Management of Asymptomatic Cholecystolithiasis
After the diagnosis of asymptomatic cholecystolithiasis, the risk of developing symptoms is 2 – 4 % per year during the first five years, then halves thereafter. The risk of biliary complications is only 0.1–0.3 % per year【1】.
Prophylactic cholecystectomy does not improve life expectancy in asymptomatic patients with gallstones, as the surgical risk outweighs the likelihood of developing biliary complications【2】. Consequently, various guidelines agree that asymptomatic cholecystolithiasis generally does not constitute an indication for surgery【3, 4, 5】.
Exception:
For asymptomatic patients with gallstones >3 cm, the German S3 Guideline (2017) recommends considering cholecystectomy, as the risk of gallbladder carcinoma is up to ten times higher in these cases【6】.
Surgical Recommendations in Obesity Surgery
The German S3 Guideline (2017) recommends performing cholecystectomy during bariatric surgery only in symptomatic patients with gallstones【4】. The EASL Guideline (2016) aligns with this recommendation but at a very low evidence level【5】. The S3 Guideline also states that simultaneous cholecystectomy can be considered for asymptomatic patients undergoing major malabsorptive small bowel procedures.
Among bariatric procedures, laparoscopic Roux-en-Y reconstruction carries the highest risk of postoperative gallstone formation compared to sleeve gastrectomy and gastric banding【7】.
The recommendation to perform simultaneous cholecystectomy only for symptomatic patients is supported by a registry study and meta-analysis【8, 9】:
- The likelihood of secondary cholecystectomy after laparoscopic Roux-en-Y reconstruction was low (6.8 %).
- In 5.3 % of cases, secondary surgery was due to symptomatic cholecystolithiasis.
- Secondary cholecystectomy was almost always performed laparoscopically (95.5 %) with very low morbidity (1.8 %).
Management of Symptomatic Cholecystolithiasis
There is consensus among all medical societies regarding the treatment of symptomatic cholecystolithiasis. The German S3 Guideline (2017) recommends cholecystectomy for uncomplicated cholecystolithiasis associated with typical biliary pain【4】.
The objectives of cholecystectomy are to prevent recurrent biliary symptoms, future complications, and gallbladder carcinoma. Without treatment:
- Approximately 70 % of patients experience recurrent colic within 2 years
- 4 % require emergency cholecystectomy【10】
- The risk of biliary complications is 1 - 3 % per year
If the patient remains symptom-free for 5 years, they are reclassified as asymptomatic stone carriers, and surgery is no longer indicated【11】
For gallbladder sludge, the German S3 Guideline recommends the same approach as for symptomatic cholecystolithiasis【4】. Conservative medical therapy or lithotripsy is considered obsolete【3】.
Antibiotic Prophylaxis in Elective Cholecystectomy
All the aforementioned guidelines agree that prophylactic antibiotic administration is unnecessary for low-risk patients undergoing elective cholecystectomy. While there is no prospective, randomized study with sufficiently large patient numbers to address this question definitively, several meta-analyses, registry data from Germany and Sweden, and a Cochrane review support this position【12, 13】.
The SAGES guidelines concur for low-risk patients and provide additional recommendations【14】:
- High-risk patients (e.g., age > 60 years, diabetes, biliary colic within 30 days before surgery, jaundice, cholangitis, or acute cholecystitis) may benefit from antibiotics to reduce wound infection rates.
- If antibiotics are administered, they should be given 1 hour before the skin incision.
- In open cholecystectomy or conversion from laparoscopic to open procedures, antibiotic prophylaxis can reduce wound infection rates from 15 % to 6 %【13】.
Recommendation for Porcelain Gallbladder
In the past, the risk of gallbladder carcinoma associated with calcified gallbladders (porcelain gallbladder) was estimated at up to 62 %. However, recent studies indicate this figure is significantly overestimated【15, 16】.
Despite this revision, prophylactic cholecystectomy is still recommended for asymptomatic patients with porcelain gallbladder due to the persistent malignancy risk【4, 5, 14】.
Recommendation for the Management of Gallbladder Polyps
- The incidence of gallbladder polyps in Germany is approximately 6 %【17】. Adenomas are present in about 5 % of these patients, and adenomas > 1 cm are associated with up to a 50 % risk of malignancy, warranting prophylactic cholecystectomy【18】. For larger adenomas (1.8 – 2 cm), the risk of carcinoma increases further, and open cholecystectomy is recommended from an oncological perspective【19】.
