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3/20/2015 LaparoscopicCholecystectomy

LaparoscopicCholecystectomy
Author:DannyASherwinter,MDChiefEditor:KurtERoberts,MDmore...

Updated:Aug6,2014

Background
Whereasitistruethatnooperationhasbeenmoreprofoundlyaffectedbytheadventoflaparoscopythan
cholecystectomyhas,itisequallytruethatnoprocedurehasbeenmoreinstrumentalinusheringinthelaparoscopic
agethanlaparoscopiccholecystectomyhas.Laparoscopiccholecystectomyhasrapidlybecometheprocedureof
choiceforroutinegallbladderremovalandiscurrentlythemostcommonlyperformedmajorabdominalprocedurein
Westerncountries. [1]

ANationalInstitutesofHealthconsensusstatementin1992statedthatlaparoscopiccholecystectomyprovidesa
safeandeffectivetreatmentformostpatientswithsymptomaticgallstonesandhasbecomethetreatmentofchoice
formanypatients. [2]Thisprocedurehasmoreorlessendedattemptsatnoninvasivemanagementofgallstones.

Theinitialdrivingforcebehindtherapiddevelopmentoflaparoscopiccholecystectomywaspatientdemand.
Prospectiverandomizedtrialswerelateandlargelyirrelevantbecauseadvantageswereclear.Hence,laparoscopic
cholecystectomywasintroducedandgainedacceptancenotthroughorganizedandcarefullyconceivedclinicaltrials
butthroughacclamation.

Laparoscopiccholecystectomydecreasespostoperativepain,decreasestheneedforpostoperativeanalgesia,
shortensthehospitalstayfrom1weektolessthan24hours,andreturnsthepatienttofullactivitywithin1week
(comparedwith1monthafteropencholecystectomy). [3,4]Laparoscopiccholecystectomyalsoprovidesimproved
cosmesisandimprovedpatientsatisfactionascomparedwithopencholecystectomy.

Althoughdirectoperatingroomandrecoveryroomcostsarehigherforlaparoscopiccholecystectomy,theshortened
lengthofhospitalstayleadstoanetsavings.Morerapidreturntonormalactivitymayleadtoindirectcostsavings.
[5]Notallsuchstudieshavedemonstratedacostsavings,however.Infact,withthehigherrateofcholecystectomy
inthelaparoscopicera,thecostsintheUnitedStatesoftreatinggallstonediseasemayactuallyhaveincreased.

Trialshaveshownthatlaparoscopiccholecystectomypatientsinoutpatientsettingsandthoseininpatientsettings
recoverequallywell,indicatingthatagreaterproportionofpatientsshouldbeofferedtheoutpatientmodality. [6]

Laparoscopiccholecystectomyhasreceivednearlyuniversalacceptanceandiscurrentlyconsideredthecriterion
standardforthetreatmentofsymptomaticcholelithiasis. [7,6]Manycentershavespecialshortstayunitsor23
houradmissionsforpostoperativeobservationfollowingthisprocedure. [6]

Indications
Thegeneralindicationsforlaparoscopiccholecystectomyarethesameasthoseforthecorrespondingopen
procedure.Althoughlaparoscopiccholecystectomywasoriginallyreservedforyoungandthinpatients,itnowisalso
offeredtoelderlyandobesepatientsinfact,theselatterpatientsmaybenefitevenmorefromsurgerythrough
smallincisions.

Asymptomatic(silent)gallstones

Cholecystectomyisnotindicatedinmostpatientswithasymptomatic(silent)gallstones,becauseonly23%ofthese
patientsgoontobecomesymptomaticeachyear.Foranaccuratedeterminationoftheindicationsforelective
cholecystectomy,theriskposedbytheoperation(withindividualpatientagecomorbidfactorstakenintoaccount)
mustbeweighedagainsttheriskofcomplicationsanddeathiftheoperationisnotdone. [8]

Thewidespreaduseofdiagnosticabdominalultrasonographyhasledtotheincreasingdetectionofclinically
unsuspectedgallstones.Thisdevelopment,inturn,hasgivenrisetoagreatdealofcontroversyregardingthe
optimalmanagementofasymptomaticgallstones. [9]

Patientswhoareimmunocompromised,areawaitingorganallotransplantation,orhavesicklecelldiseaseareat
higherriskforthedevelopmentofcomplicationsandshouldbetreatedirrespectiveofthepresenceorabsenceof
symptoms.

