Laparoscopic cholecystectomy is considered the “gold standard” for the surgical treatment of gallstone disease. It has the same indications as for open cholecystectomy. The optimal timing of surgery will depend on the patient’s overall medical condition and underlying diagnosis.
●Preoperative evaluation
•Liver function tests (LFTs) should be obtained preoperatively. Elevation in the serum total bilirubin and alkaline phosphatase concentrations should raise concerns about complicating conditions.
•Ultrasonography (US) of the right upper quadrant establishes the diagnosis of gallstones, abnormalities of the gallbladder wall, common bile duct (CBD) dilatation, stones, or evidence of acute inflammation of the gallbladder.
•If a patient has a dilated CBD, CBD stones, or jaundice, preoperative endoscopic retrograde cholangiopancreatography (ERCP) or intraoperative cholangiography and possible CBD exploration should be performed.
•Preoperative discussion with the patient should include the possibility of conversion to an open procedure. The patient should be informed about the risks of bile duct injury, bowel injury, vascular injury, and reoperation or need for postoperative ERCP.
•For high-risk patients undergoing laparoscopic cholecystectomy or all patients undergoing laparoscopic cholecystectomy with a high-risk procedure defined above, we suggest prophylactic antibiotics (Grade 2C). Appropriate agents are in this table.
For low-risk patients undergoing laparoscopic cholecystectomy without a high-risk procedure, some UpToDate contributors do, while other UpToDate contributors do not, administer prophylactic antibiotics. There are data to support either practice.
●Standard procedure
The most important consideration in a cholecystectomy is the clear identification of the cystic artery and duct prior to division. The “critical view of safety” should be achieved prior to clipping or dividing any tubular structures.
●Alternative techniques
Alternative minimally invasive techniques of laparoscopic cholecystectomy (eg, needlescopic, single-incision laparoscopic) can be used (where available) for select patients who desire minimal pain and optimal cosmesis.
●Conversion to open surgery
A laparoscopic operation should be converted to an open procedure if the surgeon encounters a situation demanding manual palpation and direct vision for correction. Surgeons should convert to open operations without hesitation if the need arises
