Cholecystectomy

David Ray Velez, MD
The Operative Review of Surgery. 2023; 1:63-76.

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Table of Contents

Minimally Invasive Cholecystectomy (Laparoscopic or Robotic)
Open Cholecystectomy
Management of the Difficult Gallbladder
Subtotal Cholecystectomy
Complications

References

Minimally Invasive Cholecystectomy (Laparoscopic or Robotic)

Basics

  • Removal of the Gallbladder by Minimally Invasive Means
  • Can be Done by Traditional Laparoscopy or Robotically

Initial Positioning

  • Patient Positioned Supine
  • Arms Extended
  • Prep Nipples-to-Groin
  • Monitors are Placed with One at Each Shoulder

Abdominal Access

  • Gain Pneumoperitoneum (Veress or Hasson Technique)
    • At Umbilicus or Palmer’s Point
  • Traditionally Done Using 4 Trocars
    • 3-Port, 2-Port, and Single-Port Techniques are Evolving 2-4
  • Initial 5-mm Port Generally Placed at Umbilicus
  • Position Table in Reverse Trendelenburg (Head Up) with Right-Side Up
    • Allows Bowel to Fall Dependently Out of the Field of View
    • Position Prior to Placing Additional Ports – Liver May Fall Dependently and Necessitate Lower Port Placement than if Placed Prior to Positioning
  • Place Additional Ports
    • 12-mm Port at the Subxiphoid Site
      • Placed Immediately to the Right of the Falciform Ligament
      • Will Cause Difficulty Exchanging Instruments if Placed to the Left Due to Falciform Ligament Being in the Way
    • Two Additional 5-mm Ports Along the Right Subcostal Margin
      • Placed Below the Edge of the Liver

Procedure

  • Expose the Gallbladder
    • Retract the Fundus Cephalad
    • Retract the Body Laterally
    • *If Difficult to Grab – Consider Decompressing the Gallbladder by Needle-Aspiration
  • Expose the Critical View of Safety
    • *See Below
  • Divide the Cystic Duct & Cystic Artery
    • Two Clips Away from the Gallbladder & One Clip Near the Gallbladder
    • *Terms Proximal & Distal are Generally Discouraged Due to Variability in Meaning (Proximal to the Gallbladder vs Proximal from the Origin) 5,6
  • Dissect the Gallbladder Off the Liver Bed and Remove
    • Consider Using an Endoscopic Retrieval Bag
  • Ensure Hemostasis
  • Close Incision Sites

Endoscopic Retrieval Bag

  • Minimize Risk of Tumor Dissemination in Gallbladder Cancer 7
  • Minimize Risk of Spilling Infected Bile, Stones, or Purulence in Acute Cholecystitis 8-10
  • No Proven Benefit in Reducing Infection Rate After Elective Surgery 11
    • May Consider Avoiding in Absence of Acute Cholecystitis, Accidental Intraoperative Perforation, or Suspected Carcinoma 11

Critical View of Safety 14

  • Hepatocytic Triangle (Triangle of Calot) Cleared of All Fat & Fibrous Tissue
  • Lower Third of the Gallbladder Separated from Liver to Expose the Cystic Plate
  • Only Two Structures Are Seen Entering Gallbladder (Cystic Artery and Cystic Duct)
    • “Doublet View” – Seen from Both the Anterior and Posterior Views to Confirm the Critical View
  • *See the SAGES Safe Cholecystectomy Program

Intraoperative Cholangiogram (IOC) & Common Bile Duct Exploration (CBDE)

Trocar Placement 1

Critical View of Safety 12

Critical View of Safety 13

Open Cholecystectomy

Indications 15

  • Indications:
    • Patient’s Informed Request for an Open Procedure
    • Known Dense Adhesions in the Upper Abdomen
    • Known Gallbladder Cancer
    • Surgeon Preference
  • Relative Contraindications for Laparoscopic Cholecystectomy:
    • Generalized Peritonitis
    • Septic Shock from Cholangitis
    • Severe Acute Pancreatitis
    • Untreated Coagulopathy
    • Lack of Equipment
    • Lack of Surgeon Expertise
    • Prior Abdominal Operations Which Prevent Safe Abdominal Access or Progression of the Procedure
    • Advanced Cirrhosis with Hepatic Failure
    • Suspected Gallbladder Cancer

Procedure

  • Right Subcostal Incision (Kocher Incision)
    • 15-cm Incision 2-cm Below the Costal Margin
    • Can Connect Laparoscopic Incisions if Converted
    • Can Also Perform by an Upper Midline Incision
  • Dissect and Remove the Gallbladder
    • Retrograde/Anterograde Approaches – See Below
  • Ensure Hemostasis
    • Venous Bleeding Can Generally Be Controlled by Holding Constant Pressure for 5-10 Minutes
    • Other Options: Hemostatic Agents, Hemostatic Sutures
  • Close Fascia in Two-Layers
    • Use Running Slowly Absorbable Suture (PDS)
    • Posterior Layer: Transversalis Fascia and Peritoneum
    • Anterior Layer: Anterior Fascia
    • Do Not Include the Muscle – Increases Risk for Muscle Necrosis with No Increased Strength to Closure
  • Close Skin

