Laparoscopic Cholecystectomy

With a length of about 8cm and a diameter of roughly 4cm, the gallbladder is among the smallest of organs in the digestive system (WebMD, 2011). Although it is small in stature, it is mighty big in terms of functionality and importance to the whole human body. This small pocket of tissues is located just beneath the liver and serves as not only the liver-small intestine go-between, but also a collection tank for the bodily fluid bile. Bile, a bitter, yellow fluid, is a digestive enzyme that is produced by the liver to help in the breakdown of ingested fats (WebMD, 2011).

The liver, gallbladder, and small intestine are connected via small channels, or ducts, and when the liver produces bile, some is funneled directly into the small intestine, but most is diverted into the gallbladder. When in the gallbladder, bile is then squirted down into the small intestine, in varying amounts, as needed. Amazingly, these ducts are not just one way channels starting from the liver and eventually ending in the small intestine; they are actually two-way streets that allow bile to be filtered back into the gallbladder when pressure in the small intestine mounts due to the production of excess bile.

Although this process resembles a flawless system, mishaps can still occur. For reasons unknown to scientists, bile within the gallbladder can sometimes crystallize and harden, forming what are known as gallstones. Multiple gallstones cause Cholecystitis, or severe inflammation of the gallbladder (WebMD, 2011) Cholecystitis causes debilitating pain and profuse vomiting in the individuals it infects. When something goes awry within the gallbladder or ductwork, removal surgery is the most common resolution because one cannot “pass” a gallstone similar to how one would a kidney stone. For this case study, Cecilee M. L. James was just age 18 when she endured textbook gallbladder attacks so severe she would be rendered unconscious. Due to numerous blood panels, ultrasounds, and the inevitable laparoscopic cholecystectomy, this one tiny organ has changed her life. ***

The patient, Cecilee Mary Louise James, was 18 years of age, weighted approximately 130 pounds and stood 5’5” tall in the summer vacation of 2010. During a routine doctor’s appointment needed to go back to school, she complained of having had severe pain that radiated down the right side of her abdomen and extended into her low back. She told her normal family doctor, Dr. Brenda Wolfe, M.D., that these pain attacks started at the beginning of the summer, came about three times a week, and lasted anywhere from 30 to 45 minutes. Ms. James also disclosed to Dr. Wolfe that the pain would eventually stop because she would be overcome by bouts of nausea and vomiting, severe diarrhea, or sometimes black outs. When asked by both her doctor and mom why she did not mention her pain attacks at the beginning of the summer, her response was, “I just thought the pain was a side effect of the new HIV medications.”

Having had HIV infection since she was born, Cecilee has lived through and experienced pretty much every side effect different medicines have to offer. Around the time somewhere in late May/early June of 2010, Cecilee had started four new HIV medications and merely by coincidence this is when her pain attacks also started. For her HIV she was taking 400mg (2 tabs once daily) of Darunavir, 300mg (a tab once daily) of Truvada, 100mg (a tab once daily) of Ritonavir, and 400mg (1 tab every 12 hours) of Raltegravir. This particular HIV regiment has a wide range of possible side effects that mimics gallbladder disease. The Isentress (Raltegravir) and Truvada can cause episodes of dizziness, stomach and back pain, and the Norvir (Ritonavir) and Prezista (Darunavir) can cause severe allergic reactions and diarrhea. Because of the pain her HIV medicines cause, Cecilee is also an avid 200mg Advil taker as well.

After hearing her laundry list of symptoms, Dr. Wolfe ordered a complete blood panel checking not only Cecilee’s CD4 and viral load counts, but also cardiovascular, pancreatic, and liver enzyme levels. The results came back and showed that Ms. James’s pancreas enzymes were grossly elevated passed normal amounts, and her heart was severely stressed. She prescribed Cecilee start taking Prilosec OTC to help what she believe is just severe heart burn. “A bad case of heart burn,” Dr. Wolfe told Cecilee, “could explain the tightness in your chest and the abdominal pain.” However, the abnormally high pancreas levels also caused Dr. Wolfe to refer Cecilee to Gastroenterologist Dr. I.W Chang, just in case.

A Gastroenterologist is a medical doctor who specializes in the diagnosis and treatment of diseases of the digestive system. Dr. Chang is labeled as one of the best Gastroenterologists in the Lake County Area. When Cecilee when to see Dr. Chang, she was left very disheartened because he firmly felt nothing was wrong with her. While in the examination room he, too, listened to her symptoms and his response was, “Ms. James you seem to be describing a disease of the gallbladder to a ‘T’, but you are so young, are not even close to being overweight, and your medical history says there is no family history of gallbladder disease. So in my opinion it cannot possible be your gallbladder that is causing all your pain. That’s the good news, however, the bad news is I am ordering you to schedule an upper GI scope be done so we can see what is really going on.” During that Monday night’s Chicago Bears football game, Cecilee’s pain attacks came back with a vengeance; she was experiencing pain so severe she could not physically move. Being rushed to the ER was her only immediate resolution. In the ER, they gave the patient morphine the help manage the pain.

