Background Information:

What are the other Names for the Procedure?

• Lap Choley
• Laparoscopic Gallbladder Surgery
• Removal of Gallbladder with Video Assistance

What is Laparoscopic Cholecystectomy surgical procedure?

Gallbladder Removal by Laparoscopy (or Laparoscopic Cholecystectomy) is the surgical removal of the gallbladder, performed for various reasons; the most common reason being symptomatic gallstones.

What part of the Body does the Procedure involve?

Gallbladder Removal by Laparoscopy involves the following:

• Gallbladder
• Cystic duct (a tube-like structure that ‘comes off’ of the gallbladder)
• Cystic artery (a blood vessel that carries blood to the gallbladder)
• Liver

Why is the Laparoscopic Cholecystectomy surgical procedure Performed?

The most common indication for performing a Laparoscopic Cholecystectomy is symptomatic gallstones causing pain (biliary colic). Other indications include:

• Acute cholecystitis: Inflammation of the gallbladder that commonly occurs due to gallstones
• Choledocholithiasis: A condition, wherein the gallstone travels out of the gallbladder and blocks the common bile duct, preventing the flow of bile into the small bowel. In a majority of the cases, the stone in the duct is addressed first, prior to gallbladder removal
• Gallstone pancreatitis: A condition, wherein the stone travels out of the gallbladder and blocks the pancreatic duct. The pancreatitis condition is addressed first, prior to gallbladder removal
• Biliary dyskinesia: A condition in which the gallbladder ejection is decreased, thus decreasing its function. A poorly-functioning gallbladder can cause indigestion and hence, sometimes, the gallbladder has to be removed
• Gallbladder polyp, more than 10 mm in size
• Trauma to the gallbladder
• Porcelain (calcified) gallbladder; a condition that causes the gallbladder to function poorly

What are some Alternative Choices for the Procedure?

• Gallstones, once formed, do not disintegrate (or go away) on their own. Hence, an attempt is made to reduce their increase in size, or prevent new gallstones from forming. Some may be temporarily managed with drugs, or by making certain dietary adjustments, such as reducing fat intake. This treatment has a low, short-term success rate. The symptoms will eventually continue, unless the gallbladder is removed
• Surgical removal of the gallbladder is the time-honored and safest treatment of gallbladder disease

Open Cholecystectomy is an alternative to Laparoscopic Cholecystectomy, but due to the advantages of laparoscopic surgery (such as tiny incisions, less post-operative pain, faster recovery, earlier return to routine activity), nowadays, majority of the cases are performed laparoscopically.

What are the Recent Advances in the Procedure?

Recent advances to Gallbladder Removal by Laparoscopy procedure include the following:

• Robotic Cholecystectomy
• NOTES procedure for the removal of gallbladder

Robotic Cholecystectomy:

• It is a minimally invasive robotic procedure for gallbladder removal
• During this procedure, the surgeon sits at a console viewing 3-D, high-definition images, while using controls below the display, to move robotic arms with attached surgical instruments
• The system translates the surgeon’s hand, wrist, and finger movements, into precise, real-time movements of surgical instruments inside the patient
• In some centers, unlike traditional robotic surgeries that require 3-4 small incisions used as access ports for the robotic arms, the new technology allows for a single incision at the belly button where instruments are placed, and the diseased organ is removed
• The US Food and Drug Administration (FDA) approved the new procedure in December 2011 for the Intuitive da Vinci® Robotic Surgical System

NOTES (Natural Orifice Transluminal Endoscopic Surgery) for removal of gallbladder:

• It is an experimental surgical technique through which, "no incision/scar-less" abdominal operations can be performed with an endoscope, passed through a natural orifice (mouth, urethra, anus etc.), than through an internal incision in the stomach, vagina, bladder, or colon, thus avoiding any external incisions or scars
• This technique has been used for diagnostic and therapeutic procedures in animal models, including transgastric (through the stomach) organ removal
• Most recently, the transvesical (through the urinary bladder) and the transcolonic (through the colon) approaches have been advocated by some researchers, as being more suited to access upper abdominal structures that are often more difficult to work with using a transgastric approach
• In 2007, first human transgastric cholecystectomy was reported in USA. The first series of transvaginal NOTES Cholecystectomy was performed in Brazil, in 2007
• With fewer potential complications, the transvaginal access to NOTES seems to be the most safe and feasible, for clinical application. But, the procedure has a disadvantage of being possible only in women
• Proponents and researchers in this field recognize the potential of this technique to revolutionize the field of minimally invasive surgery, by eliminating abdominal incisions
• NOTES could be the next major paradigm shift in surgery, just as laparoscopy was the major paradigm shift, during the 1980s and 1990s

What is the Cost of performing the Laparoscopic Cholecystectomy surgical procedure?

