Table 3

Indications for cholecystectomy Gallstones

Conditions* When to perform surgery

Biliary painFirst open operative day

8
Biliaryfor the detection
dyskinesiaFirst of day
open operative gallstones. In a
Calcified gallbladderFirst open operative day Acute cholecystitisUrgent (within 72 hours)
CholedocholithiasisAfter
small number the ofcommon bile ductno objective
patients,
is cleared
evidence of gallstones will be found
Gallstone pancreatitisBefore discharge but after
despite
pancreatitis the presence of classic biliary
resolves
pain. If there is a high
index of
*Onlysuspicion
patients who arefor gallbladder
dis- ease,
fit for surgery.
patients should undergo testing to rule
out biliary dyskinesia. In the majority
(94 percent) of patients with dyskinesia,
symptoms improve or the disease is cured
after cholecystectomy.9 Dyskinesia was
defined by a gall- bladder ejection
fraction of less than 50 percent using a
cholecystokinin cholecystoscintigraphy Table 4
(hepatobiliary iminodiacetic acid) scan in Benefits of laparoscopy over laparotomy
conjunction with typical clinical
symptoms.9 Better cosmesis Less postoperative pain
Less tissue
Earlier return to work Lower costsdamage Shorter or no hospital stay
Surgical Treatment of Gallstone Lowercan
mortality
be extremely difficult to repair, and
disease Cholecystectomy remains the management at a tertiary care center with
primary procedure for the management of
symptomatic gallstone disease. It is safe, surgeons expe- rienced in biliary injuries
has the lowest risk of recurrence, and should be strongly considered.13
provides 92 percent of patients with
complete relief of their biliary pain.10 nonsurgical Treatment of Gallstone
Indications for cholecystectomy are listed disease
in Table 3. lap- aroscopic cholecystectomy
continues to have numerous advantages oral dissolution therapy using bile acids
compared with the open technique (Table 4), has successfully dissolved gallstones in an
and the safety of the laparoscopic approach
extremely limited patient popu- lation. The
to the treat-
clinical efficacy of bile acid therapy was
ment of gallstone disease in various
deter- mined in patients with symptomatic
patient populations is gaining clinical
radiolucent gallstones smaller than 15 mm
acceptance (Table 5).
within a functioning gallbladder. In this
Between 5 and 26 percent of patients
study,14 a 56 percent reduction in biliary
undergoing elec- tive laparoscopic
pain was reported
cholecystectomy will require conversion to
11,12
an open procedure. A common reason for
conver- sion is the inability to clearly
identify the biliary anatomy. In a recent
meta-analysis,11 researchers compared the
outcomes of laparoscopic cholecystectomy
for more than 78,000 patients in 98
studies with the outcomes of open
cholecystectomy for more than 12,000
patients in 28 stud- ies. The researchers
found a decreased mortality rate in
patients undergoing laparoscopic
cholecystectomy com- pared with those
undergoing open cholecystectomy (8.6 to 16
deaths per 10,000 patients versus 66 to 74
deaths per 10,000 patients, respectively)
but also noted a higher rate of common bile
duct injury (36 to 47 injuries per 10,000
patients versus 19 to 29 injuries per 10,000
patients, respectively).11 Common bile duct
injuries associated with cholecystectomy
 after three months and a mean gallstone
dissolution rate of 59 percent occurred
after 12 months of treatment with 10 mg per
kg per day of ursodeoxycholic acid.
Gallstone
recurrenceisadisadvantageofthistreatment;
approximately 25 percent of patients develop
recurrent gallstones within five years.15
Presently, bile acid therapy is indicated
only for patients unfit or unwilling to
undergo surgery.5
management of common Gallstone
complications
AcUTE chOlEcySTITIS
Acute cholecystitis develops in up to 10
percent of patients with symptomatic
gallstones and is caused by the com-

Table 5
Vanishing contraindications
to laparoscopic cholecystectomy

Acute cholecystitis Obesity

Pregnancy
Advanced age Chronic obstructive
pulmonary disease* Previous abdominal surgery
Cirrhosis

*Excluding patients with sever chronic obstructive pulmonary

disease.
Child class A and B cirrhosis only; laparoscopic cholecystectomy not indicated for end-stage cirrhosis.
No prospective clinical trials of laparoscopic cholecystectomy in pregnant women have been conducted.
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