Laparoscopic cholecystectomy refers to the removal of the gallbladder through small incisions in the abdomen. Over Million minimally invasive cholecystectomies are performed annually, with the majority being removed through a laparoscopic approach. This is the procedure of choice for patients with asymptomatic, symptomatic, and most forms of complicated gallbladder disease. Of recent an increasing number of these cases are being performed as single incision laparoscopic cholecystectomy or one key hole laparoscopic cholecystectomy surgeries
The indications for one key hole laparoscopic cholecystectomy, 4 key hole laparoscopic cholecystectomy do not differ from open cholecystectomy. One key hole laparoscopic surgery is offered by surgeons and centres which have expertise in it. Hence it is frequently not mentioned or offered by many centres. In limited studies one key hole surgery has shown additional benefits of minimal pain, reduced wound related complications such as wound infection and incisional hernia as there are less number of incisions compared to 4 key hole surgery. It also offers better cosmesis with no obviously visible scars.
Though listed as relative contraindications for laparoscopic surgery in most of these cases, I perform laparoscopic cholecystectomy and in some selected cases also offer single(one) key hole laparoscopic cholecystectomy.
The preferred approach to gallbladder disease requiring cholecystectomy during pregnancy is to attempt conservative management followed by an elective cholecystectomy months after delivery. If conservative management fails, the safety of both the mother and the baby are dependent on the timing of surgery. Operating during the first trimester confers risks of teratogenesis and miscarriage. Surgery during the second trimester is preferred as interventions during this period are associated with the fewest complications. The gravid uterus during the third trimester can prevent adequate visualization, while operative interventions during this period are also associated with increased risks of preterm labor and delivery.
Once the diagnosis is confirmed, patients should be rehydrated, and analgesics are administered. If antibiotics are given, regimens consist of broad spectrum antibiotics such as piperacillin-tazobactam, ampicillin-sulbactam, or a fluoroquinolone with metronidazole. Given the inflammation, edema, and overall condition of the gallbladder and gallbladder fossa during an episode of acute cholecystitis, surgeons have historically advocated for a “cool down” period prior to cholecystectomy. The results of randomized controlled trials evaluating early (within 24-72 hours of the diagnosis) and late cholecystectomy, however, have established that early cholecystectomy is technically feasible and leads to a shorter total hospital stay. A recent meta-analysis further noted no significant differences in conversion rates or complications in those receiving an early operation. Hence as a general rule of thumb, I offer single key hole and or 4 key hole laparoscopic cholecystectomy as the procedure of choice for early acute cholecystitis.
Management includes vigorous fluid replacement, pain control, and correction of metabolic abnormalities. Urgent ERCP (within 24 hours) is performed in patients who have concomitant cholangitis. Early ERCP (within 72 hours) is performed in those with a high suspicion of persistent common bile duct (CBD) stones (e.g. visible CBD stone on imaging, jaundice, persistent dilated CBD). In cases without cholangitis or suspicion of persistent CBD stones on MRCP, we perform Endoscopic Ultrasound to look for any smaller CBD stones and if present do an ERCP. If just gallstones or stigmata of passed gallstones are present we perform laparoscopic (1 or 4 key hole) cholecystectomy. We offer definitive surgical intervention at the index admission if possible. Otherwise, surgery is performed no later than 2 to 4 weeks after discharge. In cases where it is unclear whether gallstones are still present in the common bile duct, laparoscopic intra-operative cholangiography and laparoscopic common bile duct exploration with choledochoscopy is offered at my clinic.
Only elevated bilirubin and alkaline phosphatase have sensitivities greater than 50% in aiding in the diagnosis of choledocholithiasis. In all these cases MRCP is performed, additionally some cases may need Endoscopic ultrasound if suspicion of small CBD stones is high. The indications for preoperative ERCP are based on MRCP findings, Endoscopic ultrasound findings and are similar to those found in Gallstone pancreatitis. Laparoscopic intraoperative cholangiography, laparoscopic choledochoscopy and laparoscopic CBD exploration are performed in cases where ERCP is unsuccessful.
Only 8 – 10% of these cases are diagnosed preoperatively. Several ultrasonographic findings are suggestive of carcinoma. These include: a complex mass filling the gallbladder lumen, marked thickening of the gallbladder wall, and any the identification of polypoid or fungating structures associated with the gallbladder. Further considerations include gallstone size (with an increased risk associated with increased size) and gallbladder wall calcification (with an incidence of 12.5 – 61% associated with porcelain gallbladder). All patients with suspected gallbladder cancer pre op have CT scan, MRI scan with MRCP and PET CT scan based on need. Still most of the early gallbladder cancers are discovered in the operating room, necessitating the examination of the gallbladder after removal – particularly in patients aged 50 or older (4% incidence that increases with age). If the depth of invasion can be established on pre operative imaging, simple laparoscopic cholecystectomy is adequate in tumors that do not extend beyond the gallbladder lamina propria (Tis and T1a tumors). The management of T1b disease although remains controversial, hepatoduodenal lymph node dissection with or without combined resection of the gallbladder fossa which is usually recommended is done as a laparoscopic surgery in my centre.
I have been performing laparoscopic cholecystectomy for over 30 years and as a pioneering surgeon of single key hole laparoscopic surgery in South East Asia, I have been doing single Key hole laparoscopic cholecystectomy for over 15 years. Conversion from one key hole to 4 key hole surgery is about 5% and open surgery is about 3%. Over these years, I have maintained a nil mortality for all these cases.
Senior Consultant Single Keyhole Laparoscopic Surgeon
MBBS, M.S (Gen Surg – KEMH, Bombay), FAMS
Over 30 years of clinical experience in gastrointestinal and metabolic surgery
His clinical focus includes:
Dr. Ravi routinely performs laparoscopic (keyhole) and endoscopic procedures, which are associated with smaller incisions and faster recovery times compared to traditional open surgery.
(Based on standard clinical outcomes for minimally invasive techniques.)
He holds a university academic appointment and is actively involved in teaching medical students and surgical trainees in Singapore, reflecting his commitment to medical education and continuous learning.
Dr. Ravi is affiliated with various international and local professional bodies including:
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