surgery (notes) is an experimental technique where the laparoscope is inserted through natural orifices and internal incisions, rather than skin incisions, to access to the abdominal cavity. this offers the potential to eliminate visible scars. since 2007, cholecystectomy by notes has been performed anecdotally via transgastric and transvaginal routes. as of 2009 the risk of gastrointestinal leak, difficulty visualizing the abdominal cavity and other technical limitations limited further adoption of notes for cholecystectomy. open cholecystectomy in open cholecystectomy, a surgical incision of around 8 to 12 cm is made below the edge of the right rib cage and the gallbladder is removed through this large opening, typically using electrocautery. open cholecystectomy is often done if difficulties arise during a laparoscopic cholecystectomy, for example, the patient has unusual anatomy, the surgeon cannot see well enough through the camera, or the patient is found to have cancer. it can also be done if the patient has severe cholecystitis, emphysematous gallbladder, fistulization of gallbladder and gallstone ileus, cholangitis, cirrhosis or portal hypertension, and blood dyscrasias. biopsy after removal, the gallbladder should be sent for pathological examination to confirm the diagnosis and look for any incidental cancer. incidental cancer of the gallbladder is found in approximately 1% of cholecystectomies.: 1019 if cancer is present in the gallbladder, it is usually necessary to re-operate to remove parts of the liver and lymph nodes and test them for additional cancer. post-operative management after surgery, most patients are admitted to the hospital for routine monitoring. for uncomplicated laparoscopic cholecystectomies, people may be discharged on the day of surgery after adequate control of pain and nausea. patients who were high-risk, those who required emergency surgery, and/or those undergoing open cholecystectomy usually need to stay in the hospital several days after surgery. long-term prognosis in 95% of people undergoing cholecystectomy as treatment for simple biliary colic, removing the gallbladder completely resolves their symptoms. up to 10% of people who undergo cholecystectomy develop a condition called postcholecystectomy syndrome. symptoms are typically similar to the pain and discomfort of biliary colic with persistent pain in the upper right abdomen and commonly include gastrointestinal distress (dyspepsia). some people following cholecystectomy may develop diarrhea. the cause is unclear, but is presumed to be due to disturbances in the biliary system that speed up enterohepatic recycling of bile salts. the terminal ileum, the portion of the intestine where these salts are normally reabsorbed, becomes overwhelmed, does not absorb everything, and the person develops diarrhea. most cases resolve within weeks or a few months, though in rare cases the condition can last for years. it can be controlled with medication such as cholestyramine. considerations pregnancy it is generally safe for pregnant women to undergo laparoscopic cholecystectomy during any trimester of pregnancy. early elective surgery is recommended for women with symptomatic gallstones to decrease the risk of spontaneous abortion and pre-term delivery. without cholecystectomy, more than half of such women will have recurrent symptoms during their pregnancy, and nearly one in four will develop a complication, such as acute cholecystitis, that requires urgent surgery. acute cholecystitis is the second most common cause of acute abdomen in pregnant women after appendectomy. porcelain gallbladder porcelain gallbladder (pgb), a condition where the gallbladder wall shows calcification on imaging tests, was previously considered a reason to remove the gallbladder because it was thought that people with this condition had a high risk of developing gallbladder cancer. however, recent studies have shown that there is no strong association between gallbladder cancer and porcelain gallbladder, and that pgb alone is not a strong enough indication for a prophylactic cholecystectomy. alternatives to surgery there are several alternatives to cholecystectomy for people who do not want surgery, or in whom the benefits of surgery would not outweigh the risks. conservative management conservative management for biliary colic involves a "watch and wait" approach—treating symptoms as-needed with oral medications. experts agree that this is the preferred treatment for people with gallstones but no symptoms. conservative management may also be appropriate for people with mild biliary colic, as the pain from colic can be managed with pain medications like nsaids (ex: ketorolac) or opioids. conservative management for acute cholecystitis involves treating the infection without surgery. it is usually only considered in patients at very high risk for surgery or other interventions listed below. it consists of treatment with intravenous antibiotics and fluids. ercp in ercp, the endoscope enters through the mouth and passes through the stomach and start of the small intestine to reach the bile ducts. this is a cholangiogram, an x-ray of the bile ducts using contrast medium to make the bile ducts visible. 1 – duodenum. 