GUIDELINES FOR THE CLINICAL APPLICATION OF LAPAROSCOPIC BILIARY TRACT SURGERY

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PREAMBLE

Laparoscopic cholecystectomy, first performed in 1985, has become the standard of care for patients requiring cholecystectomy. In 1992, an NIH Consensus Development Conference concluded "laparoscopic cholecystectomy provides a safe and effective treatment for most patients with symptomatic gallstones, laparoscopic cholecystectomy appears to have become the procedure of choice for many of these patients."⁽¹⁾ SAGES first offered guidelines for the clinical application of laparoscopic cholecystectomy in May, 1990. These guidelines have since been updated for content and have been expanded to include all laparoscopic biliary tract surgery.

THE ROLE OF THE GENERAL SURGEON

Since preoperative and intraoperative variables may mandate open cholecystectomy in some patients, laparoscopic biliary tract surgery should be restricted to surgeons with sufficient technical skills and clinical judgment to secure and maintain privileges in open biliary tract surgery.

OPERATIVE SETTING

Laparoscopic biliary tract surgery should be performed in the operating room with appropriate equipment and personnel for both laparoscopic and open operations. The surgeon must be satisfied that the operating room personnel, video equipment, and instrumentation are acceptable for laparoscopic biliary tract surgery. Every member of the team must be able to observe the operation comfortably.

LAPAROSCOPIC CHOLECYSTECTOMY

Technique

The principles of the technique for laparoscopic cholecystectomy are well established and have been documented in detail⁽²⁾. Points worthy of emphasis include:

• The cystic duct should be identified at its junction with the gallbladder
• Traction of the gallbladder infundibulum should be lateral rather than cephalad
• Meticulous dissection of the cystic duct and cystic artery is essential
• All energy sources may cause occult injury
• Perforations of the gallbladder should be controlled to prevent loss of stones
• Spilled stones should be retrieved if possible and irrigation is useful for small stones and bile
• Biliary tract imaging should be applied liberally to identify surgically important anomalies, clarify difficult anatomy, and detect common bile duct stones⁽³⁾
• The surgeon should convert to open operation for unresolvable technical difficulties or anatomic uncertainties or anomalies, especially in cases of acute cholecystitis

Indications and Relative Contraindications for Laparoscopic Cholecystectomy

The indications for laparoscopic cholecystectomy have not changed, and remain identical to those for open cholecystectomy. However, the absolute contraindications from the 1980's have changed. Absolute contraindications include inability to tolerate general anesthesia and uncorrectable coagulopathy. The safety of any procedure depends principally on the individual surgeon=s experience and ability to manage potential problems⁽⁴⁾. Some conditions make the operation more difficult:

Prior Surgery

Up to half of patients undergoing attempted laparoscopic cholecystectomy have had prior abdominal surgery. Previous upper abdominal surgery does not always result in adhesions that prevent safe right upper quadrant access. The surgeon must consider the best means for obtaining abdominal access. If using closed (Veress) technique, maximizing the distance from old scars minimizes risk of inadvertent injury. If using open (Hasson) technique, careful identification and dissection of adhesions is necessary. Optical trocars are an appropriate alternative. Adhesions may require adjustment of the laparoscopic view or laparoscopic adhesiolysis, however bowel injury is possible. Additional trocars may be helpful.

Obesity

Obese patients are at high risk for gallstones. Careful preoperative assessment for obesity-related co-morbidities is vital. Measures to minimize deep venous thrombosis and pulmonary complications are believed to be especially important in this group (see SAGES statement on DVT prophylaxis). Access to the abdominal cavity is often challenging because of the thickness of the abdominal wall. The umbilicus is typically the shortest distance between the skin and the peritoneum, however an extensive panniculus may displace the umbilicus caudally. Long instruments may be necessary. Use of gravity to displace intra-abdominal fat and viscera is valuable. The benefits of early ambulation and easier breathing afforded by laparoscopy may diminish postoperative complications.

Pregnancy

Pregnant women may require cholecystectomy. First trimester surgery risks teratogenesis and miscarriage. Third trimester surgery risks preterm labor and premature delivery, as well as difficulties related to poor visualization. The second trimester is safest, with less risk for preterm labor. If possible, elective surgery should be postponed until after delivery. Although research studies show pneumoperitoneum may cause transient fetal tachycardia, fetal hypertension, and maternal and fetal acidosis, clinical studies suggest the risks are low to both mother and fetus. Safety measures have been detailed⁽⁵⁾.