Polyps < 1 cm:
These have a significantly lower risk of malignancy, so immediate cholecystectomy is not required. However, patients should undergo regular sonographic monitoring. Surgery is indicated if biliary symptoms or additional risk factors develop, such as:
- Age > 50 years.
- Solitary polyps.
- Gallstones.
- Rapidly growing polyps【18, 20】.
Diagnostic Accuracy:
Endosonography is superior to transcutaneous ultrasound for diagnosing gallbladder polyps (87 – 97 % vs. 52 – 76 %)【21】.
Guideline Recommendations:
- SAGES (2010):
- Laparoscopic cholecystectomy is recommended for large, solitary polyps or those with associated symptoms.
- A “wait-and-watch” strategy is suggested for small polyps (< 5 mm)【14】
- ASL (2016):
- Cholecystectomy for polyps > 1 cm, regardless of symptoms or the presence of gallstones.
- Cholecystectomy for patients with primary sclerosing cholangitis and gallbladder polyps.
- No cholecystectomy for asymptomatic gallstones and small polyps (< 5 mm)【5】
- German S3 Guideline (2017):
- Recommends cholecystectomy for patients with gallstones and polyps ≥1 cm, regardless of symptomatology【4】
Recommendations in Liver Cirrhosis (Child-Pugh A and B)
Patients with liver cirrhosis are predisposed to developing cholecystolithiasis. Studies on laparoscopic cholecystectomy in Child-Pugh A and B patients have demonstrated acceptable morbidity rates (9.5 – 23 %) and mortality rates (0 – 6.3 %). A prospective randomized study showed the superiority of laparoscopic over open cholecystectomy in these patients【22】.
Laparoscopic cholecystectomy is not recommended for Child-Pugh C patients due to the significantly higher risk.
All the aforementioned guidelines agree on these recommendations, albeit with varying levels of evidence and recommendation grades.
Acute Cholecystitis Guidelines
The most common complication of cholecystolithiasis is acute cholecystitis, which in over 90% of cases is caused by a transient or persistent obstruction of the cystic duct by calculi. In such cases, the standard treatment is laparoscopic cholecystectomy.
Guideline Recommendations for Timing of Cholecystectomy in Acute Cholecystitis:
- German S3 Guideline (2017):
- Early laparoscopic cholecystectomy is recommended, ideally within 24 hours of hospital admission【4】
- EASL Guideline (2016):
- Early cholecystectomy should be performed, preferably within 72 hours of admission, by an experienced surgeon【5】
- SAGES Guideline (2010):
- Early cholecystectomy (within 24–72 hours of diagnosis) is associated with reduced hospital costs and length of stay, without increasing conversion rates or complications【14】.
- Tokyo Guidelines (2013):
- Treatment strategy depends on the severity of acute cholecystitis:
- Grade I (mild) and Grade II (moderate):
Early laparoscopic cholecystectomy, ideally shortly after symptom onset if the patient is operable. - Grade III (severe):
Initial focus on stabilizing organ function before surgery.
Note:
The Tokyo Guidelines (2013) have been criticized for being overly conservative; updated evidence favors immediate cholecystectomy within 24–48 hours, even for Grade II cases【23-25】
Gallbladder Carcinoma
Incidental gallbladder carcinomas are found in less than 1% of cholecystectomy specimens. Further treatment depends on the tumor’s T-stage. The German S3 Guideline, in alignment with the SAGES guidelines, states that gallbladder removal alone is sufficient for carcinoma in situ (Tis) or mucosal carcinoma (T1a)【5, 14】.
In these early tumor stages, there is no lymphatic or perineural spread【26】. Consequently, liver resection or lymphadenectomy is not required.
For all tumor stages ≥ T1b, oncological re-resection is recommended for curative intent. This involves wedge resection with a 2 – 3 cm liver margin. Achieving R0 status yields excellent outcomes, with favorable 4-year survival rates【26】.
Laparoscopic Cholecystectomy During Pregnancy
Gallstones and sludge develop in approximately 5 % of all pregnant women, with 1 % experiencing gallstone-related complications during pregnancy【27】. Conservative management leads to recurrent symptoms in 92% of patients in the first trimester, 64% in the second trimester, and 44 % in the third trimester. The fetal mortality rate from biliary complications is 12 – 60 %, significantly higher than the 1.2 % associated with indicated laparoscopic cholecystectomy. Current studies show no significant differences in fetal mortality or preterm delivery rates between open and laparoscopic cholecystectomy (5 % vs. 4 %)【28】.
