Guidelines for Laparoscopic Cholecystectomy
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Based on SAGES GUIDELINES FOR THE CLINICALAPPLICATION OF LAPAROSCOPIC BILIARY TRACTSURGERY, Practice/Clinical Guidelines published on:
01/2010 by the Society of American Gastrointestinal and Endoscopic Surgeons
(SAGES)
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Edited by Mina Azer
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Indications for laparoscopic operations on the gallbladder and biliary tree
Include but are not limited to symptomatic
cholelithiasis, biliary dyskinesia, acute cholecystitis, and complications
related to common bile duct stones including pancreatitis with few relative or absolute
contraindications. (Level II, Grade A).
Relative contra-indications for laparoscopic biliary tract surgery
Untreated coagulopathy, lack of
equipment, lack of surgeon expertise, hostile abdomen, advanced cirrhosis/liver
failure, and suspected gallbladder cancer. (Level II, Grade A).
Antibiotic prophylaxis
Antibiotics are not required in low
risk patients undergoing laparoscopic cholecystectomy. (Level I, Grade A).
Antibiotics may reduce the incidence
of wound infection in high risk patients (age > 60 years, the presence of
diabetes, acute colic within 30 days of operation, jaundice, acute
cholecystitis, or cholangitis). (Level I, Grade B).
If given, they should be limited to a
single preoperative dose given within one hour of skin incision. (Level II,
Grade A).
Among
papers suggesting antibiotic prophylaxis is helpful is a recent randomized
study which found fewer wound infections with ampicillin-sulbactam versus
cefuroxime, particularly for infection caused by enterococcus in the setting of
high-risk patients undergoing elective cholecystectomy.[i]
Deep Venous Thrombosis prophylaxis[ii]
Risk Factors 0 or 1: None, Pneumatic compression devices, Unfractioned Heparin or LMWH.
Risk factors 2 or more: Pneumatic
compression devices, Unfractioned Heparin or LMWH.
Room set-up and patient positioning:
With no data to guide choices,
surgeon preference should dictate room set-up. (Level III, Grade A).
Some
surgeons tuck the left arm to improve the working space of the operating
surgeon.
Equipment:
In the absence of data, surgeon
preference should dictate choice of equipment. (Level III, Grade A).
Abdominal access:
There are no demonstrable differences
in the safety of open versus closed techniques for establishing access;
decisions regarding choice of technique are left to the surgeon and should be based
on individual training, skill, case assessment. (Level I, Grade A).
Potentially
life threatening injuries to blood vessels occurred in 0.9 per 1000 procedures
and to the bowel in 1.8 per 1000 procedures.[iii]
Safe technique:
The safety of laparoscopic
cholecystectomy requires correct identification of relevant anatomy. (Level
I, Grade A).
Intraoperative cholangiogram may
reduce the rate or severity of injury and improve injury recognition. (Level
II, Grade B).
The
general principle of not dividing any structure until you are certain of its
identification applies here.
Common Bile Duct Assessment:
Intraoperative cholangiography may
decrease the risk of bile duct injury when used routinely and allows access to
the biliary tree for therapeutic intervention; reliable algorithms to determine
the need for selective cholangiography have yet to be developed. (Level II,
Grade B).
In experienced hands, Intraoperative
laparoscopic ultrasound helps delineate relevant anatomy, detect bile duct
stones, and decrease the risk of bile duct injury. (Level II, Grade B).
Management of Choledocholithiasis:
There are several approaches and
current data does not suggest clear superiority of any one approach; decisions
regarding treatment are most appropriately made based on surgeon preference as
well as the availability of equipment and skilled personnel. (Level I, Grade
A).
Laparoscopic transcystic common bile
duct exploration may employ a number of techniques from simple to advanced; it
is frequently successful, but may be hampered by analomous anatomy, proximal
stones, strictures and large or numerous stones. (Level II, Grade B).
Laparoscopic choledochotomy requires
advanced laparoscopic skills, but has good clearance rates; the open bile duct
may be addressed with closure over a T-tube, an exteriorized transcystic drain,
or primary closure with or without endoluminal drainage. (Level II, Grade
B).
Laparoscopic endobiliary stent
placement adds little operative time to the cholecystectomy, and facilitates
ERCP and stone clearance. (Level II, Grade B).
ERCP with stone extraction may be
performed selectively before, during or after cholecystectomy with little
discernable difference in morbidity and mortality and similar clearance rates
when compared to laparoscopic common bile duct exploration, though routinely
performed preoperative ERCP will likely result in unnecessary procedures with
higher than acceptable mortality and morbidity rates. (Level I, Grade A).