Polypoid Lesions of the Gallbladder/Porcelain Gallbladder

Ultrasonographic characterization of a gallbladder polyp, or radiographic evidence of gallbladder calcification, raises suspicion for gallbladder cancer. Lesion diameter <1.0 cm is associated with benign disease, and may be followed up with serial ultrasound for growth. Gallbladders containing lesions between 1.0 and 1.8 cm may be removed laparoscopically unless invasion of the liver or surrounding structures is apparent. Polyps of diameter >1.8 cm are more likely to be neoplastic, implying the need for laparotomy and more extensive resection^(6,7). Association of gallbladder calcification and cancer is less well defined, although a pattern of selective mucosal calcification seems to be more predictive of cancer than complete intramural calcification⁽⁸⁾.

Reasons for Intraoperative Conversion to Open Cholecystectomy

Conversion to open cholecystectomy is appropriate and should not be considered a complication in cases where the key technical points of the procedure are not possible. If laparoscopic dissection leaves uncertainty about the patient's anatomy, or if concern for injury exists, the surgeon should convert to laparotomy without hesitation. If the surgeon encounters anatomic anomalies, or if inflammation, adhesions, intra-abdominal fat or bleeding makes visualization of the gallbladder difficult, conversion is in the best interests of the patient when the situation cannot be made clear laparoscopically. The treatment of gallbladder cancer is controversial, but most authorities believe it should be treated by open procedure.

Postoperative Management

Since laparoscopic cholecystectomy is usually performed under general anesthesia, patients should be observed in a post-anesthesia care unit. Laparoscopic cholecystectomy may be performed as a same-day, outpatient procedure. Standard of care requires decisions regarding inpatient versus outpatient convalescence to be made on a case-by-case basis by the surgeon.

The possibility of bile or enteric leak, or other complication, must be considered in any patient not recovering satisfactorily in 24-48 hours⁽⁹⁾. Prompt investigation by imaging and appropriate laboratory tests is indicated.

When compared to open cholecystectomy, laparoscopic cholecystectomy may reduce mortality⁽¹⁰⁾, shorten hospitalization⁽¹¹⁾, and hasten return to work⁽¹²⁾.

LAPAROSCOPIC MANAGEMENT OF CHOLEDOCHOLITHIASIS

Clinical suspicion for choledocholithiasis mandates a strategy for assuring short-and long-term biliary tract patency. Diagnosis and management of choledocholithiasis depends on the availability of local resources and consultants⁽¹³⁾.

Although endoscopic retrograde cholangiography (ERC) should not be performed in all patients with cholelithiasis, suspicion for common bile duct (CBD) stones may prompt preoperative ERC. If choledocholithiasis is proven, endoscopic extraction is indicated, usually by sphincterotomy⁽¹⁴⁾. After ERC and sphincterotomy, interval laparoscopic cholecystectomy should usually be performed. Failure to remove CBD stones endoscopically requires surgical removal either by open or laparoscopic common bile duct exploration (CBDE).

In cases where the CBD status is not definitively addressed prior to laparoscopic cholecystectomy and intraoperative cholangiogram or ultrasound confirms choledocholithiasis, options available to the surgeon include but are not limited to^(15,16):

• Open CBD exploration
• Laparoscopic CBDE via the cystic duct or a choledochotomy
• Intraoperative ERC/sphincterotomy
• Postoperative ERC/sphincterotomy
• Observation (only for very small CBD stones)
• Cystic duct drainage (allows drainage and access to the duct)
• Biliary duct stents
• Biliary bypass or sphincterotomy

The optimal approach to CBD stones found at laparoscopic operation depends upon the relative skills of the surgeon and the endoscopic experience and resources available.

Laparoscopic CBDE is a complex biliary procedure that requires a well-trained operating room team and additional facilities and equipment beyond those required for laparoscopic cholecystectomy⁽¹⁷⁾. Specialized equipment, including guidewires, balloon catheters, flexible endoscopes and appropriate accessories, is essential.

Successful laparoscopic CBDE depends on surgeon experience, hepatic and biliary anatomy, cystic duct size, stone characteristics, and CBD diameter. In general, CBD stones less than 8 mm in diameter are amenable to trans-cystic extraction, whereas choledochotomy is required for larger stones. Performance of a choledochotomy requires the surgeon to be adept in laparoscopic suturing techniques.

