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Lap Cholecystectomy—Minimally Invasive Option

Dr. Puerto discusses Missy, a miniature schnauzer with a gallbladder mucocele.

David Liebman

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Missy is an 11-year-old female spayed miniature schnauzer. She was happy, active and, to the owners, appeared normal. But she had a ticking time bomb inside.

Her veterinarian had examined her regularly and had noted progressive increases in her liver enzymes. Missy was referred to radiologist Jessica Basseches, DVM, for an abdominal ultrasound. Her scan revealed that Missy had a fulminant gallbladder mucocele with no active evidence of inflammation.

Gallbladder mucocele is a condition in dogs in which there is accumulation of mucus in the gallbladder.

It has recently been reported as the most common cause of canine extrahepatic biliary duct obstruction.

It is most commonly seen in older small- to medium-sized dogs. Cocker spaniels, Shetland sheepdogs and miniature schnauzers appear to be predisposed to the condition. There has been a weak association reported with hyperadrenocorticism (Cushing’s disease) and gallbladder mucocele.

Findings

Gallbladder mucocele may be an incidental finding but can be clinical in about 75 percent of patients diagnosed. Inflammation and necrosis of the gallbladder may result in gallbladder rupture and bile peritonitis. Clinical signs may be vague in milder cases, but in more severe cases, vomiting and abdominal discomfort are often noted. Elevations of liver enzymes and bilirubin are common.

Missy was referred to me for a surgical consultation. I examined Missy and recommended a laparoscopic cholecystectomy.

A preoperative workup was performed through Missy’s veterinarian. Missy was diagnosed with pituitary dependent Cushing’s disease by her primary veterinarian and started on therapy prior to her cholecystectomy to reduce perioperative risks. Ursodiol therapy was also started at the initial surgical consult.

Missy’s ultrasound was repeated a month later and the mucocele was unchanged. We decided that it was best to remove Missy’s gallbladder before it developed cholecystitis and possible rupture.

We were very excited to offer this as a laparoscopic cholecystectomy to shorten Missy’s recovery and reduce her pain.

Return of Missy

Missy returned to our Center for Animal Referral and Emergency Services (CARES) in Langhorne, Pa., and was admitted.

Brian Bretz, DVM, and I performed the laparoscopic cholecystectomy during the minimally invasive surgery clinic the center offered in May. The gallbladder was successfully removed through tiny incisions.

Specialized instruments were used to dissect the gallbladder and remove it from the liver. The gallbladder was then emptied within a specimen retrieval bag and extracted from the abdomen.

Missy’s recovery from surgery was exceptional and rapid. She was discharged to home in two days.

Laparoscopic cholecystectomy is one of the most commonly performed laparoscopic surgeries in humans and has become the standard of care.

It is a new procedure in veterinary medicine.

Mayhew et al recently published a study of six patients who underwent laparoscopic cholecystectomy in Veterinary Surgery in 2008. Surgeries on all patients were completed successfully and they recovered. The study showed laparoscopic cholecystectomy can be performed safely in dogs with uncomplicated gallbladder mucocele, such as in Missy.

Making the Diagnosis

The diagnosis of gallbladder mucocele is typically made by ultrasound.

There is a characteristic appearance to the gallbladder termed Kiwi gallbladder.

Thickening of the gallbladder wall, edema of wall, or localized effusion may indicate cholecystitis and possible gallbladder rupture.

Non-surgical management with choleretics, such as ursodeoxycholic acid, has been anecdotally reported to have some success and may be tried in patients without clinical signs. The treatment of choice in dogs with clinical signs, elevation of liver enzymes or evidence of gallbladder inflammation or rupture is cholecystectomy.

We feel that having the option of a less painful surgical treatment with laparoscopic cholecystectomy offers promise for earlier treatment of this gallbladder disease before development of complications and mortality associated with severe cholecystitis and gallbladder rupture.

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