The cost of Gallbladder Removal by Laparoscopy surgical procedure depends on a variety of factors, such as the type of your health insurance, annual deductibles, co-pay requirements, out-of-network and in-network of your healthcare providers and healthcare facilities.

In many cases, an estimate may be provided before the procedure. The final amount depends upon the findings during the surgery/procedure and post-operative care that is necessary.

When do you need a Second Opinion, prior to the Procedure?

• It is normal for a patient to feel uncomfortable and confused with a sudden inflow of information regarding Gallbladder Removal by Laparoscopy surgical procedure and what needs to be done
• If the patient needs further reassurance or a second opinion, a physician will almost always assist in recommending another physician
• Also, if the procedure involves multiple surgeries or has many alternatives, the patient may take a second opinion to understand and choose the best one. They can also choose to approach another physician independently

What are some Helpful Resources?

http://www.sages.org/publication/id/PI11/ (accessed on 05/16/2014)

http://digestivehealth.beaumont.edu/robotic-laparoscopic-cholecystectomy-procedure (accessed on 05/16/2014)

Prior to Laparoscopic Cholecystectomy surgical procedure:

How is the Laparoscopic Cholecystectomy surgical procedure Performed?

The Gallbladder Removal by Laparoscopy is performed in the following manner:

• General anesthesia is administered, so that the patient is asleep throughout the procedure
• Using a narrow tube-like instrument (cannula), the surgeon enters the abdomen in the area of the belly button
• A laparoscope (a tiny telescope) connected to a special camera is inserted through the cannula, giving the surgeon a magnified view of the patient's internal organs on a television screen
• Other cannulas are inserted, which allow the surgeon to delicately separate the gallbladder from its attachments and then, remove it through one of the openings
• Many surgeons perform an x-ray procedure, called a cholangiogram, in order to identify stones, which may be located in the bile duct, or to ensure that the structures have been identified
• If the surgeon finds one or more stones in the common bile duct, then he/she may:
  • Remove them with a special scope
  • Choose to have them removed later, through a second minimally invasive procedure
  • Convert it to an open operation, in order to remove all the stones during the operation
• After the surgeon removes the gallbladder, the small incisions are closed with sutures, or using surgical tapes

Where is the Procedure Performed?

• A Gallbladder Removal by Laparoscopy procedure is usually performed in an outpatient surgery center facility or a hospital. Normally, the individual can go home, once the procedure is completed
• However, the physician may keep the patient under overnight observation, if necessary
• In some cases the patient may be kept under observation for a longer period of time, under advice by the physician

Who Performs the Procedure?

The procedure is performed by a physician trained in general surgery, with assistance from an anesthesiologist.

How long will the Procedure take?

• The time taken for a Laparoscopic Cholecystectomy is usually about 1-2 hours
• However, the surgery time may be prolonged, in the setting of an inflammation

What do you need to tell your Physician before the Procedure?

It is very important to provide the following information to your healthcare provider. This enables your healthcare provider in assessing the risks for the surgical procedure and helps avoid unnecessary complications.

• Provide a complete list of medications you are currently, taking to your physician. This information is useful for a variety of reasons. For example, it can help your healthcare provider prevent complications due to a drug interaction
• If you are allergic to any specific medication or food items
• If you are taking blood thinners, such as aspirin, warfarin, herbal supplements, or any other such medications
• If you or your family members, have a history of bleeding disorders, or if there is a tendency to bleed more than normal
• If you have diabetes, high blood pressure, chest pains, or have previously suffered from a heart attack
• If you have ever been diagnosed with blood clots in your leg (deep vein thrombosis) or lung (embolism of lung)
• If you have a history of frequent bone fractures (this may affect bone-healing, if bones are involved as part of your procedure)
• A list of all previous surgical procedures you have undergone, like for example: Removal of appendix, gallbladder, or any other part, of your body; surgical repair of any body part, such as hernia repair, perforation of bowel wall, etc.

