cholecystectomy

胆嚢摘出術 　

WordNet

1. surgical removal of the gall bladder (usually for relief of gallstone pain)

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出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2015/06/09 22:17:53」(JST)

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Cholecystectomy
Intervention
X-Ray during Laparoscopic Cholecystectomy
ICD-9-CM	575.0
MeSH	D002763

Laparoscopic Cholecystectomy as seen through laparoscope

Cholecystectomy (/ˌkɒləsɪsˈtɛktəmi/; plural: cholecystectomies) is the surgical removal of the gallbladder. It is a common treatment of symptomatic gallstones and other gallbladder conditions. Surgical options include the standard procedure, called laparoscopic cholecystectomy, and an older more invasive procedure, called open cholecystectomy.

Indications

Indications for cholecystectomy include inflammation of the gall bladder (cholecystitis), biliary colic, risk factors for gall bladder cancer, and pancreatitis caused by gall stones.

Cholecystectomy is the recommended treatment the first time a person is admitted to hospital for cholecystitis. Cholecystitis may be acute or chronic, and may or may not involve the presence of gall stones. Risk factors for gall bladder cancer include a "porcelain gallbladder," or calcium deposits in the wall of the gall bladder, and an abnormal pancreatic duct.

Cholecystectomy can prevent the relapse of pancreatitis that is caused by gall stones that block the common bile duct.

Procedure

Laparoscopic cholecystectomy

Laparoscopic cholecystectomy has now replaced open cholecystectomy as the first-choice of treatment for gallstones and inflammation of the gallbladder unless there are contraindications to the laparoscopic approach. This is because open surgery leaves the patient more prone to infection. Sometimes, a laparoscopic cholecystectomy will be converted to an open cholecystectomy for technical reasons or safety.

A US Navy general surgeon and an operating room nurse discuss proper procedures while performing a laparoscopic cholecystectomy surgery.

Laparoscopic cholecystectomy requires several small incisions in the abdomen to allow the insertion of operating ports, small cylindrical tubes approximately 5 to 10 mm in diameter, through which surgical instruments and a video camera are placed into the abdominal cavity. The camera illuminates the surgical field and sends a magnified image from inside the body to a video monitor, giving the surgeon a close-up view of the organs and tissues. The surgeon watches the monitor and performs the operation by manipulating the surgical instruments through the operating ports.

To begin the operation, the patient is placed in the supine position on the operating table and anesthetized. A scalpel is used to make a small incision at the umbilicus. Using either a Veress needle or Hasson technique, the abdominal cavity is entered. The surgeon inflates the abdominal cavity with carbon dioxide to create a working space. The camera is placed through the umbilical port and the abdominal cavity is inspected. Additional ports are opened inferior to the ribs at the epigastric, midclavicular, and anterior axillary positions. The gallbladder fundus is identified, grasped, and retracted superiorly. With a second grasper, the gallbladder infundibulum is retracted laterally to expose and open Calot's Triangle (cystic artery, cystic duct, and common hepatic duct). The triangle is gently dissected to clear the peritoneal covering and obtain a view of the underlying structures. The cystic duct and the cystic artery are identified, clipped with tiny titanium clips and cut. Then the gallbladder is dissected away from the liver bed and removed through one of the ports. This type of surgery requires meticulous surgical skill, but in straightforward cases, it can be done in about an hour.

Recently, this procedure is performed through a single incision in the patient's umbilicus. This advanced technique is called Laparoendoscopic Single Site Surgery or "LESS" or Single Incision Laparoscopic Surgery or "SILS". In this procedure, instead of making 3-4 four small different cuts (incisions), a single cut (incision) is made through the navel (umbilicus). Through this cut, specialized rotaculating instruments (straight instruments which can be bent once inside the abdomen) are inserted to do the operation. The advantage of LESS / SILS operation is that the number of cuts are further reduced to one and this cut is also not visible after the operation is done as it is hidden inside the navel. A meta-analysis published by Pankaj Garg et al. comparing conventional laparoscopic cholecystecomy to SILS Cholecystectomy demonstrated that SILS does have a cosmetic benefit over conventional four-hole laparoscopic cholecystectomy while having no advantage in postoperative pain and hospital stay. A significantly higher incidence of wound complications, specifically development of hernia, has been noted with SILS. SILS has also been associated with a higher risk for bile duct injury

Open cholecystectomy

Open cholecystectomy is occasionally performed in certain circumstances, such as failure of laparoscopic surgery, severe systemic illness causing intolerance of pneumoperitoneum, or as part of a liver transplant. In open cholecystecomy, a surgical incision of approximately 10 to 15 cm is typically made below the edge of the right ribcage. The liver is retracted superiorly, and a top-down approach is taken (from the fundus towards the neck) to the remove of the gallbladder from the liver, typically using electrocautery.

Open cholecystectomy is associated with greater post-operative pain and wound complications such as wound infection and incisional hernia compared to laparoscopic cholecystectomy, so it is reserved for select cases.

