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BILIARY DISEASES

GENERAL CONSIDERATIONS

Approximately 10–20% of the population has gallstones, making biliary pathology an increasing consideration in a patient with abdominal pain. Females are twice as likely to have gallstones. Gallstones are more frequently seen with increasing age and obesity, and are more common in Caucasians and Native Americans than African Americans. Most patients with cholelithiasis remain asymptomatic and never require surgery, but the sequelae of biliary disease remains significant: symptomatic cholelithiasis, gallstone pancreatitis, acute cholecystitis, chronic cholecystitis, choledocholithiasis, and ascending cholangitis. Understanding the basic pathophysiology of each of these conditions is essential to appropriately diagnose and treat patients with biliary disease.

A basic understanding of biliary disease requires a vocabulary of terms used in describing them. Many have similar sounding names and can be confusing. A summary of the definitions can be found in Table 33-1. Although the treatment of most biliary diseases ultimately requires cholecystectomy, each condition must be evaluated and treated in a unique fashion.

Table 33–1.Basic definitions.

OPERATIVE PROCEDURES & COMPLICATIONS

Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy has replaced the open operation as the gold standard for removing the gallbladder. Many studies have documented an improved recovery time, decreased postoperative ileus, and decreased pain along with improved aesthetics associated with laparoscopy.

Although associated with less morbidity, laparoscopic cholecystectomy does require pneumoperitoneum (insufflation of carbon dioxide gas into the abdomen) and may not be feasible in patients with other severe comorbid conditions (eg, the morbidly obese, severe congestive heart failure, advanced pulmonary disease, uncontrolled coagulopathy). If operation is required, open cholecystectomy remains the only viable option for these patients.

Advanced Laparoscopic & Robotic Cholecystectomy

In carefully selected patients, both single-incision laparoscopic cholecystectomy (SILC) and robotic cholecystectomy have been shown to be feasible and safe approaches in institutions with available technology. Although both techniques have been noted to have slightly longer operative times (mean difference of 18.5 minutes), a steep learning curve is observed and no increase in overall complication rates has been reported.

Postoperative Complications

The most feared complication of laparoscopic cholecystectomy is injury to the common bile duct. The reported incidence of bile duct injuries varies from 0% to 3% depending on the underlying pathology necessitating cholecystectomy. Minor biliary injuries include cystic duct leaks and biliary leaks from the hepatic ...

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