Biliary Tract: Cholecystectomy

Laparoscopic Cholecystectomy

Basics

  • Laparoscopic Removal of the Gallbladder

Procedure

  • Access Abdomen – x4 Trocars (Periumbilical & x3 Subcostal)
  • Expose Gallbladder
    • Position Reverse Trendelenburg & Left Side Down
    • Retract Fundus Cephalad
    • Retract Body Laterally
    • *If Difficult to Grab – Consider Decompression by Needle-Aspiration
  • Expose the Critical View of Safety
  • Divide Cystic Duct & Cystic Artery
    • Two Clips Away from the Gallbladder & One Clip Near the Gallbladder
    • *Terms Proximal & Distal to the Gallbladder are Generally Discouraged Due to Variability in Meaning
  • Dissect Gallbladder from Liver Bed & Remove
  • Ensure Hemostasis
  • Close Incision Sites

Considerations

  • Critical View of Safety – SAGES Safe Cholecystectomy Program
    • Only Two Structures Entering Gallbladder (Cystic Artery/Duct)
    • Triangle of Calot Cleared of All Fat & Fibrous Tissue
    • Lower Third of Gallbladder Separated from Liver
  • Encouraged Liberal Use of Intraoperative Cholangiography (IOC)
    • Especially in Difficult Cases with Unclear Anatomy
    • Routine Use Unnecessary
  • If Approaching a Zone of Significant Risk – Finish by a Safe Method:
    • Conversion to Open
    • Subtotal Cholecystectomy After Removal of All Stones
    • Cholecystostomy Tube
    • Low Threshold for Calling in Help of Other Experienced Surgeons

Intraoperative Cholangiogram (IOC) & Bile Duct Exploration

Laparoscopic Complications

  • Retained Stone
    • Stone Retained in Common Bile Duct
    • If Intraoperative Concern: Leave T-Tube
      • Wait 4-6 Weeks for Tract to Mature Before Instrumentation/Cholangiogram
      • If CBD Stone Still Present: Extract Through T-Tube
        • Maybe ERCP
    • Best Predictor: Persistent High Total Bilirubin
  • Spilled Stone
    • Stone Spilled into the Peritoneal Cavity
    • Can Cause Abscess
    • Tx: Laparoscopic Drainage & Stone Removal
      • Percutaneous Drain Will Recur
  • Biliary Injury (0.26-0.60%)
  • Bleeding (0.11-1.97%)
  • Abscess (0.14-0.30%)
  • Bowel Injury (0.14-0.35%)

Conversion to Open Procedure

  • Rate of Conversion: Generally Reported as 5-10%
    • *Modern Rates Lower and Decreasing
  • Risks for Conversion: Elderly, Emergency Status, Male, Low Albumin & Previous Abdominal Surgery
  • Modern Surgeons are Generally More Comfortable with Laparoscopic Approaches with Conversion Often Providing Less Benefit
    • All Surgeons, However, Should Be Comfortable Opening if Necessary

Critical View of Safety 1

Critical View of Safety 2

Laparoscopic Port Placement

Open Cholecystectomy

Basics

  • Open Removal of the Gallbladder

Indications

  • Absolute:
    • Unable to Safely Complete Laparoscopic Cholecystectomy
    • Unable to Tolerate Pneumoperitoneum
    • Hemodynamically Unstable
    • Refractory Coagulopathy
    • Strong Suspicion of Gallbladder Cancer
  • Relative:
    • Prior Abdominal Surgery with Significant Adhesions
    • History of Cholecystoenteric Fistula
    • Cirrhosis

Procedure

  • Right Subcostal Incision (Connect Laparoscopic Incisions if Converted)
  • “Bottom-Up” Approach
    • Starting at Infundibulum
    • First Divide Cystic Duct, Then Free from Liver Bed
    • Similar Approach as Laparoscopic
  • “Top-Down” Approach (Most Commonly Preferred)
    • Starting at Fundus
    • First Free from Liver Bed, Then Divide Cystic Duct
    • Minimize Chance of Duct Injury

Complications

  • Compared to Laparoscopic: Higher Mortality & Infection
  • Bile Leak – Rare

References

  1. Wauben LS, Goossens RH, van Eijk DJ, Lange JF. Evaluation of protocol uniformity concerning laparoscopic cholecystectomy in the Netherlands. World J Surg. 2008 Apr;32(4):613-20. (License: CC BY-NC-2.0)
  2. Dziodzio T, Weiss S, Sucher R, Pratschke J, Biebl M. A ‘critical view’ on a classical pitfall in laparoscopic cholecystectomy! Int J Surg Case Rep. 2014;5(12):1218-21. (License: CC BY-NC-ND-3.0)