The Benefits and Risk of Laparoscopic Cholecystectomy
18 Apr 2005
In 1991 Dr. Joacques Perissat at the University of Bordeau, in France, announced to the World Congress of Surgeons that he had removed a gallbladder (cholecystectomy), using optical instruments inserted through a few small incisions. Now, 90 percent of
of gallbladder operations are done by fiber-optics. What are the advantages and what is its most devastating complication? And the crematorium is the cure for some gallstones.
An emergency cholecystectomy is required when a stone blocks the common bile duct (CBD) resulting in an acute inflammation of the gallbladder. To prevent this from happening, patients are often advised to have a cholecystectomy before this complication occurs. It’s technically easier and safer to remove a gallbladder when the organ isn’t inflamed.
In the past it was more difficult for doctors to decide if and when a cholecystecomy should be done. The problem? Some gallstones can remain in the gallbladder for a lifetime without causing trouble. So why subject patients without symptoms to an abdominal incision and several weeks of recuperation? One can argue these stones are best left to the crematorium when they are unexpectedly found by ultrasound.
Since laparoscopy surgery results in less pain and a speedy recovery, more and patients without symptoms are advised to have a cholecystectomy to prevent possible later complications. For this button-hole surgery an optical instrument, like the periscope on a submarine, is inserted through a small cut in the abdomen. This allows the surgeon to view the abdominal organs directly and he can also see the whole operative area on a TV screen.
But advising patients without symtoms to have surgery is where sound judgment and informed consent is vital. As a professor of surgery at The Harvard Medical School counselled, "It’s impossible to make a patient feel any better who doesn’t have any symptoms!"
But if God is in Heaven, the birds singing and the sun shining laparoscopy beats the large abdominal incision by a mile.
The problem is that little holes in the abdomen can, on occasion, trigger catastrophic problems for patients. The most devastating complication is injury to the common bile duct, the small tube that carries bile from the gallbladder to the small bowel. Injury to the CBD means jaundice, and if it’s not treated, results in death.
In one study of 613,706 cholecystectomy patients done by laparoscopy 2380 suffered injury to the CBD (0.39 percent). Another study reported an injury incidence of 0.5 percent.
CBD injuries occur for several reasons. Like everything else practice makes perfect whether you’re a plumber or a surgeon. So injuries are more likely to occur during the learning curve of surgeons. It’s entirely different to operate by open abdominal incision from manipulating instruments through the laparoscope.
Experienced surgeons, like wise generals, also know when to retreat during a laparoscopy procedure. If they encounter an acutely inflamed gallbladder, extensive adhesions from previous operations, abnormal anatomy or other technical difficulties they will call it quits and switch to an abdominal incision. A less experienced surgeon may continue and get into trouble.
Prevention is always better than cure and there’s no better example than CBD injury. Once the duct has been injured, repairing it is a tedious and difficult task often associated with long-term complications. Anthony Eden, Britain’s former Prime Minister, eventually died from this complication even though the injured CBD was repaired by the world’s leading surgeon.
For patients who have had several attacks of gallbladder pain it makes sense to remove this organ before it requires an emergency operation. But those without symptoms should weigh the situation carefully with their family doctor and specialist before agreeing to an elective cholecystectomy.
I’m sure many readers know of people who have had successful laparoscopy surgery for gallbladders and injured knees. But there is a subtle difference between these diverse procedures. If a knee operation gives a less than perfect result it’s not life-threatening. One can learn to live with a bothersome knee. One cannot survive with a severed common bile duct.
A recent report in the Journal of The Canadian Medical Association claims that laparoscopic cholecystectomy to prevent later complications may be of overall benefit to the health of patients. It’s the word, "may" that merits close attention.