Additionalreasonstoconsiderprophylacticlaparoscopiccholecystectomyincludethefollowing:

Calculigreaterthan3cmindiameter,particularlyinindividualsingeographicregionswithahighprevalence
ofgallbladdercancer
Chronicallyobliteratedcysticduct
Nonfunctioninggallbladder
Calcified(porcelain)gallbladder [9]
Gallbladderpolyplargerthan10mmorshowingarapidincreaseinsize [10]
Gallbladdertrauma [8]
Anomalousjunctionofthepancreaticandbiliaryducts

Morbidobesityisassociatedwithahighprevalenceofcholecystopathy,andtheriskofdevelopingcholelithiasisis
increasedduringrapidweightloss.RoutineprophylacticlaparoscopiccholecystectomybeforeRouxenYgastric
bypass(RYGB)iscontroversial,butlaparoscopiccholecystectomyshouldclearlyprecedeorbeperformed
concurrentlywithRYGBinpatientswithahistoryofgallbladderpathology. [11]

Symptomaticgallstonedisease

Biliarycolicwithsonographicallyidentifiablestonesisthemostcommonindicationforelectivelaparoscopic
cholecystectomy. [8,12]

Acutecholecystitis,ifdiagnosedwithin72hoursaftersymptomonset,canandusuallyshouldbetreated
laparoscopically.Beyondthis72hourperiod,inflammatorychangesinsurroundingtissuesarewidelybelievedto
renderdissectionplanesmoredifficult.Thismay,inturn,increasethelikelihoodofconversiontoanopenprocedure
to25%.Randomizedcontroltrialshavenotborneoutthis72hourcutoffandhaveshownnodifferenceinmorbidity.
Otheroptionsincludeintervallaparoscopiccholecystectomyafter46weeksandpercutaneouscholecystostomy. [13,
14,15]

Biliarydyskinesiashouldbeconsideredinpatientswhopresentwithbiliarycolicintheabsenceofgallstones,anda
cholecystokinindiisopropyliminodiaceticacid(CCKDISIDA)scanshouldbeobtained.Thefindingofagallbladder
ejectionfractionlowerthan35%at20minutesisconsideredabnormalandconstitutesanotherindicationfor
laparoscopiccholecystectomy. [16]

Complexgallbladderdisease

Gallstonepancreatitis

Oncetheclinicalsignsofmildtomoderatebiliarypancreatitishaveresolved,laparoscopiccholecystectomycanbe
safelyperformedduringthesamehospitalization.Patientsdiagnosedwithgallstonepancreatitisshouldfirstundergo
imagingtoruleoutthepresenceofcholedocholithiasis.Thiscanbeachievedbymeansofpreoperativemagnetic
resonancecholangiopancreatography(MRCP),endoscopicretrogradecholangiopancreatography(ERCP),
endoscopicultrasonography(EUS),orintraoperativecholangiography(IOC). [17]

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Incasesofacutemoderatetoseverebiliarypancreatitis(5Ransoncriteria),laparoscopiccholecystectomyshouldbe
delayed. [18]

Choledocholithiasis

Thefollowingtreatmentoptionsareavailableforpatientsfoundtohavecholedocholithiasis:

PreoperativeERCPwithsphincterotomy
PostoperativeERCPwithsphincterotomy
LaparoscopicIOCwithlaparoscopiccommonbileduct(CBD)exploration
OpenCBDexplorationandTtubeplacement

Inapatientwithdocumentedcholedocholithiasis,asinglelaparoscopicprocedurethattreatsbothcholelithiasisand
choledocholithiasisinasinglesettingispreferable.Thisapproachappearstobecosteffectiveandtobeassociated
withashorterhospitalstaythana2stageprocedure(eg,preoperativeERCPwithsphincterotomyfollowedby
laparoscopiccholecystectomy)wouldbe.Inexperiencedhands,laparoscopicCBDexplorationappearstohavehigh
successrates(7591%).Theexactalgorithmfolloweddependsonlocalexpertise.