What Preparations are needed, prior to the Procedure?

• The physician may evaluate the individual’s medical history to gain a comprehensive knowledge of the overall health status of the patient including information related to the medications that are being currently taken
• Some medications increase a person’s chances of bleeding and it may be recommended to discontinue them for a period of time, before the procedure is performed
• Blood tests may be performed to determine, if there is a bleeding tendency or any other medical conditions that prevents the person from undergoing the procedure
• Do inform the physician if you are allergic to any local anesthetics, lidocaine, etc.
• Avoid application of any cosmetics, deodorant, or topical medicines on the area, prior to the procedure
• It is advisable to quit smoking and the use of any nicotine based products, for a while, before the surgery
• Consumption of alcoholic drinks must also be avoided for a period of time, as instructed
• The patient must avoid eating or drinking at least 8 hours prior to the surgical procedure, depending on when the procedure is arranged
• For persons suffering from diabetes, it is important that the blood sugar stays within the normal range; if not their diabetologist may have to control blood sugar by recommending insulin and/or a combination of oral medicines

What is the Consent Process before the Procedure?

A physician will request your consent for Gallbladder Removal by Laparoscopy procedure using an Informed Consent Form.

Consent for the Procedure: A “consent” is your approval to undergo a procedure. A consent form is signed after the risks and benefits of the procedure, and alternative treatment options, are discussed. This process is called informed consent.

You must sign the forms only after you are totally satisfied by the answers to your questions. In case of minors and individuals unable to personally give their consent, the individual’s legal guardian or next of kin, shall give their consent for the procedure.

What Tests are needed, before the Laparoscopic Cholecystectomy surgical procedure?

The following tests may be recommended by the healthcare provider:

• Blood tests are performed to check hemoglobin, infection count (white cell count), kidney function (blood urea nitrogen, creatinine) and liver function tests
• Ultrasound is most commonly used to find gallstones
• In some instances, a CT scan may also be used
• CCK-HIDA scan may be used to check for the ejection fraction of the gallbladder, or to diagnose cholecystitis

What are some Questions for your Physician?

Some of the basic questions that you might ask your physician are as follows:

• What is a Gallbladder Removal by Laparoscopy procedure?
• Why is this procedure necessary? How will this procedure help?
• What does the procedure involve?
• How soon should I get it done? Is there an emergency?
• Who are the medical personnel involved in this procedure?
• What are the risks while performing the procedure?
• What are the possible complications that might take place, during recovery?
• How long will it take to recover? When can I resume normal work?
• How many such procedures have you (the physician) performed?
• Are there any lifestyle restrictions or modifications required, after the procedure is performed?
• Are there any follow-up tests, periodic visits to the healthcare facility required, after the procedure?
• Is there any medication that needs to be taken for life, after the procedure?
• What are the costs involved?

During the Laparoscopic Cholecystectomy surgical procedure:

What kind of Anesthesia is given, during the Procedure?

General anesthesia is administered during a Gallbladder Removal by Laparoscopy procedure.

How much Blood will you lose, during the Procedure?

• Since the procedure is under laparoscopic (minimally-invasive) approach, there is little blood loss involved
• If complications arise during the surgical procedure, it could lead to further loss of blood

What are the possible Risks and Complications during the Laparoscopic Cholecystectomy surgical procedure:

There are general factors that increase the risk of getting complications during a Gallbladder Removal by Laparoscopy procedure and they include:

• Obesity: Generally greater the degree of obesity, greater is the surgical risk
• Smoking: Longer the smoking history (in pack years smoked), greater the surgical risk
• Advancing age
• Poorly controlled diabetes, as evidenced by a high hemoglobin A1c and a high fasting glucose
• Poorly functioning kidney, as evidenced by increased BUN (blood urea nitrogen) and blood creatinine
• Poorly functioning liver, as evidenced by increased blood liver function tests
• Hypertension (increased blood pressure), especially if it is poorly controlled
• Poor nutritional status (malnutrition with mineral and vitamin deficiencies)
• Poor lung function, as evidenced by abnormal lung function tests
• History of bleeding disorders
• Longstanding illness, such as autoimmune disorders, chronic infections
• Poor immune system due to a variety of causes

The possible risks or complications that may arise during the surgery are:

• Bleeding
• Injury to the neighboring structures
• Anesthetic complications
• Need for further procedures

While there are risks associated with any kind of operation, the vast majority of Laparoscopic Gallbladder Surgery patients experience few or no complications.

