Indications and diagnosis
Laparoscopic cholecystectomy is one of the most common and routine surgical procedures. Laparoscopic cholecystectomy is indicated when stones (gallstones) have been formed within the lumen of the gallbladder that cause symptoms. The most common associated symptoms include pain at the right upper quadrant of the abdomen, or upper mid-back or right shoulder blade between 30 minutes to an hour after a meal (usually one that contains fat), nausea, vomiting, jaundice (yellow skin), fever and dyspepsia. Cholecystectomy is also indicated in high risk patients (on blood thinners, with serious medical problems) who have stones but no symptoms and also in some patients without stones who have a dysfunctional gallbladder. In contrast, to kidney stones, gallstones cannot be simply removed or broken without simultaneous gallbladder removal. The diagnosis of gallstones (cholelithiasis) is usually made with an upper abdominal ultrasound.

Hospital stay and common side-effects of gallstones
It is important that you consult with your primary care physician or general surgeon if you know you have gallstones or associated symptoms because gallstones can move and cause serious infections, jaundice (yellow skin) or pancreatitis (inflammation of the pancreas). It is also important that you proceed with laparoscopic cholecystectomy as soon as the diagnosis is made because the procedure is technically easier and more likely to be completed laparoscopically if the diagnsosis and treatment is not delayed. Furthermore based on Dr. Raftopoulos’ experience prompt treatment of gallstones will be more likely associated with same day surgery without the need of a night stay. In contrast, if there is delay in treatment and there is already an infection present, then there is usually a need for one or more days of hospitalization.

Procedure and postoperative course
Laparoscopic cholecystectomy is typically performed with four 1.5 to 2.5 cm (3/4 to 1 inch) incisions that are covered with a plastic waterproof dressing. Postoperative pain is usually located just below and to the right of the breastbone where the largest incision is located from which the gallbladder is removed. Postoperative pain is adequately controlled with Paracetamol or Acetaminophen. Dr. Raftopoulos usually recommends that you stay on a clear liquid diet postoperatively until your first bowel movement. Once the bowel function returns then there is no limitation in your diet. You may shower right after your surgery and return to your work within a few days.

Complications of cholecystectomy
According to Dr. Raftopoulos’ experience complications of cholecystectomy are very rare and occur in less than 1% of patients. Complications are less likely to occur if cholecystectomy is performed as soon as diagnosis is made. The most important complications of cholecystectomy are a bile leak and retained stones at the main bile duct. Both of these problems can be managed usually nonoperatively with an endoscopic procedure called ERCP. Postoperative bleeding and infection are very rare complications. Inflammation of the pancreas may also occur in rare instances if a stone is retained within the main bile duct and blocks the pancreatic duct. The most serious complication which is fortunately very rare is the injury of another bile duct other that the cystic duct (duct which connects the gallbladder with the main bile duct). Such injuries usually require an extensive open procedure.

Dr. Raftopoulos’ experience
Dr. Raftopoulos has extensive experience with laparoscopic cholecystectomy especially in extremely obese patients which represents a special and more complex group of patients. Dr. Raftopoulos has presented his experience in this complex group of patients at a podium presentation at the 29th Annual Meeting of the American Society for Metabolic and Bariatric Surgery (link 1, as in Greek version) which took place in June 2012. The Annual Meeting of the American Society for Metabolic and Bariatric Surgery* represents the largest and most prestigious meeting for obesity surgery worldwide. For more information please contact our office..

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Brian Pellini, MD¹, Chhatrala, Ravi, MD, Cushman Alexis, PA¹, Judy Carty, RD¹, Ioannis Raftopoulos, MD, PhD, FACS^1,2
1Bariatric Center at Saint Francis Hospital and Medical Center, Hartford, CT, USA.
²University of Connecticut, Farmington, CT, USA

Objective: The management of pre-existing cholelithiasis (PEC) in morbidly obese patients (MOP) undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) remains controversial. This study aims to assess the outcomes of laparoscopic cholecystectomy (LC) before (A), during (B) or after LRYGB (C).
Methods: MOP who were considered for LRYGB between September 2003 and October 2011 and had PEC were included in the study. All patients underwent an abdominal ultrasound preoperatively. Qualified MOP were randomly assigned to receive a LC before, during or after LRYGB. Postoperative cholecystectomy was performed electively at 6-12 months postoperatively or sooner for acute symptoms. P < .05 was significant.

Results: 132 MOP were randomly assigned to undergo LC before (n=39, 29.5%), during (n=31, 23.5%), or after LRYGB (n= 62, 47%).

	A	B	C	p
Age	46.1+11.4	43.3+10.3	40+11.9	.054
% Males	16.1%	6.5%	15.4%	.4
BMI	47.4+7.5	45.7+6.1	31.8+6.5	<.0001
Preoperative symptoms	17.9%	6.5%	21%	.2
Complex presentation1	0%	0%	21%	.0003
Unexpected intraoperative findings2	28.2%	14.3%	10.2%	.08
Complications	2.6%	6.5%	3.3%	.6
Readmissions	5.1%	14.3%	11.1%	.49
Re-operations	0%	3.2%	6.5%	.25
Hospital stay	0.3+0.9	0.8+0.83	1.4+2.6	<.0001
Pathology –       normal –       acute cholecystitis –       chronic cholecystitis	5.1% 25.6% 69.3%	0% 26.8% 73.2%	1.6% 19.4% 79%	.8

¹Acute cholecystitis, pancreatitis, choledocholithiasis; ²Acute cholecystitis, hydrops, cystic duct obstruction; ³Difference from mean stay of LRYGB

Conclusions: LC prior to LRYGB is safe despite increased BMI and can be performed with a lower hospital stay. Significant unexpected pathologic and intraoperative findings are often present among MOP undergoing LC even if PEC is clinically asymptomatic.