Laparoscopic Cholecystectomy

Codes

Laparoscopic cholecystectomy without cholangiogram 47562

Laparoscopic cholecystectomy with cholangiogram 47563

Laparoscopic cholecystectomy with common bile duct exploration 47564

Introduction

The laparoscopic cholecystectomy (lap chole) is one of the most common surgeries preformed in the United States. If you as a student are on a general surgery service, you will surely become familiar with it. The lap chole is a great teaching case to involve students on because of the relevant anatomy, commonality of the procedure, and the fact that they are often able to drive the camera due to the singular camera position. Knowing a few key facts before going into this procedure will ensure that your attending knows that you are well prepared and ready to handle responsibilities in the OR.

Indications

• Symptomatic cholelithiasis: The gallbladder is removed when a patient has recurrent episodes of symptomatic gallstones meaning that gallstones from the gallbladder are intermittently blocking the cystic duct. These are mostly like the prototypical clinical scaffold you learn during your pre-clinical times of right upper quadrant pain, postprandial attacks and possibly a Murphy’s sign.

• Acute cholecystitis: This is when the gall bladder becomes inflamed. The most common cause is blockage of the cystic duct by a gallstone. Another cause is acalculus cholecystitis in which the gallbladder becomes inflamed, thought to be due to lack of motility to drain the bile. This is usually seen in patients who are already critically ill. Cholecystitis and the associated inflammation will make the patient ill. So in addition to RUQ pain and Murphy’s sign, they may also have nausea, vomiting or fever.

• Choledocholithiasis: This is when a stone from the gallbladder gets lodged in the common bile duct. It can cause similar pain and symptoms to symptomatic cholelithiasis. However, it also has a risk of causing ascending cholangitis, a severe infection in which inflammation and infection move from the common bile duct into the liver causing the triad of fever, jaundice and RUQ pain (Charcot’s Triad). The correct initial procedure is again an ERCP followed by an interval lap chole.

• Gallstone pancreatitis: This is pancreatitis caused by a gallstone obstructing the path of pancreatic fluid where it enters the duodenum at the ampula of vatar. The initial treatment is stabilization and fluid resuscitation, bowel rest, ERCP to remove the offending stone and interval lap chole to prevent future attacks.

Etiology

• Remember the 4 F’s of cholelithiasis: fat, female, fertile (pregnant), and forty. It is theorized that estrogen levels have a role in gallstone formation.

Relevant anatomy

• Triangle of Calot: composed of the borders of the cystic duct, common hepatic duct and the inferior surface of the liver. In this space lives the cystic artery, right hepatic artery, and the lymph node of Calot.
• What is the most likely artery to cause significant bleeding during a lap chole = right hepatic artery.
• What is this amorphous blobby circle next to the cystic duct = the node of Calot.
• What part of the digestive tract is closest to where the surgery is taking place = the duodenum (next is the stomach).
• What vessels do we want to avoid when choosing where to place the laparoscopic ports = the inferior epigastrics.