Indications and relative contraindications for laparoscopic CBDE are comparable to those for open CBDE.

OTHER BILIARY TRACT PROCEDURES

Other laparoscopic procedures on the biliary tract have been performed (e.g. cholecystojejunostomy, hepaticojejunostomy). Such procedures should be restricted to surgeons with extensive laparoscopic experience who are skilled in suturing techniques.

REFERENCES

1. “Gallstones and Laparoscopic Cholecystectomy.” NIH Consensus Conference, JAMA, 1992; 269:1018-1024.

2. Hunter JG. “Exposure, Dissection, and Laser Versus Electrosurgery in Laparoscopic Surgery.” Am J Surg 1993;165:492-496.

3. Sackier JM, Berci G, Phillips E, Carroll B, Shapiro S, Paz-Partlow M. “The Role of Cholangiography in Laparoscopic Cholecystectomy.” Arch Surg 1991;126:1021-1026.

4. Soper NJ. “Effect of Nonbiliary Problems on Laparoscopic Surgery.” Am J Surg 1993; 165:522-526.

5. Curet MJ. “Special Problems in Laparoscopic Surgery. Previous Abdominal Surgery, Obesity, and Pregnancy.” Surg Clin North Am 2000;80:1093-110.

6. Csendes A. “Late Follow Up of Polypoid Lesions of The Gallbladder Smaller Than 10mm.” Am J Surg 2001;557-560

7. Kubota K, Bandai Y, Noie T, IshizakiY, Teruya M, Makuuchi M. “How Should Polypoid Desions of The Gallbladder Be Treated in The Era of Laparoscopic Cholecystectomy?” Surgery 1995;117:481-7.

8. Stephen AE, Berger DL. “Carcinoma in The Porcelain Gallbladder: A Relationship Revisited.” Surgery 2001;129:699-703.

9. Morgenstern L, Berci G, Pasternak E. “Bile Leakage After Biliary Tract Surgery--A Laparoscopic Perspective.” Surg Endosc 1993;7:432-439.

10. Zacks SL, Sandler RS, Rutledge R, Brown RS Jr. “A Population-Based Cohort Study Comparing Laparoscopic Cholecystectomy and Open Cholecystectomy.” Am J Gastroenterol 2002;97:334-40.

11. Grace PA, Quereshi A, Coleman J, Keane R, McEntee G, Broe P, Osborne H, Bouchier-Hayes D. “Reduced Postoperative Hospitalization After Laparoscopic Cholecystectomy.” Br J Surg 1991;78:160-2.

12. Vandenbergh HC, Wilson T, Adams SE, Inglis MJ. “Laparoscopic Cholecystectomy: Its Impact on National Health Economics.” Med J Australia 1995;162:587-90.

13. Perissat J, Huibregtse, Keane FB, Russell RC and Neoptolemos JP. “Management Of Bile Duct Stones In The Era of Laparoscopic Cholecystectomy.” Br J Surg 1994; 81:799-810.

14. Neoptolemos JP, Carr-Locke DL, Fossard DP. “Prospective Randomized Study of Preoperative Endoscopic Sphincterotomy Versus Surgery Alone For Common Duct Stones.” Br J Surg 1987;294:470-474.

15. Berci G, Morgenstern L. “Laparoscopic Management of Common Bile Duct Stones: A Multi-Institutional SAGES Study.” Surg Endosc 1994;8:1168-1175.

16. Fitzgibbons RJ Jr, Gardner GC. “Laparoscopic Surgery And The Common Bile Duct.” World J Surg 2001;25:1317-24.

17. Berci G, Cushieri A, eds. Bile Ducts and Bile Duct Stones. WB Saunders Co. Philadelphia, 1997.

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These guidelines were developed by the Society of American Gastrointestinal Endoscopic Surgeons (SAGES). They were revised by the SAGES Guidelines Committee October 2002, and were reviewed and approved by the SAGES Board of Governors, November 2002.

This is a revision of SAGES publication #0006 originally printed May 1990, revised January 1994, and October 1999.

Requests for reprints should be sent to:
Society of American Gastrointestinal and Endoscopic Surgeons
11300 W. Olympic Blvd, Suite 600
Los Angeles, CA 90064
(310) 437-0544
FAX: (310) 437-0585
E-mail: sagesweb@sages.org
Website: www.sages.org

 

 

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