Retrograde (“Bottom-Up”) Approach

  • *Similar Approach as a Laparoscopic Cholecystectomy
  • Start Dissection at the Infundibulum
  • Identify the Critical View of Safety
  • Divide the Cystic Duct and Cystic Artery
    • Ligate with Clips or Sutures
  • Dissect the Gallbladder Off the Liver Bed and Remove

Antegrade (“Top-Down”) Approach

  • Also Known as “Fundus-Down” or “Dome-Down” Approach
  • *Most Commonly Preferred Approach
  • Start Dissection at the Fundus
    • Place a Clamp on the Gallbladder Fundus to Provide Traction
  • Free the Gallbladder Posteriorly and Laterally from the Cystic Plate
  • Expose the Cystic Duct and Cystic Artery
  • Divide the Cystic Duct and Cystic Artery
    • Ligate with Clips or Sutures

Management of the Difficult Gallbladder

Grading Systems

  • Nassar Grading 17
  • Parkland Grading Scale for Cholecystitis 18
  • The Tokyo Guidelines 2018 for Acute Cholecystitis 19
  • American Association for the Surgery of Trauma (AAST) Emergency General Surgery (EGS) Score 20
  • *No Single Scoring System Universally Adopted – AAST EGS Score is Commonly Accepted

Intraoperative Cholangiogram (IOC)

  • Should Be Used Liberally, Especially in Difficult Cases with Unclear Anatomy
  • Routine Use is Controversial – Evidence is Insufficient 21,22
    • Currently Considered Not Mandatory, Although Practice May Improve Outcomes in More Challenging Cases
  • *See Intraoperative Cholangiogram (IOC)

Options if Approaching a Zone of Significant Risk 14

  • Conversion to an Open Procedure
  • Subtotal Cholecystectomy After Removal of All Stones
    • *See Below
  • Cholecystostomy Tube
  • Low Threshold for Calling in Help of Other Experienced Surgeons

Conversion to Open Procedure

  • Conversion to an Open Procedure Should Not Be Considered a “Complication”
  • Rate of Conversion: Generally Reported as 1-15% 23,24
    • Modern Rates Lower and Decreasing
  • Conversion Increases Operative Time, Complication Rates, and Length of Stay 25,26
  • Risk Factors for Conversion: 27,28
    • Older Age (≥ 50-65 Years)
    • American Society of Anesthesiologists (ASA) Classification
    • Male Gender
    • Emergency Admission
    • Acute Cholecystitis
    • Gallbladder Wall Thickness
    • CBD Stones/Jaundice
    • Dilated CBD
    • Low Albumin
    • Cirrhosis
    • 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

Nasser Grading 16

Subtotal Cholecystectomy

Definitions

  • Definitions: 29
    • Subtotal Cholecystectomy: Removal of Almost All of the Gallbladder
    • Partial Cholecystectomy: Removal of Only Part of the Gallbladder
      • Quantitively Less Than a Subtotal Cholecystectomy Although Often Used Interchangeably
    • Fundectomy: Removal of Only the Top-Half or Less of the Gallbladder
  • Types of Subtotal Cholecystectomy: 29
    • Subtotal Fenestrating Cholecystectomy: Does Not Produce a Remnant Gallbladder
      • Generally the Preferred Technique in These Situations
      • Higher Risk of Bile Leak and Bile Fistula – Most Resolve Spontaneously
    • Subtotal Reconstituting Cholecystectomy: Produces a Remnant Gallbladder
      • Higher Risk for Recurrent Stones or Cholecystitis from the Remnant

Fenestrating Technique

  • Gallbladder is Opened and Drained at the Fundus
  • Bile, Stones, and Debris are Suctioned or Removed
  • The Gallbladder Incision is Extended Posteriorly Around the Gallbladder Neck
    • Cystic Duct/Artery are Not Dissected
    • All Dissection Should Remain Superior to the “Line of Safety” Extending from Rouviere’s Sulcus
    • “Shield” of McElmoyle: The Bottom Lip of the Free Peritonealized Gallbladder is Left Behind to Protect from Entering the Hepatocytic Triangle
  • The Anterior Wall of The Gallbladder is Completely Removed
    • The Posterior Wall is Generally Left on the Cystic Plate Although the Superior-Most Portion May Be Excised
  • Remnant Mucosa is Ablated by Cautery or Argon Beam
  • May Consider Purse-String Closure of the Cystic Duct from the Inside if Feasible – Often Foregone Due to Safety Concerns
  • Leave a Drain Near the Stump to Drain the Presumed Bile Leak (3x Risk)