What Post-Operative Care is needed at the Healthcare Facility after the Laparoscopic Cholecystectomy surgical procedure:

At the healthcare facility, generally there is no requirement for any post-procedure care, unless any complications arise.

• However, immediately following the surgery, the patient is kept in a post-operative recovery unit for observation
• Apart from this, no particular care is needed unless any complications are seen to arise

After the Laparoscopic Cholecystectomy surgical procedure:

What are the possible Risks and Complications after the Laparoscopic Cholecystectomy surgical procedure?

Post Gallbladder Removal by Laparoscopy procedure, the following complications may arise:

• Infection
• Bleeding from the site of surgery
• Pain and discomfort
• Pneumonia (infection of the lungs)
• Blood clot formation (embolism and thromboembolism)
• Heart problems
• Bile leakage into the abdomen, from the tubular channels leading from the liver to the intestine may occur, in some rare cases

Numerous medical studies show that the complication rate for Laparoscopic Gallbladder Surgery is comparable to the complication rate for Open Gallbladder Surgery, when performed by a properly trained surgeon.

What is the Prognosis after the Surgery?

• After the Gallbladder Removal by Laparoscopy surgery, it may take about 2-3 weeks for a complete recovery
• Laparoscopic Cholecystectomy has an excellent prognosis; however, if there are complications, it could lead to a longer recovery period

When do you need to call your Physician?

Do contact your physician, if you notice any of the following symptoms after a Laparoscopic Cholecystectomy procedure:

• Pain around the surgical wound
• Swelling and redness
• Bleeding or fluid drainage from the incision wound
• Fever
• Dizziness
• Signs of infection

What Post-Operative Care is needed at Home after the Laparoscopic Cholecystectomy surgical procedure?

At home, the following post-operative care is recommended, after a Laparoscopic Cholecystectomy procedure:

• For few hours after the surgery, have a diet consisting only of liquids or semi-solids
• Avoid any strenuous physical activities, before slowly getting back to your regular daily routine
• Keep incision wounds clean and dry
• Complete the prescribed course of medications
• Avoid pain killers, unless prescribed by your physician
• Avoid any possibilities of constipation; take medications, if required so

How long does it normally take to fully recover, from the Procedure?

It takes about 2-3 weeks, to fully recover from the Gallbladder Removal by Laparoscopy (Laparoscopic Cholecystectomy) procedure.

Additional Information:

What happens to tissue (if any), taken out during the Procedure?

The gallbladder tissue is taken for further examination and later disposed, as per the standard medical procedure.

When should you expect results from the pathologist regarding tissue taken out, during the Procedure?

• The gallbladder tissue removed is processed in the laboratory under a pathologist's supervision
• The slide(s) are prepared once the tissue is processed, and this is examined by a pathologist and a pathology report issued
• Depending on the complexity of the case, issue of the report may take anywhere between 72 hours to a week's time

Who will you receive a Bill from, after the Laparoscopic Cholecystectomy surgical procedure?

It is important to note that the number of bills that the patient may receive depends on the arrangement the healthcare facility has with the physician and other healthcare providers.

Sometimes, the patient may get a single bill that includes the healthcare facility and the consultant physician charges. Sometimes, the patient might get multiple bills depending on the healthcare provider involved. For instance, the patient may get a bill from:

• The outpatient facility or hospital
• General surgeon
• An anesthesiologist 
• A pathologist

Individuals are advised to inquire and confirm the type of billing, before the Gallbladder Removal by Laparoscopy surgical procedure is performed.

Thanks and Gratitude:

We sincerely acknowledge and thank Dr. Douglas J. Jones for reviewing the article. His valuable input and feedback has helped enrich the contents of this article.

Douglas J. Jones, MD FACS
Board Certified General Surgeon and Faculty Member
University of Illinois, College of Medicine at Urbana-Champaign
506 S. Mathews Ave., Urbana, IL 61801, USA