Preoperative
endoscopic sphincterotomy/Laparoscopic cholecystectomy and Laparoscopic cholecystectomy/Intraoperative
endoscopic sphincterotomy are both good options for dealing with preoperatively
diagnosed CBDS, but when there is enough experience and facilities, LC/IOES, as
a single-stage treatment, would be preferable.[iv]
Dissection of the gallbladder from the liver bed:
The more conventional approach
starting at the gallbladder infundibulum and working superiorly, or the top
down approach, may be used with electrocautery, ultrasonic dissection, or hydrodissection
as the surgeon prefers. (Level II, Grade B).
Ultrasonic
dissection has been studied for dissection of the gallbladder from the liver
bed, as well as division and sealing of the cystic artery and cystic duct
without clips; in prospective randomized trials, ultrasonic dissection has been
found to be comparable in terms of operative times, gallbladder perforation,
bleeding, and bile leak.[v] In addition, hydrodissection with a high-pressure
water stream has been used to dissect the gallbladder from the liver bed.[vi] The standard technique
works well and, with no compelling data to use these alternative techniques,
the choice is left to the operating surgeon.
Extraction of the gallbladder:
With no data to guide choice of
technique, the gallbladder may be extracted as the surgeon prefers. (Level
III, Grade C)
Use of Drains:
Drains are not needed after elective
laparoscopic cholecystectomy and their use may increase complication rates. (Level
I, Grade A).
Drains may be useful in complicated
cases particularly if choledochotomy is performed. (Level III, Grade C).
While
use of drains postoperatively after laparoscopic biliary tract surgery is at
the discretion of the operating surgeon, recent studies including a randomized
controlled trial and meta-analysis of 6 randomized controlled trials found
drain use after elective laparoscopic cholecystectomy increases post-operative
pain, wound infection rates and delays hospital discharge; the authors
furthered stated they could not find evidence to support the use of drains
after laparoscopic cholecystectomy.[vii]
Conversion to laparotomy:
Conversion should not be considered a
complication and surgeons should have a low threshold for conversion; the
decision to convert to an open procedure must be based on Intraoperative assessment
weighing the clarity of the anatomy and the surgeon’s skill/comfort in
proceeding. (Level II, Grade A).
Common bile duct injuries:
Factors which have been associated
bile duct injury include surgeon experience, patient age, male sex, and acute
cholecystitis. (Level II, Grade C).
The safety of laparoscopic
cholecystectomy requires correct identification of relevant anatomy.(Level
I, Grade A).
Intraoperative cholangiogram may
reduce the rate or severity of injury and improve injury recognition. (Level
II, Grade B).
If major bile duct injuries occur,
outcomes are improved by early recognition and immediate referral to experienced
hepatobiliary specialists for further treatment before any repair is attempted
by the primary surgeon, unless the primary surgeon has significant experience
in biliary reconstruction. (Level II, Grade A).
Techniques
for prevention and/or recognition focus primarily on careful anatomic
definition[viii]
to ensure the "critical view" prior to dividing any structures
Management of specific conditions
Biliary dyskinesia:
Patients with symptoms of biliary
obstruction without evidence of gallstones, but with abnormal gallbladder
emptying may benefit from laparoscopic cholecystectomy. (Level II, Grade B).
Acute cholecystitis:
Laparoscopic cholecystectomy has
become the preferred approach in patients with acute cholecystitis. (Level
II, Grade B).
Early cholecystectomy (within 24-72
hours of diagnosis) may be performed without increased rates of conversion to
an open procedure, without an increased risk of complications, and may decrease
cost and total length of stay. (Level I, Grade A).
In critically ill patients with acute
cholecystitis, radiographically guided percutaneous cholecystostomy is an
effective temporizing measure until the patient recovers sufficiently to undergo
cholecystectomy. (Level II, Grade B).
Gallstone pancreatitis:
Laparoscopic cholecystectomy has
become the preferred approach for removing the source of stones in cases acute
pancreatitis due to gallstones. (Level II, Grade B).
Severe pancreatitis with ongoing
multi system organ failure requires immediate clearing of any biliary
obstruction followed by supportive care until the patient recovers sufficiently
to tolerate cholecystectomy. (Level I, Grade A).
When pancreatitis caused by
gallstones is mild and self limited, urgent cholecystectomy should be performed
after symptoms have subsided and laboratory values have normalized, usually
during the same hospital admission. (Level II, Grade B).
Laparoscopic cholecystectomy surgery in the setting of cirrhosis:
Laparoscopic cholecystectomy is
relatively safe in patients with Child’s A or B cirrhosis. (Level I, Grade B).
Laparoscopic cholecystectomy is not
recommended for Child’s C patients. (Level III, Grade C).
Bleeding is the most frequent
complication; coagulopathy and thrombocytopenia should be corrected
preoperatively, and dilated pericholecystic and abdominal wall veins or
recanalized umbilical veins be treated with care. (Level II, Grade A).
