Cholecystectomy is the surgical procedure for removing the gallbladder.
, the gallbladder is a pear-shaped organ located just below the liver in the right side of the abdomen. Its task is to collect and store the bile produced by the liver, concentrating it and pouring it into the intestine after meals, especially fats, to promote digestive processes. The gallbladder, therefore, is not a vital organ and patients who have undergone cholecystectomy are able to resume an absolutely normal life. Only in the first days or weeks after the operation, some subjects complain of digestive problems (diarrhea), easily controllable by appropriate drugs; after recovering the operation, a "digestive intolerance to particularly abundant and high-fat meals" may persist, as well as reflux phenomena gastroesophageal.
We invite the reader without in-depth medical knowledge to keep in mind the anatomical reference of the image on the side to better understand the technicalities used in the course of the article.
, which for several years has largely replaced the open surgical procedure, called open cholecystectomy.The advantages of the laparoscopic technique are important, both in terms of healthcare costs and in terms of benefits for the patient. Not surprisingly, it is known to be a minimally invasive surgical technique.
, an abdominal ultrasound, and a general amnesthetic evaluation to investigate the patient's clinical history in view of anesthesia and surgery. During the preparatory phase, the doctor will also investigate the possible use of drugs that could be suspended in view of the cholecystectomy. For example, if the subject takes anticoagulants (Coumadin, sintrom) and / or antiplatelet drugs (Plavix, Aspirin) it is generally necessary suspend therapy from 5 to 7 days before cholecystectomy, replacing them with an appropriate dose of low molecular weight heparin (enoxaparin or similar).
A couple of days before laparoscopic cholecystectomy, a preoperative endoscopic retrograde cholangiopancreatography (see below) may be required, through which stones located in the common bile duct are searched for and possibly removed.
Before surgery, it is required - unless otherwise prescribed - the abstention from drinking and food for at least 6 hours before the surgery; in the days that proceed, intestinal cleansing may also be required through the use of laxatives osmotic. Personal hygiene is also important, so much so that some centers suggest cleansing with special antibacterial soaps.
Before the operation, antibiotics are administered intravenously, in order to reduce the risk of infection. Once the patient has been anesthetized, the skin of the abdomen is carefully disinfected with an antiseptic solution: the cholecystectomy can then begin. The prophylaxis of deep vein thrombosis can be carried out by administering low molecular weight heparin, or by using elastic stockings for graduated compression of the lower limbs.
WHO IS IT SUITABLE FOR?
The doctor may decide to perform a laparoscopic cholecystectomy in the presence of gallbladder and biliary tract stones, and / or related complications. In particular, surgery is indicated in the presence of symptomatic gallbladder stones (presence of stones in the gallbladder accompanied by episodes of biliary colic or other typical symptoms), choledocholithiasis (presence of stones in the choledochus or in the common bile duct), cholecystitis ( inflammation of the gallbladder with distension of the same due to local accumulation of water, mucus - hydrops - and possibly pus - empyema), obstructive pancreatitis (inflammation of the pancreas due to the presence of stones in the choledochus, such as to prevent the correct outflow of pancreatic juice in the intestine ).
WHAT RISKS DO YOU RUN IF YOU DECIDE NOT TO UNDERGO THE INTERVENTION?
The risks materialize in the possibility of a worsening of the symptoms of the underlying pathology for which surgery is recommended. These complications range from the recurrence of biliary colic, jaundice and painful abdominal symptoms, up to real medical emergencies such as perforation of the gallbladder. with peritonitis.
HOW TO DO IT?
The first laparoscopic cholecystectomy was performed in 1987 by Philippe Mouret, in Lyon, France. During the operation, the surgeon makes three or four small incisions, with a diameter of 0.5 - 1 cm, in the patient's abdomen, which act as a way of access for the insertion of special watertight cannulas (trocars), to the inside which run the small surgical instruments necessary for the operation. The operative space for the correct maneuvering of these instruments is created by insufflation of carbon dioxide (pneumoperitoneum) with a Veress needle, after skin incision at the sub-umbilical level. The pneumoperitoneum is created, through the first trocar, the laparoscope is inserted into the abdomen: an instrument equipped with a micro-camera connected to optical fibers and a light source, which allows a "visual exploration of the internal abdominal region on the special screen of the operating room.
Under this visual guide from inside the abdomen, the other 3 trocars are inserted into their respective incisions. Inside these cannulas run the surgical instruments necessary for traction, dissection, cutting and removal of the gallbladder, as well as for coagulation and irrigation / aspiration: a forceps or a feeler pushes the liver upwards; a forceps isolates the cystic duct and moves the gallbladder to the most suitable position dissecting it from nearby structures; again by means of pliers, metal clips are positioned to constrict the cystic duct and the cystic artery; finally, a scissors or other instrument resects the organ. Once the gallbladder has been removed, it is extracted and checked for any bleeding, then the surgical field is washed, the insufflated carbon dioxide is aspirated and the skin incisions saturated with clips or sutures.
NOTES: The initial isolation of the cystic duct allows you to inject contrast media into it to perform an X-ray of the biliary tract (intraoperative cholangiography) and thus highlight any stones inside the common bile duct. If these are present they can be removed, always under laparoscopic guidance, in a similar way to that seen for cholecystectomy, directly or with the help of a basket or a balloon. Nevertheless, in the face of the suspicion of stones in the choledochus, whenever possible, it is preferred to perform a preoperative endoscopic retrograde cholangiopancreatography for diagnostic and operative purposes, this is because the exploration of the common bile duct during laparoscopic cholecystectomy is difficult. operative, a small flexible tube is made to go down along the esophagus, the stomach and the duodenum up to the point where the choledochus (Vater's papilla) opens, inside which it is channeled to inject contrast media into the common bile duct; by dilating the walls by papillosphinterotomy, the removal of the stones is facilitated by means of special instruments. Two days after the removal of these stones, laparoscopic cholecystectomy can be performed.
AFTER LAPAROSCOPIC CHOLECYSTECTOMY
The operation is performed under general anesthesia. Upon awakening from the anesthesia, the patient is taken back to his room. He can therefore start drinking eight hours after surgery and eat lightly from the day after. During this time, painkillers may be required. Discharge usually takes place on the second or third postoperative day. At the latest. within a week - 10 days the patient can resume his normal working life See also: Diet and Nutrition after Cholecystectomy
RISKS AND COMPLICATIONS
Laparoscopic cholecystectomy surgery is the most performed in the world. For this reason, given the standardization of procedures, the risk of complications has stabilized overall at less than one percent. Below is an extract of the information for patients prepared by the operating unit of general surgery of the S. Andrea Hospital in La Spezia, which can be consulted at this link together with the bibliographical references.
Possible Risks
During convalescence, it is advisable to immediately alert the healthcare facility where the operation was performed if symptoms such as: severe abdominal pain, stomach cramps, high fever or chills, yellowing of the skin (jaundice), infection of the wound (which becomes foul-smelling and secreting materials) or major alterations of the alvus (constipation or diarrhea) that last for more than three days.
. Considering the invasiveness of the procedure, recovery from surgery is slower, the wound is more prone to infection and less pleasing, from an aesthetic point of view, to the patient. Discharge occurs within 5 days of the operation (compared to 24-72 hours for laparoscopic cholecystectomy) and the incision of the abdominal muscles requires a longer period of abstention from physical efforts.
