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Gall Bladder Removal

Laparoscopic cholecystectomy is a routine gallbladder removal procedure. It is considered extremely safe and effective for removal of symptomatic gallstones. Decreased post-operative pain and reduced need for postoperative analgesia make it a preferred procedure for management of gallstones.

Indications for gallbladder removal

Complex gallbladder diseases

  • Gallstone pancreatitis – Patients will undergo MRCP, ERCP, EUS and IOC prior to the procedure. Surgery is performed only after clinical manifestations of biliary pancreatitis have been cleared.
  • Mirizzi syndrome – The gallstones are lodged in the cystic duct or the Hartmann pouch. The common hepatic duct is thus compressed causing obstructive jaundice. Endoscopic stone fragmentation along with papillotomy and stenting are performed before cholecystectomy.
  • Choledocholithiasis – Preoperative or postoperative ERCP with sphincterotomy and laparoscopic CBD exploration are some options available for treatment followed by a laparoscopic cholecystectomy.
  • Incidental gallbladder cancer – It is usually an incidental finding during a laparoscopic cholecystectomy.

Silent gallstones or asymptomatic gallstones

  • Silent gallstones have a tendency to become symptomatic. With comorbidity factors considered, elective laparoscopic cholecystectomy is performed to avoid the risk of complications. Prophylactic cholecystectomy may be performed in the following cases:
    • Nonfunctional gallbladder
    • Chronic obliteration of cystic duct
    • Trauma to the gallbladder
    • Calcified gallbladder
    • > 10mm gallbladder polyp

Symptomatic gallstones disease

  • Biliary colic with stones identified under sonography
  • Acute cholecystitis treated laparoscopically within 72 hours of detection

Technique

  • Skin is prepared with chlorhexidine, laterally to the anterior iliac spine and to the inguinal ligaments just below the nipple line
  • The area is draped with sterile drapes
  • A longitudinal incision about 1.5 cm is made along the inferior aspect of the umbilicus
  • A Kocher clamp is used to grasp the reflection of the linea alba
  • The linea alba is elevated into the cephalad
  • A no. 15 blade is used to make a 1.2 cm longitudinal incision in the linea alba
  • The peritoneum is then elevated with two straight clamps
  • 11-mm blunt Hasson trocar is placed before insufflating the abdominal cavity to a 15 mm Hg pressure
  • White balanced laparoscope is advanced into the abdominal cavity
  • A deepened incision about 1.2 cm is made below the xiphoid process
  • Under direct vision, the 11 mm trocar is advanced towards the gallbladder
  • The gallbladder is elevated with a 5 mm grasper
  • Port sites are chosen and incisions are made
  • Another 5 mm grasper with locking mechanism is placed
  • Once the cystic duct is straightened, adhesions are lysed carefully with hook cautery
  • Critical view is obtained and sustained
  • The peritoneum is incised within 1 cm of the liver first and then the incision continues towards the fundus of the gallbladder
  • The gallbladder is retracted caudomedially with a similar dissection to its lateral surface

Dr. Deepak performs combined cholecystectomy in conjunction with intra-abdominal surgeries such as splenectomy, hernia repair, appendectomy etc.

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