Procedural risks and complications

Abdomen of a 45-year-old male approximately one month after a laparoscopic cholecystectomy. Surgical incision points are highlighted; the one at top right is barely visible. The gall bladder was removed via the incision at the navel. There is a fourth incision (not shown) on the patient's right lower flank, used for draining. All incisions have healed well and the most visible remaining effect of surgery is from the pre-operative hair removal.

The 1-week-old incisions of a post-operative laparoscopic cholecystectomy patient as indicated by red arrows. The 3 abdominal incisions are approximately 6mm, while the fourth incision near the umbilicus is 18mm, each closed with dissolvable sutures. Minor inflammation can be seen surrounding each site due to skin irritation caused by removal of Tegaderm dressings.

Laparoscopic cholecystectomy does not require the abdominal muscles to be cut, resulting in less pain, quicker healing, improved cosmetic results, and fewer complications such as infection and adhesions. Most patients can be discharged on the same or following day as the surgery, and can return to any type of occupation in about a week.

An uncommon but potentially serious complication is injury to the common bile duct, which connects the cystic and common hepatic ducts to the duodenum. An injured bile duct can leak bile and cause a painful and potentially dangerous infection. Many cases of minor injury to the common bile duct can be managed non-surgically. Major injury to the bile duct, however, is a very serious problem and may require corrective surgery. This surgery should be performed by an experienced biliary surgeon.

Abdominal peritoneal adhesions, gangrenous gallbladders, and other problems that obscure vision are discovered during about 5% of laparoscopic surgeries, forcing surgeons to switch to the standard cholecystectomy for safe removal of the gallbladder. Adhesions and gangrene can be serious, but converting to open surgery does not equate to a complication.

A Consensus Development Conference panel, convened by the National Institutes of Health in September 1992, endorsed laparoscopic cholecystectomy as a safe and effective surgical treatment for gallbladder removal, equal in efficacy to the traditional open surgery. The panel noted, however, that laparoscopic cholecystectomy should be performed only by experienced surgeons and only on patients who have symptoms of gallstones.

In addition, the panel noted that the outcome of laparoscopic cholecystectomy is greatly influenced by the training, experience, skill, and judgment of the surgeon performing the procedure. Therefore, the panel recommended that strict guidelines be developed for training and granting credentials in laparoscopic surgery, determining competence, and monitoring quality. According to the panel, efforts should continue toward developing a noninvasive approach to gallstone treatment that will not only eliminate existing stones, but also prevent their formation or recurrence.

One common complication of cholecystectomy is inadvertent injury to analogous bile ducts known as Ducts of Luschka, occurring in 33% of the population. It is non-problematic until the gall bladder is removed, and the tiny supravesicular ducts may be incompletely cauterized or remain unobserved, leading to biliary leak post-operatively. The patient will develop biliary peritonitis within 5 to 7 days following surgery, and will require a temporary biliary stent. It is important that the clinician recognize the possibility of bile peritonitis early and confirm diagnosis via HIDA scan to lower morbidity rate. Aggressive pain management and antibiotic therapy should be initiated as soon as diagnosed.

During laparoscopic cholecystectomy, gallbladder perforation can occur due to excessive traction during retraction or during dissection from the liver bed. It can also occur during extraction from the abdomen. Infected bile, pigment gallstones, male gender, advanced age, perihepatic location of spilled gallstones, more than 15 gallstones and an average size greater than 1.5 cm have been identified as risk factors for complications. Spilled gallstones can be a diagnostic challenge and can cause significant morbidity to the patient. Clear documentation of spillage and explanation to the patient is of utmost importance, as this will enable prompt recognition and treatment of any complications. Prevention of spillage is the best policy.

Biopsy

After removal, the gallbladder should be sent for pathological examination to confirm the diagnosis and look for an incidental cancer. If cancer is present, a reoperation to remove part of the liver and lymph nodes will be required in most cases.

Long-term prognosis

A minority of the population, from 5% to 40%, develop a condition called postcholecystectomy syndrome, or PCS. Symptoms can include gastrointestinal distress and persistent pain in the upper right abdomen.

As many as 20% of patients develop chronic diarrhea. The cause is unclear, but is presumed to involve the disturbance to the bile system. Most cases clear up within weeks or a few months, though in rare cases the condition may last for many years. It can be controlled with medication such as cholestyramine.

Complications

The most serious complication of cholecystectomy is damage to the common bile duct. This occurs in about 0.25% of cases. Damage to the duct that causes leakage typically manifests as fever, jaundice, and abdominal pain several days following cholecystectomy. A lacerated, leaky bile duct may be repaired through a procedure called ERCP, or endoscopic retrograde cholangiopancreatography.

• emphysematous cholecystitis
• bile leak ("biloma")
• bile duct injury (about 5–7 out of 1000 operations. Open and laparoscopic surgeries have essentially equal rate of injuries, but the recent trend is towards fewer injuries with laparoscopy. It may be that the open cases often result because the gallbladder is too difficult or risky to remove with laparoscopy)
• abscess
• wound infection
• bleeding (liver surface and cystic artery are most common sites)
• hernia
• organ injury (intestine and liver are at highest risk, especially if the gallbladder has become adherent/scarred to other organs due to inflammation (e.g. transverse colon)
• deep vein thrombosis/pulmonary embolism (unusual- risk can be decreased through use of sequential compression devices on legs during surgery)
• fatty acid and fat-soluble vitamin malabsorption

Epidemiology

About 600,000 people receive a cholecystectomy in the United States each year.

