Cholecystectomy

Cholecystectomy refers to the surgical removal of the gallbladder. It is most often performed for symptomatic or high-risk cholelithiasis and acute cholecystitis. It can also be a component of a more extensive surgical resection (e.g., Whipple procedure). Laparoscopic cholecystectomy is most commonly performed, while open cholecystectomy is typically reserved for select cases. The decision to proceed with surgery and its timing largely depends on patient and disease characteristics. Early complications of the procedure include infection, bleeding, bowel injury, and postcholecystectomy bile leak. Late complications include hernias, strictures, fistulas, diarrhea, and postcholecystectomy syndrome.

See also “Cholelithiasis,” “Cholecystitis,” “Choledocholithiasis,” “Cholangitis,” “Biliary cancer,” and “Pancreatic and hepatic surgery.”

Surgical removal of the gallbladder

• Symptomatic cholelithiasis
• Asymptomatic cholelithiasis with an increased risk of:
  • Gallbladder cancer [1][3][4]
  • Developing complications [4][5]
  • Becoming symptomatic [4][6][7]
• Acute calculous cholecystitis
• Acalculous cholecystitis
• Resectable pancreatic and/or hepatobiliary neoplasms (often combined with a more extensive resection) (see also “Pancreatic and hepatic surgery”)

• Absolute: none; risks are primarily related to anesthesia
• Relative
  • Hemodynamic or respiratory instability
  • Uncorrected coagulopathy or bleeding diathesis
  • History of extensive abdominal surgery
  • Cirrhosis
  • Portal hypertension
  • Morbid obesity
  • Acute phase of cholangitis

We list the most important contraindications. The selection is not exhaustive.

Timing

Timing of cholecystectomy depends on the indication and individual surgical risks (See “Surgical procedural risk assessment” and “Preoperative risk stratification tools” for details).

• Symptomatic uncomplicated cholelithiasis: electively, but as early as possible [1][8][9]
• Uncomplicated choledocholithiasis: within 72 hours of ERCP-guided stone clearance [1][10]
• Complicated cholelithiasis or choledocholithiasis: depends on the severity of complication and the patient's anesthesia risks
• Mild biliary pancreatitis: during the same hospital admission [11][12][13]
• Acute cholecystitis (see ''Treatment'' in “Acute cholecystitis” for details) [14][15]
  • Low-risk mild acute cholecystitis: early laparoscopic cholecystectomy
  • High-risk or severe acute cholecystitis: interval laparoscopic cholecystectomy
• Acute cholangitis: ∼ 6 weeks after successful ERCP-guided stone clearance [16]

Approach [2]

• Laparoscopic cholecystectomy
  • Removal of the gallbladder via a laparoscopic approach
  • Current standard of care for most indications of cholecystectomy [17]
• Open cholecystectomy
  • Removal of the gallbladder via an abdominal incision (typically right subcostal)
  • Not routinely performed
  • Indications include:
    • Unsuccessful laparoscopic cholecystectomy
    • Gallbladder cancer
    • As part of a bigger operative procedure that requires an open surgery

Intraoperative and early postoperative complications [1][2][18]

• Hemorrhage
• Transmural bowel injury
• Surgical site infection
• Postcholecystectomy bile leak [19][20][21]
  • Etiology
    • Inadequately ligated cystic duct (most common)
    • Leak from small biliary ductules from the dissected gallbladder bed
    • Injury to bile duct
  • Clinical features
    • Intraoperatively: golden yellow bile in the operative field
    • Postoperatively
      • Fever, abdominal pain, persistent paralytic ileus
      • Biliary peritonitis
      • Subhepatic collection → biloma or abscess
  • Treatment
    • Intraoperative diagnosis: repair of injured bile duct and/or placement of drain in the gallbladder fossa
    • Postoperative diagnosis: ERCP and stenting or surgical repair, depending on the severity

Delayed complications [1][2][18]

• Incisional hernia (at trocar site)
• Biliary stricture
• Biliary-enteric fistula
• Postcholecystectomy diarrhea
  • Definition: chronic diarrhea after removal of the gallbladder [2][22]
  • Pathophysiology: Removal of the gallbladder → no reservoir of bile → entry of excess bile acids into the colon → secretory diarrhea [23][24]
    • May also be functional or due to other undiagnosed causes of diarrhea
  • Diagnostics: SeHCAT test [2]
  • Treatment: Preferred first-line agent is cholestyramine. [22]
• Postcholecystectomy syndrome: persistent RUQ pain or new symptoms following gallbladder removal [2][25]
  • Incidence: 10–15% of patients [2]
  • Etiology
    • Biliary (e.g., choledocholithiasis, biliary stricture, sphincter of Oddi dysfunction)
    • Pancreatic (e.g., pancreatitis, pancreatic pseudocyst, pancreatic malignancy)
    • Other gastrointestinal causes (e.g., GERD, IBS, PUD)
    • Extraintestinal causes (e.g., coronary heart disease, pain syndromes, wound neuroma)
  • Clinical features: Commonly RUQ abdominal pain associated with GI symptoms (e.g., nausea, vomiting, diarrhea), but often variable and often nonspecific
  • Diagnostics
    • Initial tests: LFTs, transabdominal ultrasound
    • Additional tests to rule out bile duct stones: endoscopic ultrasound or MRCP [1]
  • Treatment: management of the underlying cause, e.g., ERCP-guided stone extraction for cholelithiasis [1]

We list the most important complications. The selection is not exhaustive.