The indications for making the cholecystectomy by keyhole surgery (cholecystectomy by coelioscopy are as follows:

• Symptomatic gallbladder lithiasis (biliary colic)
• Complicated gallbladder lithiasis
• Acute cholecystitis
• Chronic cholecystitis
• Pancreatitis due to a lithiasic migration
• Lithiasis of the bile duct.

Gallbladder lithiasis.

Gallbladder lithiasis is defined as the  presence of stones in the gallbladder.

Women more frequently have this problem.

Obesity and diabetes encourage the creation of these stones which are often made up of cholesterol.

Gallbladder lithiasis can be symptomatic.

Patients may suffer periods of severe pain caused by biliary colic, secondary to the distension of the gallbladder above a gallstone lodged in the neck of the gallbladder or in the cystic duct.

Typical biliary colic pain:

• Pain is often the only symptom, but it could be accompanied by nausea and vomiting.
• This symptom sometimes occurs during the night and can often start brutally, typically after a heavy meal  (eating too much fatty food and alcohol).
• The pain is situated under the ribs on the right side (right hypochondrium) or in the middle of the upper abdomen (epigastrium).
• The pain may block your breathing (inspiratory inhibition: a spontaneous Murphy sign) and move towards the right upper quadrant or between the shoulders.
• The pain increases for about 1 hour, then decreases.

All biliary colic pain which lasts longer than 5 hours probably indicates a complication: Cholecystitis, Cholangitis, or Acute pancreatitis.

Please Note:

1. Attacks of biliary colic require a visit to the doctor.
2. A clinical examination, a biological assessment and an echography allow a precise diagnosis to be made and to validate the indication for a cholecystectomy.
3. An echography is reliable for looking for gallbladder stones and signs of complications: cholecystitis, bile duct stone migration, biliary pancreatitis.

Acute cholecystitis:

Cholecystitis is an inflammation (infection) of the wall of the gallbladder containing the stones.

More often called a calculous cholecystitis.

We can distinguish 3 phases:

1. Inflammation and oedema of the gallbladder: hydrocholecystis.
2. Infection of the bile duct (intestinal bacteria): septic cholecystitis or pyocholecyst.
3. Ischaemic necrosis of the wall of the gallbladder: gangrenous cholecystitis.

Symptomatology of a cholecystitis:

• Fever (> 38.5°).
• Pain in the upper right side of the abdomen with movement to the back and in the region of the right shoulder.
• Nausea and vomiting.

Often, hospitalisation is required with a special diet and antibiotics.

The biological assessment may show an inflammatory syndrome such as an increase in white blood cells and C-reactive protein (CRP).

The examination of reference is an abdominal ultrasound.

This will show  a gallbladder with stones and thick walls, doubled in thickness and laminated. An effusion of peri-vesicular fluid is frequent.

The gall bladder, in the case of a cholecystitis, may, exceptionally become perforated leading to  a biliary peritonitis.

All diagnosed cases of chronic cholecystitis, must be operated!

If possible between 48-72 hours from the start of the onset of the acute pain.

Such surgery may become delicate due to the inflammatory phenomenon of the hepatic pedicle and adherence to neighbouring organs like the duodenum or the right colic angle.

Chronic cholecystitis:

Chronic cholecystitis is secondary to a succession of low volume cholecystites not treated by surgery and calmed by antibiotics or by favourable spontaneous resolution.

Chronic inflammation may incur:

• Scleroatrophic chronic cholecystitis. The gallbladder is reduced in size, the wall is thick and moulded around the stone.
• Chronic cholecystitis with very fibrous walls, the centre of calcium deposits – also referred to as porcelain gallbladder: with the risk of malignant transformation: cancer of the gallbladder.
• Biliodigestive fistula / cholecystoduodenal fistula / cholecystocolic fistula:  This communication between the gallbladder (or the bile duct) and the digestive tube complicates around 1 to 2% of cases of  chronic cholecystitis. A biliodigestive fistula is suspected before repeated attacks of cholecystitis and the presence of air in the bile duct (pneumobilia).
• Gallstone ileus is a bowel obstruction caused by the movement of a gallstone right up to the last intestinal loop (blocked ileo-caecal valve).

The cholecystectomy is carried out under a general anaesthetic, so you will not be conscious during the procedure.

We make 3 or 4 small incisions in the abdomen for the keyhole surgery cholecystectomy. A tube with a minuscule video camera is inserted into the abdomen through one of the incisions. It allows us to see the images on a screen in the surgery operating room and control our every move. 

The surgical instruments are introduced through the other incisions in your abdomen and your gallbladder is removed.

The cholecystectomy by keyhole surgery lasts from 30 minutes to two hours.

In the case of an cholecystectomy by keyhole surgery the patient is often authorised to return home on the day of the surgery,  however, sometimes it is necessary to stay in the clinic for one of two nights.

In general, you will be allowed to go home once you are capable of eating and drinking without any pain, and are able to walk without assistance.

It usually takes a week to recuperate fully.

Perioperative cholangiography.

Safe cholecystectomy.

The dissection of the elements of Calot’s triangle, or the cystohepatic triangle, is carried out with extreme prudence.

The cystic canal and cystic artery are identified.

No element is sectioned before making a cholangiography, which is a radiography (X-ray) of the biliary tree (cholangiogram).

