Laparoscopic Cholecystectomy

Contraindications
   * High risk for general anesthesia
   * Morbid obesity
   * Signs of gallbladder perforation, such as abscess, peritonitis, or fistula
   * Previous abdominal surgery
   * Giant gallstones or suspected malignancy
   * End-stage liver disease with portal hypertension and severe coagulopathy



Consent
Eg: You don't really need a GB. Digestion can still function. In OT, you will be given GA and undergo keyhole surgery that may leave you 4 little scars, Tummy filled with CO2 to avoid injury. And your GB is taken out in little bag.
There are small risk of complication: refer below:
Inpatient stay for 2-3 days.

Procedures

1. The patient is anesthetized in supine position.
2. A scalpel is used to make a small incision at the umbilicus.
3. The abdominal cavity is entered by using a Veress needle or Hasson technique
4. The abdominal cavity is inflated with CO2 to create working space.
5. The camera is placed through the umbilical port.
6. Additional ports are placed inferior to the ribs at the epigastric, midclavicular and anterior axillary positions.
7. The gallbladder fundus is identified, grasped, and retracted superiorly.
8. The gallbladder infundibulum is retracted laterally to expose and open Calot's triangle (the area bound by the, cystic artery, cystic duct, common hepatic duct.)
9  The triangle is dissected to clear the peritoneal covering and obtain a view of the underlying structures.
10. The cystic duct and the cystic artery are identified clipped with tiny titanium clips and cut.
11. The gall bladder is dissected away from the liver bed and removed from one of the ports
12. The gall bladder is sent for biopsy to confirm the diagnosis and look for cancer. If present, a reoperation to remove part of liver and lymph nodes will be required in most cases



Risk and Complication
GA complication : 1/30 000

1. Common bile duct injury(0.25%) --> bile leak (biloma)
2. conversion to open surgery: 5%
3. Abdominal peritoneal adhesions --> switch to open cholecystectomy
4. Injury to Ducts of Luschka (33% of population) --> biliary leak (bile peritonitis) --> require a temporary bile stent, confirm via HIDA scan. Manage pain and Antibiotic ASAP.
5. retained stone -causes jaundice- need ERCP or if a T-tube is in place by extraction with Doemia basket down the T-tube track (Burhenne manouvre), flushing or dissolution.
6. Fat digestion affected, no gall bladder to store and release high quantity.
7. Chronic diarrhoea.
8. Postcholecystectomy syndrome (eg. sphincter of oddi dysfunction-SOD), PCS (gastrointestinal distress and persistent RUQ pain)
9. Abscess, wound infection, hernia