Mirizzisyndrome

In1948,Mirizzidescribedanunusualpresentationofgallstonesthat,whenlodgedineitherthecysticductorthe
Hartmannpouchofthegallbladder,externallycompressedthecommonhepaticduct,causingsymptomsof
obstructivejaundice. [19]

Althoughaninitialtrialofdissectionmaybeperformedbyanexperiencedlaparoscopicbiliarysurgeon,onemustbe
preparedforconversionandforbiliaryreconstruction.EndoscopicstonefragmentationatERCP,withpapillotomy
andstenting,isaviablealternativetooperativesurgeryfortreatmentofMirizzisyndromeintheacutesetting. [20]
Subsequentcholecystectomymaybeperformed. [21]

Cholecystoduodenalfistula

Patientswithcholecystoduodenalfistulaleadingtogallstoneileusshouldundergoexploratorylaparotomyand
removalofthestone,followedbyexplorationoftheremainderofthegastrointestinaltractforadditionalstones.The
fistulamaybeaddressedatthetimeoftheinitialprocedurebutisprobablybetteraddressedatasecondoperation
34weekslater,afterinflammationhassubsided. [21]

Cholecystentericfistuladoesnotrepresentanabsolutecontraindicationtolaparoscopicsurgery,thoughitdoes
necessitatecarefulvisualizationoftheanatomyandgoodlaparoscopicsuturingskills. [22]

Acalculouscholecystitis

Asubstantialproportionofpatientswithacalculouscholecystitisaretooilltoundergosurgery.Inthesesituations,
percutaneouscholecystostomyguidedbycomputedtomography(CT)orultrasonographyisadvised.Ninetypercent
ofthesepatientsdemonstrateclinicalimprovement.Oncethepatienthasrecovered,thecholecystostomytubecan
beremovedwithoutsequelaethisusuallytakesplaceatabout6weeks.Intervalcholecystectomyisnotnecessary.
[23]

Incidentalgallbladdercancer

Gallbladdercancermaybeanincidentalfindingatlaparoscopiccholecystectomy,withanincidencerangingfrom
0.3%to5.0%. [24,25,26]Uncertaintyaboutthediagnosis,lackofclarityregardingofthedegreeoftumorspread,or
postoperativeidentificationofcanceronpathologicexaminationofaroutinecholecystectomyspecimenshould
warrantearlyreoperation.

NationalComprehensiveCancerNetwork(NCCN)guidelinesadvocatesimplecholecystectomyasdefinitive
treatmentforpatientswithmucosal(T1a)diseaseandanegativecysticductmarginallotherpatients(ie,those
withinvolvementofmuscleorbeyond,apositivecysticductmargin,orapositivecysticlymphnode)shouldundergo
repeatoperationforextendedcholecystectomy(whichincludeshepaticresection,lymphadenectomyand,possibly,
bileductexcision). [2]

Beforereoperation,distantmetastasesshouldbeexcludedbymeansofadetailedclinicalexaminationthatincludes
examinationbothperrectumandpervaginam,examinationforsupraclavicularlymphnodes,andCTorMRIofthe
chestandabdomen.

