Cholecystectomy is a surgical removal of the gallbladder. Cholecystectomy is a common treatment of gallstones symptoms and other gall bladder conditions. In 2011, cholecystectomy was the 8th most common operating room procedure performed in hospitals in the United States. Cholecystectomy can be done by laparoscopy, using a video camera, or through open surgical techniques.
Surgery is usually successful in relieving symptoms, but up to 10% of people may continue to experience similar symptoms after cholecystectomy, a condition called postcholecystectomy syndrome. Complications of cholecystectomy include bile duct injury, wound infection, hemorrhage, retained gallstones, abscess formation and stenosis (narrowing) of the bile ducts.
Video Cholecystectomy
Medical use
Pain and complications caused by gallstones are the most common reasons for removal of gallbladder. Gallbladder can also be removed to treat tardive bile or gallbladder cancer.
Gallstones are very common but 50-80% of people with gallstones are asymptomatic and need no surgery; their stones are noticed by chance on a stomach imaging test (such as ultrasound or CT) done for some other reason. Of the more than 20 million people in the US with gallstones, only about 30% will eventually require cholecystectomy to relieve symptoms (pain) or treat complications.
biliary colic
Biliary colic, or pain caused by gallstones, occurs when gallstones block bile ducts that drain the gallbladder temporarily. Usually, the pain from the biliary colic is felt in the upper right part of the abdomen, moderate to severe, and disappears by itself after several hours when the stone is released. Biliary colic usually occurs after meals when the gallbladder contracts to push the bile out into the gastrointestinal tract. After the first biliary colic attack, more than 90% of people will experience repeated attacks within the next 10 years. Repeated biliary colic attacks are the most common reason for removing the gallbladder, and cause about 300,000 cholecystectomies in the US each year.
Acute cholecystitis
Cholecystitis, or gall bladder inflammation caused by impaired normal bile flow, is another reason for cholecystectomy. This is the most common gallbladder complication; 90-95% acute cholecystitis is caused by gallstones that inhibit gallbladder drainage. If the blockage is incomplete and the stone passes quickly, the person experiences biliary colic. If the gallbladder is completely blocked and remains so for a long time, the person develops acute cholecystitis.
Pain in cholecystitis is similar to biliary colic, but lasts more than 6 hours and coincides with signs of infection such as fever, chills, or an increase in the number of white blood cells. People with cholecystitis will also usually have positive Murphy marks on physical examination - meaning that when a doctor asks the patient to take a deep breath and then push down on the upper right side of their abdomen, the patient stops breathing them out because of the pain from pressure on the inflamed gallbladder.
5-10% acute cholecystitis occurs in people without gallstones, and for this reason it is called acalculous cholecystitis. It usually develops in people who have abnormal bile drainage from serious illness, such as people with multi-organ failure, serious trauma, recent major surgery, or after long stay in the intensive care unit.
People with recurrent episodes of acute cholecystitis may develop chronic cholecystitis from changes in the normal anatomy of the gallbladder. This can also be an indication for cholecystectomy if the person experiences persistent pain.
Cholangitis and gallstone pancreatitis
Cholangitis and gallstone pancreatitis are less common and more serious complications of gallstone disease. Both can occur if the gallstones leave the gallbladder, pass through the cystic tract, and get trapped in the bile ducts. The common bile ducts dry the liver and pancreas, and the blockage there can cause inflammation and infection of the pancreas and bile system. Although cholecystectomy is not usually an immediate treatment option for either of these conditions, it is often advisable to prevent recurrent episodes of addition by stuck gallstones.
Gallbladder cancer
Gallbladder cancer (also called gallbladder carcinoma) is a rare indication for cholecystectomy. In cases where cancer is suspected, an open technique for cholecystectomy is usually performed.
Maps Cholecystectomy
Contraindications
There is no specific contraindication to cholecystectomy, and is generally regarded as a low-risk surgery.
However, anyone who can not tolerate surgery under general anesthesia should not undergo cholecystectomy. People can be divided into high and low risk groups using tools such as ASA physical status classification system. In this system, people who are category ASA III, IV, and V are considered at high risk for cholecystectomy. Usually this includes very elderly people and people with joint illness, such as end-stage liver disease with portal hypertension and whose blood does not freeze properly. Alternatives to the operation are briefly mentioned below.
