Cholelitheasis

Cholelitheasis

1.     In medicine, gallstones (cholelithesis) are crystalline bodies formed within the body by accretion or concretion of normal or abnormal bile component. Gallstones can occur anywhere within the biliary tree, including the gallbladder and the common bile duct. Obstruction of the common bile duct is choledocholithiasis; obstruction of the biliary tree can cause jaundice; obstruction of the outlet of the pancreatic exocrine system can cause pancreatitis. Cholelithiasis is the presence of stones in the gallbladder—chole- means “bile”, lithia means “stone”, and -sis means “process”.

Symptoms:
As gallstones move into the bile ducts and create blockage, pressure increases in the gallbladder and one or more symptoms may occur. Symptoms of blocked bile ducts are often called a gallbladder “attack” because they occur suddenly. Gallbladder attacks often follow fatty meals, and they may occur during the night. A typical attack can cause : (1) steady pain in the right upper abdomen that increases rapidly and lasts from 30 minutes to several hours, (2) pain in the back between the shoulder blades, (3) pain under the right shoulder. Although these attacks often pass as gallstones move, when gallbladder can become infected and rupture if a blockage remains.
Gall stones usually remain asymptomatic initially. They start developing symptoms once the stones reach a certain size (>8mm). A main symptom of gallstones is commonly referred to as a gallstone “attack”, also known as biliary colic, in which a person will experience intense pain in the upper abdominal region that steadily increases for approximately thirty minutes to several hours. A patient may also encounter pain in the back, ordinarily between the shoulder blades, or pain under the right shoulder. In some cases, the pain develops in the lower region of the abdomen, nearer to the pelvis, but this is less common. Nausea and vomiting may occur. These attacks are sharp and intensely painful, similar to that of a kidney stone attack. One way to alleviate the abdominal pain is to drink a full glass of water at the start of an attack to regulate the bile in the gallbladder, but this does not work in all cases. Another way is to take magnesium followed by a bitter liquid such as coffee or swedish bitters an hour later. Bitter flavors stimulate bile flow. A study has found lower rates of gallstones in coffee drinkers. Often, these attacks occur after a particularly fatty meal and almost always happen at night. Other symptoms include abdominal bloating, intolerance of fatty foods, belching, gas, and indigestion. If the above symptoms coincide with chills, lowgrade fever, yellowing of the skin or eyes, and/or clay-colored stool, a doctor should be consulted immediately. Some people who have gallstones are asymptomatic and do not feel any pain or discomfort. These gallstones are called “silent stones” and do not affect the gallbladder or other internal organs. They do not need treatment.

Cholecystectomy

2.    Cholecystectomy 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

3.    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.

Laparoscopic surgery

4.    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. 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 comparing conventional laparoscopic cholecystecomy to SILS Cholecystectomy demonstrated that SILS does have a cosmetic benefit over convention four-hole laparoscopic cholecystectomy while having no advantage in postoperative pain and hospital stay.

Procedural risks and complications

5.    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. Furthermore, flexible instruments are being used in laparoscopic surgery by some surgeons. Using the SPIDER surgical system, they can perform the cholecystectomy through a single incision through the navel. These patients often recover faster than traditional methods, and have an almost invisible scar. 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% oflaparoscopic 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

6.    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

7.     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

8.    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, orendoscopic retrograde cholangiopancreatography.

A.   emphysematous cholecystitis

B.   bile leak ("biloma")

C.   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)

D.  abscess

E.   wound infection

F.    bleeding (liver surface and cystic artery are most common sites)

G.  hernia

H.  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)

I.      deep vein thrombosis/pulmonary embolism (unusual- risk can be decreased through use of sequential compression devices on legs during surgery)

J.     fatty acid and fat-soluble vitamin malabsorption

9.    In view of the above discussion, it is crystal clear like light of the day that the answering doctor did his duty with utmost care and caution therefore there is no question of medical negligence or deficiency in service, the same is specifically denied. In order to decide whether negligence is established in any particular case, the alleged act, omission, or course of conduct that is the subject of the complaint must be judged not by ideal standards nor in the abstract but against the background of the circumstances in which the treatment in question was given. The true test for establishing negligence on the part of a doctor is as to whether he has been proven guilty of such failure as no doctor with ordinary skills would be guilty of if acting with reasonable care. Merely because a medical procedure fails, it cannot be stated that the medical practitioner is guilty of negligence unless it is proved that the medical practitioner did not act with sufficient care and skill and the burden of proving this rests upon the person who asserts it. The duty of a medical practitioner arises from the fact that he does something to a human being that is likely to cause physical damage unless it is not done with proper care and skill. There is no question of warranty, undertaking, or profession of a skill. The standard of care and skill to satisfy the duty in tort is that of the ordinary competent medical practitioner exercising an ordinary degree of professional skill. As per the law, a doctor charged with negligence can clear himself if he shows that he acted in accordance with the general and approved practice. It is not required in the discharge of his duty of care that he should use the highest degree of skill, since this may never be acquired. Even a deviation from normal professional practice is not necessary in all cases evident of negligence.