Intraoperativeidentificationofcancerisanindicationforconversiontoanopenprocedure. [27]Ifamalignant
gallbladderisremovedlaparoscopically,theriskofportsiterecurrenceishightheportofextractionshouldthenbe
excisedatthetimeofreoperation. [28,2]

Specialpopulations

Children

Laparoscopiccholecystectomyisasafeandeffectivetreatmentformostchildrendiagnosedwithbiliarydisease.
Althoughittakeslongertoperformthanopencholecystectomydoes,itresultsinlesspostoperativenarcoticuseand
ashorterhospitalstay,ashasbeenthecaseintheadultliterature. [29]

Patientswithcirrhosis

Laparoscopiccholecystectomyinsafeinmanypatientswithcirrhosis.Thelaparoscopicapproachshouldbe
consideredtheprocedureofchoiceinthepatientswithChildclassAandBcirrhosisandsymptomaticgallstone
disease.PatientswithChildclassCcirrhosiswhopresentwithsymptomaticcholelithiasisorcholecystitisshouldbe
consideredformedicalmanagementiftheyaretransplantcandidates.Someconsiderrepeatedepisodesof
cholecystitisinapatientwithChildclassCcirrhosisanindicationfortransplant. [30,31]

Diabetics

Thepresenceofdiabetesmellitus,inandofitself,doesnotconfersufficientrisktowarrantprophylactic
cholecystectomyinasymptomaticindividuals.Itshouldbekeptinmind,however,thatacutecholecystitisina
patientwithdiabetesisassociatedwithasignificantlyhigherfrequencyofinfectiouscomplications,suchassepsis.

Pregnantwomen

Biliarycolicoruncomplicatedcholecystitisinapregnantpatientistreatedwithconservativemanagementfollowed
byelectivelaparoscopiccholecystectomy.Theuseofantibiotics,analgesics,andantiemeticshelpsmostpregnant
womenavoidsurgicalintervention.Surgeryisgenerallyindicatedforpatientswithrecurrentacutecholecystitisthat
doesnotrespondtomaximalmedicaltherapy.

Classically,thesecondtrimesterisconsideredthesafesttimeforsurgicaltreatment.Thisisbecauseofthe
increasedriskofspontaneousabortionandteratogenesisduringthefirsttrimesterandtheincreasedriskof
prematurelaboranddifficultieswithvisualizationinthethirdtrimester.

Atonetime,pregnancywasconsideredtobeanabsolutecontraindicationtothelaparoscopicapproach,outof
concernforthepotentialtrocarinjurytotheuterusandtheunknowneffectsofpneumoperitoneumtothefetal
circulation.However,thisconcernhasnotbeenborneoutintheliterature,andlaparoscopiccholecystectomyisnow
consideredsafeinpregnantpatients.

Reportedpredictorsoffetalcomplicationsarelaparoscopy,diagnosis,admissionurgency,year,hospitalsize,
location,teachingstatus,andhighriskobstetriccasespredictorsofmaternalcomplicationsareanopenprocedure
andgreaterpatientcomorbidity. [32]

Recommendationsforpregnantpatientswhomustundergolaparoscopiccholecystectomyincludethefollowing:

Placementintheleftlateralrecumbentpositiontoshifttheweightofthegraviduterusoffthevenacava
Maintenanceofinsufflationpressuresbetween10and12mmHg
Monitoringofmaternalarterialcarbondioxidetension(PaCO 2)Thismaybedonebymeasuringeither

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arterialbloodgasesorendtidalCO 2theformermaybemoreaccurate

Otherrecommendationsareasfollows[33]:

Avoidanceofrapidchangesinintraperitonealpressures
Avoidanceofrapidchangesinpatientposition
Useofopentechniqueforumbilicalportplacement

Contraindications
Absolutecontraindicationsforlaparoscopiccholecystectomyincludeaninabilitytotolerategeneralanesthesiaand
uncontrolledcoagulopathy.Patientswithsevereobstructivepulmonarydiseaseorcongestiveheartfailure(eg,
cardiacejectionfraction<20%)maynottoleratecarbondioxidepneumoperitoneumandmaybebetterservedwith
opencholecystectomyifcholecystectomyisabsolutelynecessary.