When Cecilee was stable, an ultrasound of her abdomen was taken and, to the ultrasound technician’s amazement, there were 6-7 cholesterol gallstones in Cecilee’s gallbladder. Her stones had oval diameters ranging from 2-3cm to golf ball size. The ER team of Munster Community Hospital were shocked not only because someone so young and physically fit developed gallstones, but also that the patient had dealt with the pain for such a long period of time before seeking treatment. The emergency room team then referred Cecilee to surgeon Dr. Terrence Dempsey of the Lake Surgical Associates. The patient went to Dr. Dempsey for a preoperative interview. To start off the appointment, Dr. Demspey listened to Cecilee complaints about the pain and pushed on her abdomen a little as to get a feel if her gallbladder was inflated or severely inflamed. He then said, “You are probably the youngest patient I had to perform a gallbladder removal surgery on.” With that Dr. Dempsey went on to give Cecilee her options as far as surgeries go. He told her that the laparoscopic cholecystectomy was the way that is more modernly done.

He explained that patients are put under general anesthesia, four small incisions (no bigger than a half inch in length) were made in the abdomen, the abdominal cavity would then be inflated with carbon dioxide, and the gallbladder was removed. He said that although this technique was an outpatient procedure, meaning one goes in for the procedure and then is discharged that same day, there be a week of absolute bed rest at home that would proceed. This means that activities such as work, school, and driving are prohibited for one week subsequent to the surgery. However, he cautioned Cecilee that the laparoscopic cholecystectomy was being planned, because of all the medicines she is taking on the day of the surgery it will be determined whether or not her blood is stable enough to undergo the laparoscopic technique. If on surgery day she was deemed ineligible, Cecilee would undergo an open cholecystectomy, where one large incision across the abdomen is made and then the gallbladder is extracted.

The nurse then stepped in and started going over some other preparations Cecilee needed to do before surgery day. She said Cecilee should not eat or drink anything starting at 7pm the night before surgery, effective immediately and up until surgery day Cecilee cannot ingest pain relievers such as: Advil, Ibuprofen, or Aspirin because they are known blood thinners. The nurse then went over some risks and complications that can occur during a laparoscopic cholecystectomy. She said some of the complications that can occur include leakage of bile in the abdomen bleeding, pneumonia, blood clots, infection, or heart problems. She also mentioned that any laparoscopic cholecystectomy complications only occur in less than 2% of patients undergoing such a procedure.

On October, 19 2010, the patient Cecilee James was admitted into Munster Community Hospital in order to undergo a laparoscopic cholecystectomy. After her clothes were changed and she was hooked up to all the vital sign monitors in pre-op, the anesthesiologist informed her of all possible complications that could arise with the anesthesia. She said that most patients get nauseous upon waking up from the anesthesia and that vomiting was completely normal. Next, Cecilee was introduced to everyone that was going to be present in the operating room. These people consisted of 3 registered nurses, 2 nursing assistants, an anesthesiologist and her assistant, the surgeon, and 2 surgical technicians. Because of the possibility of switching to an open cholecystectomy, two surgical technicians were needed and Cecilee’s surgery was considered high risk. Once in the operating room, Cecilee was positioned on the operating table with a steep head-up in the supine position.

She was then put under with the anesthesia, in order to decompress the stomach, an oral-gastric tube was inserted, and a foley catheter was also inserted to drain the bladder. She was now ready for the surgery to being. Handheld instruments used in this procedure were trocars and cannulas (two 11mm, two 5.5mm, a 5.5mm to 11mm reducer, a 7mm-11mm reducer, and a suction irrigation cannula), graspers (2 atraumatic graspers and 1 toothed grasper) (Baillie, 2006). The sharps required were a curved dissector, a dissection hook, a pair of hook scissors, a Veress needle with needle holder, and a cautery spatula (Bernal, 2011). Other needed instruments were gallstone retrieving forceps, 3 titanium pins/clips with applicator, telescope, insufflator, and carbon dioxide (Moritz, 2011). For this particular surgery, surgeon Dr. Dempsey also choose to have available to him all the equipment needed for an open cholecystectomy as well. Some this equipment included: Kelly and right angle clamps, Kocker forceps, Kitner dissectors, Balfour and Bookwalter retractors, and knives/knife handles (Berkson, 2000).

To start off the surgery, the surgeon and the scrub nurse holding the camera stood on the left side of the patient and the surgical technician holding the fundus grasping forceps stood on the right side. The first incision is made in order to create the pneumoperitoneum. This required a 1cm subumbilical incision and the Veress needle was blindly inserted into the peritoneal cavity. Carbon dioxide was the introduced into the peritoneal cavity through the Veress needle and was insufflated to a pressure of 15mmHg (Mishra, 2008). A trocar, or port, was then placed into the insufflated peritoneum and a laparoscope was sled into the peritoneum. Now the inside of the peritoneum could be seen on the video screens on either side of the operation room and table. Next, a blanket was folded and placed underneath Cecilee’s right lower back and her head was tilted down and to the left. Now under direct vision, 3 other incisions were made with ports inserted: both the 5mm and the 1cm will be used for operating, and the last 5mm will be used for the assisting (Mishra, 2008).