Risks and complications
All operations carry the risk of serious complications including damage to nearby structures, bleeding, infection, or even death. The mortality rate of surgery in cholecystectomy is about 0.1% in people under the age of 50 and about 0.5% in people over age 50. The greatest risk of death comes from joint illness such as heart or lung disease.
Biliary Injuries
Serious cholecystectomy complications are biliary injury, or damage to the bile ducts. Laparoscopic cholecystectomy has a higher risk of bile duct injury than the open approach, with bile duct injury occurring in 0.3% to 0.5% of laparoscopic cases and 0.1% to 0.2% of open cases. In laparoscopic cholecystectomy, approximately 25-30% of biliary injuries are identified during surgery; the rest becomes clear in the early postoperative period.
Damage to the bile ducts is very serious because it causes a bile leak to the stomach. Signs and symptoms of bile leak include abdominal pain, tenderness, fever and signs of sepsis a few days after surgery, or through laboratory studies as a total increase of bilirubin and alkaline phosphatase. The complications of a bile leak can follow a person for years and can cause death. Bile leak should always be considered in any patients who do not recover as suspected after cholecystectomy. Most bile injuries require repair by surgeons with specialized training in biliary reconstruction. If the biliary injury is treated and corrected properly, over 90% of patients can have a long-term successful recovery.
Other complications
A review of security data for decades about laparoscopic cholecystectomy found the following most common complications:
The same study found the prevalence of intestinal injury, sepsis, pancreatitis, and deep vein thrombosis/pulmonary embolism to about 0.15% each.
Leakage from cystic duct stumps is a more common complication with laparoscopic approach than open approach but is still rare, occurring in less than 1% of procedures; it is treated by drainage followed by the insertion of bile duct stents.
Convert to open cholecystectomy
Experts agree that many biliary injuries in laparoscopic cases are caused by the difficulty of seeing and identifying anatomy clearly. If surgeons have problems identifying anatomical structures, they may need to convert from laparoscopy to open cholecystectomy.
Procedures
Pre-operational preparation
Before surgery, a complete blood count and liver function tests are usually obtained. Prophylactic therapy is given to prevent deep vein thrombosis. The use of prophylactic antibiotics remains controversial; However, doses may be given prior to surgery to prevent infection in certain high-risk people. Gas can be removed from the stomach by OG or NG tubes. Foley catheter can be used to empty the patient's bladder.
Laparoscopic cholecystectomy
Laparoscopic cholecystectomy uses some (usually 4) small incisions in the abdomen to allow the insertion of an operating port, a small cylindrical tube of about 5 to 10 mm in diameter, in which a surgical instrument is placed into the abdominal cavity. A laparoscope, an instrument with a video camera and a light source at its end, illuminates the abdominal cavity and sends enlarged images from the stomach to the video screen, giving the surgeon a clear view of the organ and tissue. The cystic duct and cystic artery are identified and dissected, then ligated with clips and cut to remove the gallbladder. The gall bladder is then transferred through one of the ports.
In 2008, 90% of cholecystectomy in the United States was done laparoscopically. Laparoscopic surgery is thought to have fewer complications, shorter hospital stays, and faster recovery than open cholecystectomy.
Single incision
Single incisional laparoscopic surgery (SILS) or laparoendoscopic single site surgery (LESS) is a technique in which one incision is made through the navel, not 3-4 four different small incisions used in standard laparoscopy. There appears to be a cosmetic benefit over conventional four-hole cholecystectomy cholecystectomy, and there is no advantage in postoperative pain and hospitalization compared with standard laparoscopic procedures. There is no scientific consensus on the risk of biliary tract injury with SILS compared to traditional laparoscopic cholecystectomy.
Natural transluminal orifice
Natural transluminal endoscopic surgery (NOTE) is an experimental technique in which laparoscopy is inserted through natural holes and internal incisions, rather than skin incisions, for access to the abdominal cavity. It offers the potential to eliminate visible scars. Since 2007, cholecystectomy by NOTE has been performed anecdotally via transgastric and transvaginal routes. In 2009 the risk of gastrointestinal leakage, difficulty visualizing the abdominal cavity and other technical limitations limited the further adoption of NOTE for cholecystectomy.
