Laparoscopic cholecystectomy

Laparoscopic Cholecystectomy

Since the introduction of laparoscopic cholecystectomy, the number of cholecystectomies performed in the United States has increased from about 500,000 per year to700,000 per year. Contraindications to laparoscopic cholecystectomy include coagulopathy, severe chronic obstructive pulmonary disease, end-stage liver disease, and congestive heart failure. Currently,the major contraindication to completing a laparoscopic cholecystectomy is inability to clearly identify all of the anatomic structures. The conversion rate for elective laparoscopic cholecystectomyshould be around 5%, whereas the conversion rate in the setting of acute cholecystitis may be as high as 30%. Conversion to an open procedure is not a failure, and the possibility should be discussedwith the patient preoperatively.

Patients undergoing laparoscopic cholecystectomy should be prepared and draped in a similar fashion to open cholecystectomy. The patient is supine on the operatingtable with the surgeon standing on the patient's left. The pneumoperitoneum is created with carbon dioxide gas, either with an open technique or by closed-needle technique. With the open technique, asmall incision is made either above or below the umbilicus into the peritoneal cavity. A special blunt-tipped cannula (Hasson) with a gas-tight sleeve is inserted into the peritoneal cavity and anchoredto the fascia. This technique is often used following previous abdominal surgery and should avoid infrequent but life-threatening trocar injuries. In the closed technique, a special hollowinsufflation needle (Veress) with a retractable cutting sheath is inserted into the peritoneal cavity through a periumbilical incision and used for insufflation. There is no difference in inadvertent bowel ortissue injury between the two techniques.

The laparoscope with the attached video camera is then inserted into the umbilical port and the abdomen inspected. The additional ports are inserted under...