Gallbladdercancermustbeconsideredacontraindicationforlaparoscopiccholecystectomy.Ifgallbladdercanceris
diagnosedintraoperatively,theoperationmustbeconvertedtoanopenprocedure.Theoretically,anopenprocedure
allowsamorecontrolledperformance,withlesschanceofspillagealso,lymphnodescanbesampled
intraoperativelytostagethedisease. [34]

Manyconditionsoncefelttobecontraindicationsforlaparoscopiccholecystectomy(eg,gangrenousgallbladder,
empyemaofthegallbladder,bilioentericfistulae,obesity,pregnancy,ventriculoperitonealshunt,previousupper
abdominalprocedures,cirrhosis,andcoagulopathy)arenolongerconsideredcontraindicationsbutare
acknowledgedtorequirespecialcareandpreparationofthepatientbythesurgeonandcarefulweighingofrisk
againstbenefit.

Assurgeonshaveaccumulatedextensiveexperiencewiththelaparoscopictechnique,thesecontraindicationshave
beendiscounted,andreportsaboundofsuccessfullyperformedcases. [35,36]

TechnicalConsiderations
Anatomicconsiderations

Theextrahepaticbiliarytreeconsistsofthebifurcationoftheleftandrighthepaticducts,thecommonhepaticduct,
theCBD,thecysticduct,andthegallbladder(seetheimagebelow).

Anatomyofbiliarytree.

Thegallbladderisapearshapedreservoirofbile,710cminlengthand2.55cmindiameter,thatissituatedon
theinferiorsurfaceoftheliver,partiallycoveredbyperitoneum.Itliesatthejunctionoftherightandlefthemilivers,
betweensegments4and5.Thegallbladderisdividedintofourparts:fundus,body,infundibulum,andneck.
Normally,itcontainsupto60mLoffluid,butitmaybedistendedtoacapacityashighas300mLincertain
pathologicconditions. [37]

Astheneckofthegallbladderjoinsthecysticduct,itmakesanSshapedbend.TheHartmannpouchisan
outpouchingofthewallintheregionoftheneck.Thispouchvariesinsize,largelyasaresultofdilatationorthe
presenceofstones. [16]AlargeHartmanpouchmayeasilyobscurethecysticductwithinthetriangleofCalot.

Thegallbladderissuppliedbyasinglecysticartery,whichismostcommonlyabranchoftherighthepaticarterybut
mayalsooriginatefromthelefthepatic,commonhepatic,gastroduodenal,orsuperiormesentericartery.Thecystic
arterytypicallycoursessuperiortothecysticductandposteriortothecommonhepaticartery.Itslengthvaries,
dependingonwhicharteryitoriginatesfromandwhetheritinsertsintotheneckorthebodyofthegallbladder.A
doublecysticarterymayexistin15%ofthepopulation. [38]

ThecysticductconnectsthegallbladdertothecommonhepaticducttoformtheCBD.Itisarguablythemost
importantstructuretobeidentifiedinacholecystectomy.Thecysticductrangesfrom1to5cminlengthandfrom3
to7mminwidthanextremelyshort(<2cm)cysticductmayposeasubstantialchallengeinthedissectionand
placementofclipsduringcholecystectomy.

TheCBDis59cmlongandisdividedinto3segments:supraduodenal,retroduodenal,andintrapancreatic.Itlies
anteriortotheportalveinandtotherightofthecommonhepaticartery,atthefreeborderofthelesseromentum.
TheCBDrunsbehindthefirstpartoftheduodenumontopoftheinferiorvenacavaandliesinagrooveonthe
posteriorsurfaceofthepancreatichead.Itcontinuesdowntheleftsideofthesecondpartoftheduodenum,joining
thepancreaticducttoformtheampullaofVater,whichopensintothesecondpartoftheduodenum. [39]

ThetriangleofCalotisanimportantlandmarkwhoseboundariesincludethecommonhepaticductmedially,the
cysticductlaterally,andtheinferioredgeoftheliversuperiorly.ItcontainsthecysticlymphnodeofLund(also
knownastheCalotnode)itisalsowherethecysticarterybranchesofftherighthepaticartery.Thistriangular
spaceisdissectedtoallowthesurgeontoidentify,divide,andligatethecysticductandartery.TheCalotnodeis
themainrouteoflymphaticdrainageofthegallbladder.

