Gallstone disease is one of the most common surgical conditions. Statistically, one in ten adults in Ukraine has it. When conservative treatment does not help, the only definitive option is removal of the gallbladder — cholecystectomy. Today this operation is most often performed laparoscopically, and that is what we describe here in detail.
What is laparoscopic cholecystectomy
Laparoscopic cholecystectomy is a minimally invasive operation to remove the gallbladder through several small incisions (ports) 5–12 mm in size in the abdominal wall. Unlike traditional open surgery, which requires a 10–15 cm incision, the laparoscopic method lets the surgeon work with special instruments and a video camera (laparoscope) without opening the abdomen widely.
The first laparoscopic cholecystectomy was performed in 1987 by the French surgeon Philippe Mouret. Since then the method has become the “gold standard” for treating gallbladder disease worldwide, replacing open surgery as the first choice in the vast majority of cases.
Indications for surgery
Laparoscopic gallbladder removal is recommended for the following conditions:
- Symptomatic gallstone disease — attacks of biliary colic, pain under the right ribs after meals, nausea, bloating.
- Chronic calculous cholecystitis — long-standing inflammation of the gallbladder due to stones.
- Acute cholecystitis — ideally within the first 72 hours of the attack.
- Gallbladder polyps — larger than 10 mm or growing over time.
- Large asymptomatic stones (over 2–3 cm) — because of the risk of complications.
- Functional gallbladder disorders — “porcelain” gallbladder, dysfunction.
Contraindications
Laparoscopic cholecystectomy may be contraindicated or technically impossible in the following situations:
- Severe bleeding disorders
- Severe cardiopulmonary insufficiency (pneumoperitoneum cannot be created)
- Peritonitis with diffuse abdominal inflammation
- Gallbladder cancer (in most cases)
- Severe adhesions after multiple previous operations
- Third trimester of pregnancy
In such cases the surgeon may decide to convert — switch to open surgery. This is not a failure; it is a sound decision made in the interest of patient safety.
Preparing for surgery
Proper preparation is the key to a successful operation and fast recovery. Before elective laparoscopic cholecystectomy, a standard set of examinations is performed:
Laboratory tests
- Complete blood count and blood chemistry (ALT, AST, bilirubin, alkaline phosphatase)
- Coagulation panel (blood clotting)
- Blood group and Rh factor
- Urinalysis
- Infection markers (HIV, hepatitis B and C)
Instrumental examinations
- Abdominal ultrasound — the main method for detecting stones and inflammation
- ECG and consultation with an internist
- If needed — MRCP (MRI of the bile ducts) to rule out common bile duct stones
- Chest X-ray
The day before surgery
- Last meal — at least 8 hours before surgery
- Water — up to 4 hours before, nothing after that
- Cleansing enema if prescribed
- Stop anticoagulants 5–7 days before (aspirin, warfarin — as agreed with your doctor)
- Personal hygiene, shaving of the abdomen
How the operation is performed
The operation is performed under general endotracheal anesthesia and takes on average 30–60 minutes if uncomplicated.
Main steps
- Creating the pneumoperitoneum. Carbon dioxide (CO₂) is introduced into the abdomen through a small puncture. This “inflates” the abdomen, creating working space for the instruments and a clear view. Gas pressure is kept at 10–14 mmHg.
- Inserting the trocars. Through 3–4 ports (5 mm and 10–12 mm), metal tubes called trocars are inserted; the instruments and the laparoscope with a camera are passed through them.
- Visualizing the gallbladder. The surgeon inspects the abdomen and assesses the gallbladder, liver and surrounding organs.
- Dissecting the structures. The cystic duct and cystic artery are carefully dissected to achieve the “critical view of safety” — the key step that prevents bile duct injury.
- Clipping and division. Titanium clips are placed on the duct and artery, which are then divided.
- Removing the gallbladder. The gallbladder is separated from the liver with an electrosurgical hook, placed in a special retrieval bag and removed through the umbilical port.
- Inspection and closure. The surgeon makes sure there is no bleeding or bile leakage, releases the gas and closes the ports.
Advantages of the laparoscopic approach
| Parameter | Laparoscopy | Open surgery |
|---|---|---|
| Incision length | 4 ports of 5–12 mm | 10–15 cm |
| Pain | Minimal | Significant |
| Hospital stay | 1–2 days | 5–7 days |
| Return to work | 7–10 days | 4–6 weeks |
| Cosmetic result | Barely visible scars | Long postoperative scar |
| Risk of complications | Lower | Higher |
Possible complications
Laparoscopic cholecystectomy is considered one of the safest elective operations. Nevertheless, as with any surgery, there are risks:
- Bile duct injury — the most serious but rare complication (0.3–0.5%). It depends on the surgeon's experience.
- Bleeding — from the cystic artery or the gallbladder bed.
- Bile leakage — from the gallbladder bed or the clipped stump.
- Infectious complications — port-site infection, abscesses.
- Injury to neighboring organs — bowel, blood vessels.
- Thromboembolic complications — rare, in the presence of risk factors.
Postoperative period and recovery
In hospital (1–2 days)
After surgery the patient is transferred to the ward. In the first hours there may be moderate abdominal pain and discomfort in the right shoulder (referred pain from gas irritating the diaphragm). Painkillers are given. You may get up after 4–6 hours and walk the next day. Drinking is allowed a few hours after surgery, light food the next day.
At home (weeks 1–2)
- Low-fat diet (Pevzner diet No. 5) — no fatty, fried or spicy food, no alcohol
- Small, frequent meals — 5–6 times a day
- Limit physical exertion — do not lift more than 3–5 kg
- Wound care: daily dressing or antiseptic treatment
- Stitches are removed on day 7–10 (unless absorbable)
- Shower after 2–3 days, bath after 2 weeks
Long-term nutrition
After the gallbladder is removed, bile no longer accumulates and flows into the duodenum continuously in small amounts. This requires dietary adaptation for 3–6 months:
- Avoid fatty food in the first months
- Prefer boiled, stewed and baked dishes
- Avoid overeating
- Gradually expand your diet as you adapt
Most patients return to their usual diet without significant restrictions within 3–6 months.
Life without a gallbladder: myths and facts
Many patients fear that their quality of life will drop sharply without a gallbladder. This is not true. The gallbladder is only a reservoir for bile, which is produced by the liver. After it is removed:
- The liver continues to produce bile in normal amounts
- Bile simply flows into the intestine continuously rather than “in portions”
- In 85–90% of patients, quality of life improves significantly compared with the period of illness
- Eating returns to normal within a few months
A small percentage of patients (about 10–15%) may experience the so-called “post-cholecystectomy syndrome” — diarrhea, bloating, discomfort. As a rule, these symptoms respond to medication.
Why the choice of surgeon matters
Technically, laparoscopic cholecystectomy looks like a routine operation. However, the risk of the main complication — bile duct injury — depends directly on the surgeon's experience. In experienced hands this complication occurs in 0.1–0.3% of cases, whereas for less experienced surgeons the rate may be 10–20 times higher.
I have performed more than 3,000 laparoscopic operations over 40 years of practice. Over this time I have developed a clear safety algorithm for every operation, based on Strasberg's “critical view of safety” principle, which minimizes the risk of bile duct injury.