Open cholecystectomy
In open cholecystectomy, surgical incisions of about 8 to 12 cm are made below the edges of the right rib and the gallbladder is removed through this large opening, usually using an electrocautery. Open cholecystectomy is often done if there is difficulty during laparoscopic cholecysteesis, for example, the patient has an unusual anatomy, the surgeon can not see well enough through the camera, or the patient is found to have cancer. This can also be done if the patient has severe cholecystitis, emphysematous gall bladder, gallbladder fistulisation and gallstone ileus, cholangitis, cirrhosis or portal hypertension, and blood dyscrasias.
Biopsy
After appointment, the gallbladder should be sent for pathological examination to confirm the diagnosis and look for incidental cancer. Incidental cancer of the gallbladder is found in about 1% of cholecystectomy. If cancer is present in the gallbladder, it is usually necessary to operate again to remove parts of the liver and lymph nodes and test for additional cancer.
Post-operative management
After surgery, most patients are hospitalized for routine monitoring. For uncomplicated laparoscopic cholecystectomy, people can be discharged on the day of operation after sufficient pain and nausea control. High-risk patients, those who require emergency surgery, and or those who undergo open cholecystectomy should usually stay in the hospital a few days after surgery.
Long-term prognosis
In 95% of people who underwent cholecystectomy as a treatment for simple biliary colic, removing the gallbladder completely resolved their symptoms.
Up to 10% of people undergoing cholecystectomy develop a condition called postcholecystectomy syndrome. Symptoms are usually similar to the pain and discomfort of biliary colic with persistent pain in the upper right abdomen and usually include indigestion (dyspepsia).
Some people who follow cholecystectomy may experience diarrhea. The cause is unclear, but is thought to be due to disorders in the bile system that accelerate the enterohepatic recycling of bile salts. Ileum terminal, part of the intestine where these salts are usually reabsorbed, become overwhelmed, do not absorb it all, and people develop diarrhea. Most cases recover within weeks or months, although in rare cases, this condition may last for years. Can be controlled with drugs such as cholestyramine.
Considerations
Pregnancy
It is generally safe for pregnant women to undergo laparoscopic cholecystectomy during the trimester of pregnancy. Early elective surgery is recommended for women with symptomatic gallstones to reduce the risk of spontaneous abortion and preterm delivery. Without cholecystectomy, more than half of these women will experience recurrent symptoms during their pregnancy, and nearly one in four will experience complications, such as acute cholecystitis, which require immediate surgery. Acute cholecystitis is the second most common cause of acute abdomen in pregnant women after appendectomy.
Porcelain Bladder
The porcelain gallbladder (PGB), a condition in which the gallbladder wall exhibits calcification on the imaging test, was previously thought to be the reason for gallbladder removal because it was considered that people with this condition had a higher risk of developing gallbladder cancer. However, recent research has shown that there is no strong association between gall bladder cancer and gallbladder porcelain, and that PGB alone is not a strong indication for prophylactic cholecystectomy.
Alternative for operations
There are alternatives to cholecystectomy for people who do not want surgery, or among them the benefits of surgery will outweigh the risks.
Conservative management
Conservative management of biliary colic involves a "watch and wait" approach - treating the symptoms necessary with oral medications. Experts agree that this is the preferred treatment for people with gallstones but no symptoms. Conservative management may also be appropriate for people with mild biliary colic, since colicky pain can be managed with pain medications such as NSAIDS (ex: ketorolac) or opioids.
Conservative management for acute cholecystitis involves treating infections without surgery. Usually only considered in patients at very high risk for surgery or other interventions listed below. It consists of treatment with antibiotics and intravenous fluids.