After all the incisions and ports were in position, it was now time to start dissecting the gallbladder from the three parts of the cystic triangle and the liver bed. To start, the surgical technician grasped the fundus of the gallbladder and flipped it upwards over the superior edge of the right lobe of the liver. This movement maximized the surgeon’s access to the Cystic Pedicle (also known as Calot’s triangle), a triangular fold of peritoneum containing the cystic node (which consists of a posterior and an anterior leaf), the cystic duct and artery (Mishra, 2008). The surgeon used the two operating ports to dissect around cystic pedicle using the hook diathermy, Pledget, and a grasper. He first used grasper in his left hand to start an antero-traction on the anterior edge of Hartmann’s pouch. This exposed the posterior leaf. Using a pledget placed securely in a pledget holder the posterior leaf was dissected and then the anterior leaf was bluntly dissected as well. Next, the surgeon moved on to separating the cystic artery and the cystic duct.

This separation was done by using a Maryland gasper. The grasper was gently opened parallel to and between the artery and duct. A sufficient length of the cystic duct and artery on the gallbladder side was moved so that three titanium pins could be placed. The cystic artery was then clipped, divided by the hook scissors, and one pin was placed proximally on the artery and one pin was distally placed (Mishra, 2008). Next, the duckbill grasper was used to grab the cystic artery on the gallbladder and the artery was cut between the two pins. To complete the dissection of the Calot’s triangle, a third pin was placed at the junction of the cystic duct and the gallbladder and then the last cut was made (Mishra, 2008). The last dissection step was separating the gallbladder from the liver bed. In this particular surgery, the gallbladder was divided from the liver through the areolar tissue plane that bound the Glisson’s capsule lining the liver bed and the gallbladder. The separation was performed using electrosurgical hook knife.

This portion of the procedure was done very carefully as to avoid spillage of bile or gallstones into the peritoneal cavity (Mishra, 2008). Once the gallbladder is separated from the three parts of the cystic triangle and the liver bed, the gallbladder could now be extracted from the body through the 1cm subumbilical port. To do this the neck of the gallbladder was first placed a canula and then was pulled out of the port using a screwing hand motion (Mishra, 2008). Because Cecilee had rather large gallstones, ovum forceps were inserted inside gallbladder through a tiny incision in the neck and the stones were crushed. With the gallbladder successfully removed, all the instruments and ports were removed. The subumbilical was open to let out the gas. The four port sites were sutured closed using dissolvable staples, and of course a sterile dressing was placed over all four wounds. This entire procedure took a little over two hours to complete.

After the surgery was complete, Cecilee was wheeled to her post-op room. After she woke up, the surgeon came in, said the surgery was a success and he gave her a picture of her gallbladder (see cover page). He then went on to explain everything would happen in the future as far as dietary measures. He told her now that she has no gallbladder she is warned to stay away from foods that are high in fat because her body can no longer break fats down on its own. He explained that although nothing medically bad will happen if she does eat highly fatty foods, she will suffer from extreme diarrhea. Then, the nurse talked to her about what she can expect within the next couple of days post the surgery. She said her throat would be sore due to the tube that was placed down her esophagus and her stomach area will be sore and bloated because of the lingering gas.

This case study told the tale of a Ms. Cecilee Mary Louise James and how she underwent a laparoscopic cholecystectomy. In the present day, nearly two years later, Cecilee still has some abdominal pain when she ingests foods she probably should not eat. Dr. Dempsey says some bodies take longer than others to adjust to having no gallbladder and that lingering pain is normal. As the months, go on she is able to eat more and more and her surgeon says within the next three months she could be completely recovered.

Reference List:

Baillie, John and Clavian, Pierre-Alain. (2006). Diseases of the Gallbladder and Bile Ducts: Diagnosis and Treatment. Massachusetts: Blackwell Publishing, LTD.
Berkson, D Linsday. (2000). Healthy Digestion the Natural Way. New York: John Wiley and Sons, INC. Bernal, Jeremy. (2011). The Gallbladder Survival Guide. EVL Media LTD. Dempsey, Terrence. Personal communication

Digestive Disorders Health Center. (2011). Retrieved from http://www.webmd.com. James, Cecilee. Personal communication.
Mishra, R. K. (2008). How to do Laparoscopic Cholecystectomy? Retrieved from http://laparoscopyhospital.com.
Moritz, Andreas. (2007). The Liver and Gallbladder Miracle Cleanse. Berkeley, CA: Ulysses Press.