Laparoscopic Cholecystectomy: Recommended Procedure
Laparoscopic cholecystectomy is the gold standard treatment for gallbladder removal, performed through four small incisions using video-endoscopic guidance, with the procedure ideally completed within 7-10 days of symptom onset for acute cholecystitis. 1, 2
Standard Surgical Technique
The procedure is performed through four cannulas/ports using video-endoscopic guidance. 3 The laparoscopic approach should always be attempted first except in cases of absolute anesthetic contraindications or septic shock. 4
Critical Technical Elements
Achieve the Critical View of Safety before dividing any structures - this is the most important technical aspect to prevent bile duct injury, which occurs in 0.4-1.5% of cases. 5
The standard approach involves dissection of Calot's triangle to clearly identify the cystic duct and cystic artery before division. 4
Mean operative time is approximately 75 minutes (range 25-147 minutes) for uncomplicated cases. 6
Timing Considerations
Early laparoscopic cholecystectomy should be performed within 24-48 hours after initial conservative management for acute cholecystitis, as earlier surgery is associated with shorter hospital stays and fewer complications. 4, 2 The procedure can be safely performed up to 10 days from symptom onset. 4
For pregnant patients, the second trimester is the optimal timing, though the procedure is safe in any trimester. 1
Management of Difficult Cases
When anatomic identification is difficult due to severe inflammation, adhesions, or distorted anatomy:
Perform laparoscopic or open subtotal cholecystectomy rather than risking bile duct injury. 4 This approach achieves morbidity rates comparable to total cholecystectomy in straightforward cases. 4
Consider fundus-first approach as an alternative technique when standard dissection is hazardous. 5
Convert to open surgery if there is local severe inflammation, adhesions, bleeding in Calot's triangle, or suspected bile duct injury. 4
Predictors of Conversion to Open Surgery
Conversion may be predicted by fever, leukocytosis, elevated serum bilirubin, and history of extensive upper abdominal surgery. 4 The conversion rate increases with acute disease, pancreatitis, bleeding disorders, and unusual anatomy. 7
Patient Selection and Contraindications
Laparoscopic cholecystectomy is appropriate for all patients with symptomatic gallstones regardless of age or stone size. 1, 5 Old age (>65 years) by itself does not represent a contraindication. 4
Current Absolute Contraindications
- Absolute anesthetic contraindications 4
- Septic shock 4
- Acute cholangitis 3
- Peritonitis or abdominal sepsis 3
- Major bleeding disorders 3
Special Populations
High-Risk Patients
Even in critically ill patients (APACHE score 7-14), immediate laparoscopic cholecystectomy is superior to percutaneous drainage, with only 5% complications versus 53% with drainage. 4, 2 Mortality remains equivalent between approaches, but cholecystectomy results in significantly fewer major complications and better resource utilization. 4, 2
Elderly Patients
Laparoscopic cholecystectomy in elderly patients is safe, feasible, with low complication rates and shortened hospital stays. 4 The same technical principles apply as in younger patients. 4
Postoperative Management
Hospital stay is markedly shortened compared to open cholecystectomy, with many patients eligible for same-day discharge. 7, 6 Mean postanesthesia care unit stay is approximately 200 minutes (range 95-460 minutes). 6
Success rate for true outpatient laparoscopic cholecystectomy exceeds 90%, with less than 10% requiring admission from the recovery unit and another 5% requiring readmission after discharge. 6
Common Pitfalls to Avoid
Never divide structures without achieving Critical View of Safety - this is the primary cause of bile duct injuries. 5
Do not delay surgery in suitable candidates based solely on age or comorbidities - evidence shows early laparoscopic cholecystectomy is safe even in high-risk patients. 2
Avoid overuse of gallbladder drainage procedures in surgical candidates - this leads to higher mortality, longer stays, and increased readmissions. 2
Do not persist with laparoscopic dissection when anatomy cannot be clearly identified - convert to subtotal cholecystectomy or open surgery to prevent bile duct injury. 4
Ensure surgeon has appropriate training and experience - this requires specific training, animal laboratory experience, and proctored clinical cases before independent practice. 3