This helps detect bile duct lithiasis,  check the absence of wounds to the bile duct,  and to intervene at an early stage in case there are iatrogenic lesions.

The importance of radiologic exploration to discover iatrogenic lesions in the principal bile duct during a  cholecystectomy, and in the prevention of serious, undesirable effects, is confirmed in medical literature.

The cholangiography can be carried out on an elective basis (difficult anatomy; potential lithiasis) or systematically.

Risk of conversion

Keyhole surgery cholecystectomy is not appropriate for everybody.

In certain cases, the surgeon might start with a keyhole surgery approach and then make the conversion  to a laparotomy.

The decision to convert to a laparotomy (making a larger incision) is made due to scare tissue from previous operations, or complications.

Cholecystectomy by open surgery

During an open surgery cholecystectomy, your surgeon will make a 10cm incision in the abdomen, under the ribs, on your right side.

The muscle and tissue are pulled towards the back to expose your liver and gallbladder. Your surgeon will then proceed with the operation. The incision is closed with stitches at the end.

This cholecystectomy, lasts for one to two hours.

After the cholecystectomy, you will be taken to a  recovery room or post-anaesthesia care unit (PACU) to safely regain consciousness from the anaesthesia and receive appropriate post-operative care. Then you will be taken to your room. The recuperation time can vary, depending on the surgical technique used and the state of your health.

In the case of an open cholecystectomy, you may have to remain two or three days in hospital for convalescence. Once back at home, it may take four to six weeks before you have completely recovered.

A cholecystectomy has few risks of complications, but they are:

• Potential complications during the perioperative period:
  • Haemorrhage.
  • Pancreatitis
  • Wounds, iatrogenic lesions of adjacent organs, such as bile ducts, the liver and small intestine.
  • Leakage of bile (the percentage of iatrogenic lesions of the bile duct still remains – in 2020 – twice as high by coelioscopy than by open surgery).
• Medium/Long term complications
  • Cholangitis with  residual stones.
  • Stenosis of the  principal bile duct.

The risk of complications depends on your general state of health and the reasons why you are undergoing a cholecystectomy.

The cholecystectomy is to alleviate the pain and discomfort of gallbladder stones.

Some people suffer from light diarrhoea after a cholecystectomy, but this quickly disappears.

Most patients do not have digestive problems after this type of surgery.

Your gallbladder is not essential to digestion,  but we recommend that you limit fatty foods during the two weeks following the operation.

After keyhole surgery cholecystectomy, you will be able to return to work after a few days. But in the case of an open cholecystectomy, you will be off work for much longer.

Useful information to prepare for a  cholecystectomy:

• Talk to your doctor about all the medicines and supplements you are taking.
• Continue to take most of the medicines as prescribed.
• Stop taking certain medicines as they may increase the risk of bleeding.
• Do not eat or drink the night before surgery. You may take a sip of water with your medicines,  but avoid eating and drinking at least 6 hours before the surgery.
• You will have to take a shower and use antibacterial soap before the surgery.

Plan in advance your return home and convalescence after the operation:

• Find someone who will drive your home and stay with you for a while.
• Ask a friend or family member to accompany you home and stay with you for the first night after the surgery.

Most people can go home on the day they have the cholecystectomy, but sometimes, complications can occur which require staying one or several nights in the clinic.

If the surgeon has to make a long incision in the abdomen to remove the gallbladder, you will have to stay in the clinic longer.

It is not always possible to know in advance which procedure will be used.

When planning your stay, take into consideration that you might have to stay in the clinic.

Don’t forget to bring necessary personal belongings: for example a toothbrush, comfortable clothes, and books or magazines for your free time.

Coelioscopic cholecystectomy = terms of treatment as an ambulatory patient at the Clinic Clementville, Montpellier

After the surgery:

Once you wake up, you are taken in your bed to the ambulatory surgery service. A nurse will offer you a glass of water or herb tea: at lunchtime you must eat a light meal. Tranquillisers/painkillers will be administered by perfusion, and will be left in place for 2 to 3 hours.

The nurse will pay attention to the intensity of your pain, and your capacity to have satisfactory autonomy (moving around the room, resumption of urination and bowel function, the aspect of the wounds…).

After a few hours of recuperation, the perfusion is removed and painkillers will be taken orally. The nursing team and the anaesthetist will make sure that the pain will not reappear, and that your abdominal comfort remains correct.

You may then be discharged.

The nurse will make sure that you have in your possession all necessary documents: the operative report, your health record, hospital discharge letter for future GP/Family Doctor sick note, prescription given on leaving hospital, appointment with GP/Family Doctor for 1 week later, and appointment 5 weeks later with the Surgeon.

Discharge from the clinic:

Discharge from the clinic will be authorised after a visit with the anaesthetist (along with the surgeon).

In practice, you will leave the service between 3pm and 7pm, accompanied by a member of your family.

The first evening meal must be light, we recommend soup and a yoghurt.

During the following days:

The wounds need no particular care, due to the way they have been closed = intradermal overlock stitches (surgical thread internally) and biological adhesive

You are authorised to take a shower the day after surgery.

The discharge work sick note is valid for 15 days, except for workers doing active physical work, where it is for 4 weeks.