Accessoryhepaticducts,alsoknownastheductsofLuschka,connectdirectlyfromthehepaticbedtothe
gallbladder.Theductsdrainanormalsegmentoftheliver.Whenencounteredduringalaparoscopic
cholecystectomy,theyshouldbeligatedtopreventabileleakorabiliaryfistula.

Bestpractices

Thefollowingmeasuresmayfacilitateperformanceoflaparoscopiccholecystectomy,reduceperioperativemorbidity,
orboth:

Allportsshouldbeinsertedunderdirectvision
PlacingthepatientinthereverseTrendelenburgpositionwiththerightsideuppermitsgravitytoassistin
retractionandallowsthestructurestofallawayfromthefield
Theuseofa30laparoscopeisoptionalbutsignificantlyimprovesvisualization
Thesubxiphoidincisionshouldbemadeinanobliquemannersoitcanbeextendedincaseconversionto
opencholecystectomybecomesnecessary
Anadditional5mmportplacedintheleftupperquadranttoretractafloppyliverorpressdownonavery
fattyomentumorduodenummaybethekeytosuccessinadifficultcase
Theliverbedshouldalwaysberecheckedforbleedingbeforethegallbladderiscompletelyremoved
Asubtotalcholecystectomy,asdescribedbyBornmanetal,maybeanexcellentoptionincasesofsevere
fibrosisorinflammation [40,41]
Drainsarenotroutinelyplacedbutmaybenecessaryintheeventof(1)severeacutecholecystitiswith
significantinflammation,(2)suspicionofinadequatecontrolofaductofLuschka,or(3)subtotal
cholecystectomy
Thedrainmaybeplacedlaparoscopicallyandbroughtoutthroughthemostlateralofthe5mmportsatthe
endoftheprocedure

Complicationprevention

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MajorCBD)injuries,thoughinfrequent(0.24%),canbedevastatingwhentheydooccur(seeComplicationsof
Procedure).Repairsforsuchinjuriesrangefromprimaryrepairoverastenttocholedochoenterostomy. [3]Tricksthat
canhelpthesurgeonavoidingthispotentiallyseriouscomplicationincludethefollowing:

Avoidingexcessivecephaladtractiononthegallbladdersoastopreventtentingandmisidentificationofthe
CBDasthecysticduct [42]
Beforeclippingandtransection,carefullyidentifyingthecysticductandarteryinthecriticalview(see
ConventionalLaparoscopicCholecystectomy)astheonlytwostructuresenteringthegallbladder [43]

Litigationismuchmorecommonafterlaparoscopiccholecystectomythanafteropencholecystectomy,fortwo
apparentreasons.First,bileductinjuriesaremorecommonwithlaparoscopiccholecystectomysecond,missed
intraoperativeinjuriesmaybemorecommoninlaparoscopiccholecystectomycases.

Recommendationsforthepreventionofbileductinjuriesincludeearlyconversionoflaparoscopiccholecystectomy
toopencholecystectomyandtheuseofthecriticalviewtechnique(seeConventionalLaparoscopic
Cholecystectomy)[44,45,46]

IOChasthepotentialtobenefitthesurgeoninthefollowing2ways:

PreventionofCBDinjuryAlthoughIOCmayhelppreventsuchinjuries, [47,48]theliteraturedoesnot
supportusingitonaroutinebasisthismodalityismostlikelytoyieldbenefitifusedselectivelyincasesof
unclearanatomy [49]
IdentificationofcholedocholithiasisEvenifIOCisperformedonlyselectively,manycholangiogramswould
havetobeobtainedtofindasmallnumberofstonesthus,IOCisnotcosteffectiveforthispurpose [50,51]

Inrandomizedtrials,formalresidencytraining,likeroutineuseofIOC,hasnotbeenshowntoreducethenumberof
bileductinjuries.