In a study of Medicaid-covered and uninsured U.S. hospital stays in 2012, cholecystectomy was the most common operating room procedure.

References

External links

• Soltes & Radoňak risk score for elective laparoscopic cholecystectomy difficulty
• Video of Laparoscopic Cholecystectomy
• Laparoscopic Cholecystectomy
• "Gallbladder Removal". New York Times. 2007-08-01. 
• Information and Photographs of conventional and SILS (LESS) Single Incision Laparoscopic Cholecystectomy

UpToDate Contents

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• 1. 腹腔鏡下胆嚢摘出術 laparoscopic cholecystectomy
• 2. 腹腔鏡下胆嚢摘出術の合併症 complications of laparoscopic cholecystectomy
• 3. 開腹下胆嚢摘出術 open cholecystectomy
• 4. 急性有石胆嚢炎の治療 treatment of acute calculous cholecystitis
• 5. 無石胆嚢炎 acalculous cholecystitis

English Journal

• Regional variations in cholecystectomy rates in Sweden: impact on complications of gallstone disease.

• Noel R1, Arnelo U1, Enochsson L1, Lundell L1, Nilsson M1, Sandblom G1.
• Scandinavian journal of gastroenterology.Scand J Gastroenterol.2016 Apr;51(4):465-71. doi: 10.3109/00365521.2015.1111935. Epub 2015 Nov 17.
• Objective There are considerable variations in cholecystectomy rates between countries, but it remains unsettled whether high cholecystectomy rates prevent future gallstone complications by reducing the gallstone prevalence. The aims of this study were to investigate the regional differences in chol
• PMID 26784974

• Endoscopic naso-gallbladder drainage versus gallbladder stenting before cholecystectomy in patients with acute cholecystitis and a high suspicion of choledocholithiasis: a prospective randomised preliminary study.

• Yang MJ1, Yoo BM1, Kim JH1, Hwang JC1, Baek NH2, Kim SS1, Lim SG1, Kim JH2, Shin SJ1, Cheong JY1, Lee KM1, Lee KJ1, Kim WH2, Cho SW1.
• Scandinavian journal of gastroenterology.Scand J Gastroenterol.2016 Apr;51(4):472-8. doi: 10.3109/00365521.2015.1115116. Epub 2015 Nov 23.
• Objective Endoscopic transpapillary gallbladder drainage using a nasocystic tube or plastic stent has been attempted as an alternative to percutaneous drainage for patients with acute cholecystitis who are not candidates for urgent cholecystectomy. We aimed to assess the efficacy of single-step endo
• PMID 26595503

• A randomized multicenter study of minilaparotomy cholecystectomy versus laparoscopic cholecystectomy with ultrasonic dissection in both groups.

• Aspinen S1, Harju J2, Kinnunen M1, Juvonen P1, Kokki H3, Eskelinen M1.
• Scandinavian journal of gastroenterology.Scand J Gastroenterol.2016 Mar;51(3):354-9. doi: 10.3109/00365521.2015.1091496. Epub 2015 Sep 28.
• OBJECTIVE: Ultrasonic dissection (UsD) has been used in laparoscopic cholecystectomy (LC), though it is not the golden standard technique. Applying UsD to cholecystectomy by minilaparotomy (MC) is less common and there are no prospective randomized trials comparing these two techniques. Therefore, w
• PMID 26414236

Japanese Journal

• 腹腔鏡下胆嚢摘出術 (特集 胆嚢疾患)

• Surgeon : technical magazine for veterinary surgeons : 小動物外科専門誌 20(6), 42-55, 2016-11
• NAID 40021013686

• 腹腔鏡下胆囊摘出術困難例でのHALS移行による手術の低侵襲化 (特集 HALSの意義とテクニック) -- (HALSによる肝胆膵脾の手術)

• 外科 = Surgery : 臨床雑誌 78(9), 973-976, 2016-09
• NAID 40020945378

• 急性胆嚢炎に対する待機的腹腔鏡下胆嚢摘出術の至適手術時期に関する検討

• 広島医学 69(7), 533-537, 2016-07
• NAID 40020924443

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★リンクテーブル★

リンク元	「胆嚢摘出術」「ectomy」「cholecystectomize」
拡張検索	「laparoscopic cholecystectomy」「post-cholecystectomy syndrome」

「胆嚢摘出術」

　　[★]

ectomy

英

cholecystectomy

ラ

cholecystectomia

同

胆嚢切除術

関

胆嚢

「ectomy」

　　[★]

• comb form.

• 切除(術)

• ex.

• 胆嚢摘出術 cholecystectomy

関

resection

「cholecystectomize」

　　[★]

• v.

• 胆嚢切除する

関

cholecystectomy

「laparoscopic cholecystectomy」

　　[★] 腹腔鏡下胆嚢摘出術 LC

「post-cholecystectomy syndrome」

　　[★] 胆嚢摘出術後症候群