German S3 Guideline Recommendations:
- Laparoscopic cholecystectomy may be performed during any trimester if there is a pressing indication
- Patients who develop symptoms in the first trimester should undergo early elective surgery to prevent recurrence later in pregnancy【5】
SAGES Guidelines Recommendations:
- Diagnostic laparoscopy is a safe and effective option for acute abdominal processes during pregnancy.
- Laparoscopic cholecystectomy is the treatment of choice for gallstone disease in pregnant patients, regardless of trimester.
- Indications for laparoscopic treatment of acute abdominal conditions are the same for pregnant and non-pregnant patients.
- Laparoscopy can be safely performed in any trimester.
Recommendations for Access Techniques in Laparoscopic Cholecystectomy
Laparoscopic surgery is generally the standard method for cholecystectomy. The German S3 Guideline, EASL Guideline, and SAGES Guideline provide recommendations regarding laparoscopic access techniques:
- The German S3 and EASL Guidelines specifically recommend using a 4-trocar technique for laparoscopic cholecystectomy【4, 5, 14】.
- The SAGES Guideline is less specific but supports laparoscopic approaches as safe and effective.
Alternative Techniques (SILS and NOTES):
- There is currently no substantial evidence from large, randomized studies to demonstrate a clear advantage of Single-Incision Laparoscopic Surgery (SILS) or Natural Orifice Transluminal Endoscopic Surgery (NOTES) over the standard 4-trocar approach.
- Operative time and complication rates for these alternative techniques are highly dependent on the surgeon’s expertise.
- Neither SILS nor NOTES has shown significant reductions in postoperative pain compared to the 4-trocar method【29, 30】.
Conclusion:
The 4-trocar technique remains the gold standard for laparoscopic cholecystectomy, while SILS and NOTES are currently not recommended as standard procedures due to a lack of supporting evidence.
Robotics in Cholecystectomy
Laparoscopic cholecystectomy is a highly standardized, low-complication, and technically simple procedure. As such, the benefits of robot-assisted cholecystectomy regarding morbidity and mortality are difficult to demonstrate. The advances offered by robotic surgery, such as improved visualization, instrument articulation, and ambidexterity, are not critical for this relatively straightforward procedure, as conventional laparoscopy provides sufficient capabilities.
However, robot-assisted cholecystectomy holds value as an entry point into robotic surgery. It allows surgeons to transition their training from simulation to real patients in a low-risk environment, making it a suitable starting procedure for robotic programs.
Evidence Comparing Robotic and Laparoscopic Approaches
- Gantschnigg et al. (2023):
A study of 220 procedures (50 % robotic, 50 % laparoscopic) found:
- No significant difference in mean operative time (RC: 60.2 min vs. LC: 62.0 min, p = 0.58).
- Postoperative length of stay was identical (2.65 days for both groups, p = 1).
- Total hospital costs were slightly higher for robotic cholecystectomy (€ 2088 vs. € 1726).
The authors concluded that robotic cholecystectomy is a safe and practical alternative to laparoscopic cholecystectomy. They recommended its use as a training procedure for teams starting robotic surgery programs, while emphasizing the need for prospective randomized trials to confirm these findings.
- Huang et al. (2017):
A meta-analysis published in Surgery reported that robotic cholecystectomy is associated with longer operative times, primarily due to preparation phases. However, it offers similar safety and perioperative outcomes compared to laparoscopic cholecystectomy. The authors suggested that future studies should identify specific benefits for surgeons and evaluate the potential advantages of robotic systems in acute scenarios.
- Straatman et al. (2023):
A systematic review summarized the current evidence on robotic versus conventional multiport cholecystectomy.
- Fourteen studies involving 3002 patients were analyzed.
- No differences were found between robotic and laparoscopic groups in terms of blood loss, complication rates, bile duct injuries, or hospital stay duration.
- Robotic cholecystectomy had longer operative times but a lower risk of conversion to open surgery.
- Data quality was generally poor, with significant heterogeneity and missing information on training and quality measures.
The review concluded that the longer operative times for robotic cholecystectomy likely reflect learning curves for the new technique. Postoperative recovery and complication rates were comparable across both methods.
Conclusion
While robotic cholecystectomy demonstrates comparable safety and outcomes to conventional laparoscopy, its longer operative times and higher costs limit its widespread use for this procedure. Its primary value lies in training and developing robotic programs, serving as a stepping stone for more complex robotic surgeries. Further high-quality, randomized studies are needed to explore its potential advantages in specific clinical settings.