencing the risk of bile duct injury include use of intraoperative cholangiogram and surgeon experience. The risk of common bile duct injury may be decreased by the use of intraoperative cholangiography, both with laparoscopic and open procedures. However, routine use of cholangiogram remains controversial. In laparo-scopic procedures, the risk of common bile duct injury is highest in a surgeon's initial experience. The risk of bile duct injury eventually plateaus as surgeons gain experience, and becomes similar to that with open cholecystectomy. Bile leaks can be recognized using ultrasonography and hepa-tobiliary scintigraphy, and are usually managed with endo-scopic retrograde cholangiography and stent placement.

Conversion to open cholecystectomy is required in 2 to 8% of procedures. It is more commonly required if there is difficulty in identifying the anatomy of the porta hepatis or with underlying inflammation, such as in patients with acute cholecystitis. Conversion should not be considered as a complication of a procedure, but rather as a necessary alternative in some patients.

Intraoperative cholangiogram is not standardized, and is often not performed in community practice. Use of intraoperative cholangiogram is often advocated to decrease the risk of common bile duct injuries (Flum et al, 2003). It is also useful to identify patients with unsuspected common bile duct stones, in whom further intervention may be necessary. Further options for extraction of discovered common bile duct stones include conversion to an open procedure with stone extraction, laparo-scopic common bile duct exploration, or endoscopic retrograde cholangiography. Expertise with laparoscopic stone extraction is relatively uncommon in general practice. Techniques for laparoscopic stone removal include flushing of the duct (for small stones), retrograde balloon or basket extraction through the cystic duct, or extraction under direct visualization with a choledochoscope. In experienced hands, stones can be successfully extracted in over 90% of patients, with overall operative morbidity rates of less than 10%.

In patients with acute cholecystitis, the timing of surgery has been controversial. Although laparoscopic cholecystec-tomy can be performed successfully in these patients, there may be a higher incidence of common bile duct stones. Because of the local inflammation the procedure is often technically more difficult. In this setting, intraoperative cholangiograms may be more difficult to obtain and bile duct injuries more common. Randomized trials comparing early (< 3 days) versus delayed (4 to 6 weeks) surgery for acute cholecystitis have showed no benefit to delaying surgery. Although patients in the early surgery group have longer operating times, they had similar rates of conversion to open cholecystectomy and shorter hospital stays. Thus, early operation for acute cholecystitis can be beneficial.

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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