Recent
studies generally agree laparoscopic cholecystectomy in selected cirrhotics has
a relatively low conversion rate (0- 11%), complication rate (9.5-21%), and
risk of dying (0-6.3%), with most showing worsening liver failure, including
the presence of ascites and coagulopathy, predicting poorer outcomes[ix];
a recent prospective randomized trial found laparoscopic cholecystectomy was
safer than open cholecystectomy in cirrhotics.[x]
Laparoscopic cholecystectomy in the setting of systemic anticoagulation:
Caution in chronically anticoagulated
patients is warranted even after cessation of pharmacotherapy, particularly in
those bridged with low molecular weight heparin. (Level III, Grade B).
Porcelain gallbladder:
Patients with suspected gallbladder
calcifications should be carefully studied, with open cholecystectomy
recommended for those with selective mucosal calcifications. (Level III,
Grade B).
Gallbladder polyps:
Laparoscopic cholecystectomy should
be considered for larger, especially single, polyps or those with associated
symptoms, with watchful waiting for small (<5mm) asymptomatic polyps. (Level
II, Grade B).
Gallbladder cancer:
Laparoscopic cholecystectomy is
considered curative for cancers confined to the gallbladder mucosa (T1a). (Level
II, Grade B).
Cancers which are more locally
advanced or those with nodal involvement should be referred to specialty
centers for consideration of more extensive resection or re-resection. (Level
II, Grade B).
Length of hospital stay:
Patients undergoing uncomplicated
laparoscopic cholecystectomy for symptomatic cholelithiasis may be discharged
home on the day of surgery; control of postoperative pain, nausea, and vomiting
are important to successful same day discharge. (Level II, Grade B)
Patients older than age 50 may be at
increased risk for admission. (Level II, Grade B).
Time to discharge after surgery for
patients with acute cholecystitis, bile duct stones, or in patients converted
to an open procedure should be determined on an individual basis. (Level
III, Grade A).
Single incision cholecystectomy:
The indications, contra-indications
and preoperative preparation for reduced port and single incision approaches
are the same as those for multi port cholecystectomy. (Level III, Grade A).
Access to the abdominal cavity in
reduced port and single incision approaches should follow accepted standards
for safe entry including avoidance and recognition of complications. (Level
III, Grade A).
Introduction of new instruments,
access devices or new techniques should be done with caution and/or under study
protocol, and, prior to the addition of any new instrument or device, it
should, to the extent possible, be proven safe, and not limit adherence to
established guidelines for safe performance of laparoscopic cholecystectomy. (Level
III, Grade A).
During initial procedures, a low
threshold for using additional port sites should be maintained so as to not
jeopardize a safe dissection and result. (Level III, Grade A).
References
[i]
Dervisoglou A, Tsiodras S, Kanellakopoulou K, et al. The value of chemoprophylaxis
against Enterococcus species in elective cholecystectomy: a randomized study of
cefuroxime vs ampicillin sulbactam. Arch Surg 2006;141:1162-7.
[ii]
Guidelines for deep venous thrombosis prophylaxis during laparoscopic surgery.
Surg Endosc 2007;21:1007-9
[iii]
Ahmad G, Duffy JM, Phillips K, Watson A. Laparoscopic entry techniques.
Cochrane Database Syst Rev 2008:CD006583.
[iv]
Ahmed A. ElGeidie, Gamal K. ElEbidy, Yussef M. Naeem. Preoperative versus
Intraoperative endoscopic sphincterotomy for management of common bile duct
stones. Surg Endosc (2011) 25:1230–1237
[v]
Bessa SS, Al-Fayoumi TA, Katri KM, Awad AT. Clipless laparoscopic
cholecystectomy by ultrasonic dissection. J Laparoendosc Adv Surg Tech A
2008;18:593-8.
[vi]
Caliskan K, Nursal TZ, Yildirim S, et al. Hydrodissection with adrenaline-lidocaine-saline
solution in laparoscopic cholecystectomy. Langenbecks Arch Surg
2006;391:359-63.
[vii]
Gurusamy KS, Samraj K, Mullerat P, Davidson BR. Routine abdominal drainage for
uncomplicated laparoscopic cholecystectomy. Cochrane Database Syst Rev
2007:CD006004.
[viii]
Singh K, Ohri A. Anatomic landmarks: their usefulness in safe laparoscopic
cholecystectomy. Surg Endosc 2006;20:1754-8.
[ix]
Bingener J, Cox D, Michalek J, Mejia A. Can the MELD score predict perioperative
morbidity for patients with liver cirrhosis undergoing laparoscopic
cholecystectomy? Am Surg 2008;74:156-9.
[x]
Ji W, Li LT, Wang ZM, Quan ZF, Chen XR, Li JS. A randomized controlled trial of
laparoscopic versus open cholecystectomy in patients with cirrhotic portal
hypertension. World J Gastroenterol 2005;11:2513-7.