ERCP
ERCP, short for endoscopic retrograde cholangiopancreatography, is an endoscopic procedure that removes gallstones or prevents clogging by widening parts of the bile ducts where gallstones are often trapped. ERCP is often used to remove stones trapped in the bile ducts in patients with gallbladder pancreatitis or cholangitis. In this procedure, the endoscope, or small, long and thin tube with a camera at the end, is passed through the mouth and down the throat. The doctor takes the camera through the stomach and into the first part of the small intestine to reach the opening of the bile ducts. The doctor may inject a special radiopaque dye through the endoscope into the bile ducts to see stones or other blockages in the x-rays. ERCP does not require general anesthesia and can be performed outside the operating room. While ERCP can be used to remove certain stones that cause blockage to allow drainage, it can not remove all the stones in the gall bladder. Thus, it is not considered a definitive treatment and people with recurrent complications of stones may still require cholecystectomy.
Cholecystostomy
Cholecystostomy is the drainage of the gallbladder through the insertion of a small tube through the abdominal wall. This is usually done using guidance from imaging scans to find the right place to insert the tube. Cholecystostomy may be used for people who need immediate gall bladder but have a high risk of complications from surgery under general anesthesia, such as the elderly and those with existing illnesses. Flowing pus and infected material through the tube reduces inflammation in and around the gallbladder. This could be a life-saving procedure, without requiring people to undergo emergency surgery.
This procedure comes with significant risks and complications - in one retrospective study of patients receiving percutaneous cholecystostomy for acute cholecystitis, 44% developed choledocholithiasis (one or more stones attached to the bile ducts), 27% had tubular dislodgment, and 23% developed postoperative abscess.
For some people, drainage with kolesistostomi is enough and they do not need the gallbladder removed later. For others, percutaneous cholecystostomy allows them to increase sufficiently in the short term so they can undergo surgery at a later time. There is no clear evidence to suggest that surgical removal after cholecystostomy is best for high-risk surgical patients with acute cholecystitis.
Epidemiology
About 600,000 people receive cholecystectomy in the United States each year.
In a study of US hospitals covered by Medicaid and uninsured in 2012, cholecystectomy is the most common operating room procedure.
History
Carl Langenbuch performed the first successful cholecystectomy at Lazarus hospital in Berlin on July 15, 1882. Prior to this, surgical treatment for symptomatic gallstones was limited to cholecystostomy, or the destruction of gallstones. Langenbuch's reason for developing the new technique comes from a 17th-century study on dogs that show the gall bladder into an unimportant and medical opinion among his colleagues that gallstones form in the gall bladder. Although the technique was initially controversial, cholecystectomy became established as a lower procedure of death than cholecystostomy in the 20th century.
Laparoscopic Techniques
Erich MÃÆ'¼he performed the first laparoscopic cholecystectomy on 12 September 1985 in BÃÆ'¶blingen, Germany. MÃÆ'¼he was inspired to develop a technique for laparoscopic cholecystectomy by the first laparoscopic appendix, performed by gynecologist Kurt Semm in 1980. He then designed an optical laparoscope with a large enough duct to fit a gall bladder. MÃÆ'¼he presented his technique to the Congress of the German Surgical Society in 1986, claiming to reduce postoperative pain and shorter hospitalizations. His work was filled with strong resistance by the German surgical company and he had difficulty communicating it in English. The result is ignored. MÃÆ'¼he's work was further underestimated in 1987, when he was accused of premeditated murder for postoperative patient deaths that were mistakenly associated with his innovative techniques. He was released in 1990 after further investigation. His pioneering work was finally recognized by the German Surgical Society Congress in 1992.
Philippe Mouret performed a laparoscopic cholecystectomy on March 17, 1987 in Lyon, France. The technique was quickly adopted and improved in France. It was then introduced to the whole world over the next three years. Driven by popularity among patients, laparoscopy techniques are becoming more preferred than open surgery and noninvasive treatments for gallstones.
In 2013, laparoscopic cholecystectomy has replaced open cholecystectomy as the first choice of treatment for people with uncomplicated gallstones and acute cholecystitis.
In 2014, laparoscopic cholecystectomy has become the gold standard for the treatment of symptomatic gallstones.
See also
- List of operations by type
- List of ectomes
Further reading
"Brosur Operasi untuk Pasien: Cholecystectomy". American College of Surgeons .
Referensi
Source of the article : Wikipedia
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