2 – common bile duct. 3 – cystic duct. 4 – hepatic duct. the gallbladder is not seen as the cystic duct is occluded by a surgical instrument. ercp, short for endoscopic retrograde cholangiopancreatography, is an endoscopic procedure that can remove gallstones or prevent blockages by widening parts of the bile duct where gallstones frequently get stuck. ercp is often used to retrieve stones stuck in the common bile duct in patients with gallstone pancreatitis or cholangitis. in this procedure, an endoscope, or small, long thin tube with a camera on the end, is passed through the mouth and down the esophagus. the doctor advances the camera through the stomach and into the first part of the small intestine to reach the opening of the bile duct. the doctor can inject a special, radiopaque dye through the endoscope into the bile duct to see stones or other blockages on x-ray. ercp does not require general anaesthesia and can be done outside of the operating room. while ercp can be used to remove a specific stone that is causing a blockage to allow drainage, it cannot remove all stones in the gallbladder. thus, it is not considered a definitive treatment and people with recurrent complications from stones will still likely need a cholecystectomy. cholecystostomy cholecystostomy is the drainage of the gallbladder via insertion of a small tube through the abdominal wall. this is usually done using guidance from imaging scans to find the right place to insert the tube. cholecystostomy can be used for people who need immediate drainage of the gallbladder but have a high risk of complications from surgery under general anaesthesia, such as elderly people and those with co-existing illnesses. draining pus and infected material through the tube reduces inflammation in and around the gallbladder. it can be a lifesaving procedure, without requiring that the person undergo emergency surgery. the procedure does come with significant risks and complications—in one retrospective study of patients who received percutaneous cholecystostomy for acute cholecystitis, 44% developed choledocholithiasis (one or more stones stuck in the common bile duct), 27% had tube dislodgment, and 23% developed postoperative abscess. for some people, drainage with cholecystostomy is enough and they do not need to have the gallbladder removed later. for others, percutaneous cholecystostomy allows them to improve enough in the short term that they can get surgery at a later time. there is no clear evidence one way or another to indicate that surgical removal after cholecystostomy is best for high-risk surgical patients with acute cholecystitis. frequency of use about 600,000 people receive a cholecystectomy in the united states each year.: 855 in a study of medicaid-covered and uninsured u.s. hospital stays in 2012, cholecystectomy was the most common operating room procedure. history carl langenbuch performed the first successful cholecystectomy in 1882. carl langenbuch performed the first successful cholecystectomy at the lazarus hospital in berlin on july 15, 1882. before this, surgical therapy for symptomatic gallstones was limited to cholecystostomy, or gallstone removal. langenbuch's rationale for developing the new technique stemmed from 17th century studies in dogs that demonstrated the gallbladder to be nonessential and medical opinion among his colleagues that gallstones formed in the gallbladder. although the technique was initially controversial, cholecystectomy became established as a lower mortality procedure than cholecystostomy by the 20th century. laparoscopic technique erich mühe performed the first laparoscopic cholecystectomy on september 12, 1985, in böblingen, germany. mühe was inspired to develop a technique for laparoscopic cholecystectomy by the first laparoscopic appendectomy, performed by gynecologist kurt semm in 1980. he subsequently designed an optical laparoscope with a working channel large enough to fit a distended gallbladder. mühe presented his technique to the congress of the german surgical society in 1986, claiming reduced postoperative pain and shorter hospitalization. his work was met with strong resistance by the german surgical establishment and he had difficulty communicating it in english. it was consequently ignored. mühe's work was further disparaged in 1987, when he was charged with manslaughter for a postoperative patient death that was mistakenly attributed to his innovative technique. he was exonerated in 1990 after further investigation. his pioneering work was eventually recognized by the german surgical society congress in 1992. philippe mouret performed laparoscopic cholecystectomy on march 17, 1987, in lyon, france. his technique was rapidly adopted and improved in france. it was subsequently introduced to the rest of the world over the next three years. driven by popularity among patients, the laparoscopic technique became preferred over open surgery and noninvasive treatments for gallstones. by 2013, laparoscopic cholecystectomy had replaced open cholecystectomy as the first-choice of treatment for people with uncomplicated gallstones and acute cholecystitis. by 2014 laparoscopic cholecystectomy had become the gold standard for the treatment of symptomatic gallstones. laparoscopic cholecystectomy can be a challenging procedure and surgeons must be trained with advanced laparoscopic skills to complete the operation with safety and effectiveness.