Outcomes
Laparoscopiccholecystectomyremainsanextremelysafeprocedure,withamortalityof0.220.4%. [52,53]Major
morbidityoccursinapproximately5%ofpatients. [54]Complications(seeComplicationsofProcedure)includethe
following:

Trocar/Veressneedleinjury
Hemorrhage
Postcholecystectomysyndrome
CBDinjuryorstricture
Woundinfectionorabscess
Ileus
Gallstonespillage
Deepveinthrombosis

ContributorInformationandDisclosures
Author
DannyASherwinter,MDAttendingSurgeon,DepartmentofMimiallyInvasiveSurgeryandBariatrics,
AssociateProgramDirector,DepartmentofSurgery,MaimonidesMedicalCenterDirectorofMinimallyInvasive
andBariatricSurgery,AmericanSocietyforMetabolicandBariatricSurgery(ASMBS)CenterofExcellence

DannyASherwinter,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofSurgeons,
AmericanSocietyforMetabolicandBariatricSurgery,SocietyofAmericanGastrointestinalandEndoscopic
Surgeons,andSocietyofLaparoendoscopicSurgeons

Disclosure:Nothingtodisclose.

Coauthor(s)
StalinRamakrishnanSubramanian,MDResidentPhysician,DepartmentofMedicine,BrookdaleUniversity
HospitalandMedicalCenter

Disclosure:Nothingtodisclose.

LeeSCummings,MDTransplantFellow,GeorgetownUniversityHospital

LeeSCummings,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofSurgeonsand
AmericanMedicalAssociation

Disclosure:Nothingtodisclose.

MicheleFMalit,DOResidentPhysician,DepartmentofSurgery,MaimonidesMedicalCenter

MicheleFMalit,DOisamemberofthefollowingmedicalsocieties:AmericanCollegeofOsteopathicSurgeons,
AmericanCollegeofSurgeons,AmericanMedicalStudentAssociation/Foundation,AmericanOsteopathic
Association,andStudentOsteopathicMedicalAssociation

Disclosure:Nothingtodisclose.

SunnyLeahFink,MDMultiOrganAbdominalTransplantFellow,DepartmentofTransplantSurgery,University
ofPittsburghMedicalCenter

SunnyLeahFink,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofSurgeonsand
AmericanMedicalStudentAssociation/Foundation

Disclosure:Nothingtodisclose.

HarryLAdler,MDAssistantClinicalProfessorofSurgery,MountSinaiHospitalAssistantDirectorand
ConsultingPhysician,MaimonidesMedicalCenter

HarryLAdler,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofPhysicianExecutives,
AmericanCollegeofSurgeons,andAssociationforAcademicSurgery

Disclosure:Nothingtodisclose.

ChiefEditor
KurtERoberts,MDAssistantProfessor,SectionofSurgicalGastroenterology,DepartmentofSurgery,
Director,SurgicalEndoscopy,AssociateDirector,SurgicalSkillsandSimulationCenterandSurgicalClerkship,
YaleUniversitySchoolofMedicine

KurtERoberts,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofSurgeons,Societyof
AmericanGastrointestinalandEndoscopicSurgeons,andSocietyofLaparoendoscopicSurgeons

Disclosure:Nothingtodisclose.

AdditionalContributors
JerzyMMacura,MDChiefofAdvancedLaparoscopicSurgery,DirectorofBariatricSurgery,Maimonides
MedicalCenter

JerzyMMacura,MDisamemberofthefollowingmedicalsocieties:AmericanSocietyforMetabolicand
BariatricSurgery,AmericanSocietyofAbdominalSurgeons,andSocietyofAmericanGastrointestinaland
EndoscopicSurgeons

Disclosure:Nothingtodisclose.

http://emedicine.medscape.com/article/1582292overview 4/7
3/20/2015 LaparoscopicCholecystectomy
MaryLWindle,PharmDAdjunctAssociateProfessor,UniversityofNebraskaMedicalCenterCollegeof
PharmacyEditorinChief,MedscapeDrugReference

Disclosure:Nothingtodisclose.

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