Cholecystectomy is the most common digestive surgery performed. Most of these operations are completed by laparoscopy, and many situations that were initially defined as relative contraindications to laparoscopic surgery are no longer so. However, uncontrolled coagulopathy remains one of the few current contraindications for minimally invasive cholecystectomy, and even patients with severe chronic obstructive pulmonary disease or congestive heart failure may not tolerate the pneumoperitoneum required by laparoscopic surgery. Currently, the most frequent cause of conversion from the laparoscopic technique to the open one in a cholecystectomy continues to be the impossibility of defining with certainty all the anatomical structures whose recognition is necessary during the intervention. The conversion decision after this difficulty should be considered a successful surgical criterion and not a complication. The conversion rate for elective cholecystectomies is around 5%, while in cases of emergency surgery for acute cholecystitis, the conversion rate reaches 30%..

The clinical conditions that cause an increase in the technical difficulties of laparoscopic cholecystectomy are diverse. In acute cholecystitis, videolaparoscopic cholecystectomy can be completed successfully, although at the cost of a significant increase in operating times and with the risk of a higher conversion rate than elective surgeries. Morbid obesity, once considered a relative contraindication to the minimally invasive technique, is not associated with an increased risk of conversion, but longer trocars, other specific instruments, and higher intra-abdominal pressures may be helpful in these cases. A previous procedure in the supramesocolic region can increase the technical difficulties or make the minimally invasive technique difficult, but many times placing a Hasson trocar provides an image of the adhesions present in order to judge the viability of their lysis laparoscopically. Cirrhosis itself may also allow laparoscopic cholecystectomy to be performed, although events such as difficulty retracting the hard cirrhotic liver and the risk of collateral portal hemorrhage in hypertension are cautioned.

Laparoscopic cholecystectomy

Patient preparation and operative field setup for videolaparoscopic cholecystectomy are similar to those for laparotomic cholecystectomy. The patient must be previously informed, as part of the consent to surgery, of the possibility of conversion to laparotomy, which is up to 5% in elective procedures and reaches 30% in acute cholecystitis. To have better exposure and avoid damage, it is necessary to place a bladder catheter and a nasogastric tube. Laparoscopic surgery requires, in order to create a space that allows visualization to perform surgical manipulation, the induction of a pneumoperitoneum, obtained mostly through the insufflation of carbon dioxide into the peritoneal cavity. Open and closed methods can be used for induction of the pneumoperitoneum. The open method allows, through a small supraumbilical incision, to open the peritoneal cavity under vision. The Hasson trocar is inserted, anchoring it to the fascial plane, which has a blunt tip and a channel for gas insufflation. This technique is usually used in the case of previous abdominal surgery and reduces the risk of causing potentially serious injuries after the introduction of the trocars. In the closed access technique, to perform gas insufflation, a special needle called Veress is used, which is inserted through a small supraumbilical incision and has a retractable sharp tip.

Once adequate pneumoperitoneum has been established, a 10-mm-diameter trocar is inserted through the supraumbilical incision, through which the laparoscope attached to the video terminal is inserted. Frontal (0 degrees) and angled (30 degrees) laparoscopes are available, and, regardless of the open or closed supraumbilical incision technique, the other trocars are inserted under laparoscopic vision after initial exploration of the abdominal cavity. Most surgeons use a second 10mm-diameter trocar placed in the subxiphoid area and two 5mm diameter trocars in the right subcostal area, one along the anterior axillary line and one along the anterior axillary line. midclavicular. However, there are also laparoscopes with a diameter of 5 mm and instruments with a diameter of 3 mm. The two minor accesses have the function of allowing the entry of instruments that maintain the gallbladder in a suitable position for performing an antegrade cholecystectomy. The lateral approach is used to bring the gallbladder cranially by pulling the lower hepatic border upward to expose the gallbladder and cystic duct. Through the small 5 mm medial approach, the gallbladder infundibulum is stretched to the right to expose Calot's triangle. This maneuver may require the lysis of any loose adhesions between the omentum or duodenum and the gallbladder. The junction between the gallbladder and the cystic duct is recognized by the separation of the visceral peritoneum at the level of the gallbladder neck, which becomes skeletonized. Once the cystic duct has been identified, optional intraoperative cholangiography can be performed by placing a clip in the proximal portion of the duct, cutting its anterior wall, and cannulating it distally with a catheter through which to infuse contrast medium. Next, two clips will be placed on the distal stump of the sectioned cystic duct and one on its initial section. A dilated cystic duct may need to be ligated for added safety. The cystic artery is then identified and divided. This generally runs parallel and posterior to the cystic duct. After identification and isolation of the cystic artery, it is ligated using clips and sectioned. Once the gallbladder has been deprived of its vascular supply by the cystic artery or its branches, the gallbladder is dissected from its bed using the hook (electrified hook-shaped instrument). The visceral peritoneum at the border between the gallbladder and the liver is tensioned by means of grasping instruments inserted into the small-bore accesses and dissected, and then the loose tissues of the avascular space located between the gallbladder and the liver are dissected. Liver, and thus the gallbladder is released. Complete hemostasis of the gallbladder bed is performed, and the gallbladder containing the stones is removed through the periumbilical access port, possibly due to enlargement. In the event that the gallbladder is damaged during removal or is severely inflamed or gangrenous, it can be removed once placed in a plastic bag. The rates of complications and mortality of this operation are similar to those of the most representative series of elective laparotomy cholecystectomy. The mortality risk in both cases is 0.1%, and cardiovascular complications are the main cause of death. The most significant surgical complication of laparoscopic cholecystectomy is injury to the main bile duct, which occurs in less than 10% of cases. The need to convert laparoscopic surgery to open cholecystectomy occurs in less than 5% of patients with chronic cholecystitis. Furthermore, the conversion rate is increased in elderly, obese, and male patients. The long-term results of laparoscopic cholecystectomy in a selected series of patients with chronic cholecystitis are excellent. About 90% of patients with a history of biliary colic report the disappearance of symptoms after surgery, while in patients with atypical symptoms or with generic dyspepsia in the absence of painful episodes (history of intolerance to fatty foods, flatulence, bloating, and belching), the results are less satisfactory.

Laparotomic cholecystectomy

The access route for laparotomic cholecystectomy can be the median or right subcostal (Kocher) incision. Preliminary identification and sectioning of the cystic duct and cystic artery can reduce the risk of bleeding during gallbladder dissection. Using lateral traction exerted on the neck of the gallbladder, the visceral peritoneum is stretched and incised at the level of Calot's triangle, identifying, ligating and sectioning the cystic duct. If necessary, cholangiography is performed. Finally, the cystic artery is recognized and dissected with ligatures. If the anatomy is difficult to recognize, the gallbladder can be removed by initiating the dissection from the fundus toward the neck (retrograde cholecystectomy), which facilitates recognition of the cystic duct and artery. Dissection of the body of the gallbladder is performed by cauterization of the peritoneal fold. The presence of an anomalous duct penetrating directly from the gallbladder bed is rarely found, and this relief dictates its ligation. At the end of the operation, a suction drain will be placed if the need exists.