Reconstituting Technique

  • Similar to a Fenestrating Technique
  • Instead of Leaving Open, The Lumen is Closed with Sutures or Staplers
  • Produces a Small Remnant Gallbladder

Complications

Postcholecystectomy Diarrhea

  • Definition: ≥ 3 Loose Stools Per Day After Cholecystectomy
  • Risk: 2.1-57.2% 30
  • Most Often Stops After Days-Weeks but Can Last for Years
  • Causes:
    • Increased Enterohepatic Circulation 31
    • Increased Bile Salts in the Colon – From Interruption of a Negative Feedback Loop in Bile Acid Synthesis 32
    • Altered Gut Microbiome 33
  • Patients with Prior Gastrointestinal Symptoms are at Higher Risk 30
  • Treatment Options:
    • Dietary Modifications
    • Cholestyramine (Bile Acid Sequestrant)
    • Loperamide

Postcholecystectomy Syndrome

  • Definition: Complex of Heterogenous Symptoms That Persist/Recur Colic After Cholecystectomy 34
  • Risk: 5-30% 35
  • Symptoms: 34
    • Abdominal Pain
    • Dyspepsia
    • Nausea and Vomiting
    • Jaundice
    • Fever
  • Risk Factors: 36,37
    • Urgent Surgery
    • Lack of Gallstones
    • Increased Duration of Preoperative Symptoms
    • Female Sex
    • Younger Age (20-29 Years)
  • Biliary Causes: 34
    • Retained Stones
    • Biliary Injury
    • Bile Leak
    • Bile Duct Stricture
    • Remnant Gallbladder with Stones/Inflammation
    • Remnant Cystic Duct with Stones/Inflammation
    • Biliary Dyskinesia
  • Non-Biliary Causes: 34
    • Pancreatitis
    • Pancreatic Tumor
    • Pancreatic Divisum
    • Hepatitis
    • Peptic Ulcer Disease
    • Mesenteric Ischemia
    • Diverticulitis
    • Esophageal Disorders
    • Intestinal Motility Disorders
    • Coronary Artery Disease
    • Intercostal Neuritis
    • Wound Neuroma
    • Psychiatric Disorders
  • Diagnosis Can Be Difficult
    • Options: US, CT, or MRCP
    • May Require Sphincter of Oddi Manometry
  • Treatment: Based on Specific Cause

Biliary Injury

  • Risk for Major Bile Duct Injuries: 38
    • Elective Surgery: 0.1%
    • Emergent Surgery: 0.3%
  • 30-Day Mortality: 2% 39
  • Effort to Avoid:
    • Use of the Critical View of Safety Prior to Transection
    • Liberal Use of Intraoperative Cholangiogram – Studies Show Higher Incidence When IOC is Performed but Confounded by the Fact that IOC is More Frequently Used in Difficult Cases 40,41
    • *See Management of the Difficult Gallbladder Above
  • One of the Most Feared and Morbid Complication of Cholecystectomy
  • *See Biliary Injury

Intraoperative Gallbladder Perforation

  • Incidence: 10-33% 42
    • Possibly Under-Reported in Literature Due to Poor Documentation in Operative Reports with Retrospective Analysis 42
  • Risk Factors: 42-44
    • Acute Cholecystitis
    • Dense Adhesions
    • Tense Distended Gallbladder Not Decompressed
    • Difficult Operation
    • Learning Surgeons/Residents
  • Steps When Gallbladder is A Risk for Perforation: 42,45
    • During Dissection Off the Liver Bed – Most Common
    • Manipulation by Laparoscopic Instruments
    • Slippage of Cystic Duct Clips
    • Gallbladder Tearing During Retrieval from a Port Site
  • Generally Harmless with No Adverse Consequences in Most Cases 42
    • Perforation is a Risk for Spilled Stones and Postoperative Abscess 45
    • Bile Can Cause a Chemical Peritonitis 42

Retained Stone

  • Definitions Vary:
    • Retrained Stone: Refers to Any Stone Left Behind and Not Removed During Cholecystectomy
      • Can be in the Peritoneal Cavity or in the Common Bile Duct
    • Spilled/Dropped Stone: Specifically Refers to a Stone Left in the Peritoneal Cavity After Gallbladder Perforation
  • Retained Common Bile Duct Stone
    • Mechanisms: 46
      • Spontaneous Migration from the Gallbladder Between Preoperative Imaging and Surgery
      • Migration During Gallbladder Manipulation
      • Asymptomatic Radiolucent Stones Already Present in the CBD but Not Detected by Preoperative Imaging
      • Preoperative Imaging Missed a CBD Stone Already Present
      • Primary CBD Stone Developed After Surgery
    • Can Present Days-Years After Surgery
    • Risk for a Clinically Significant Retained CBD Stone: 1-3% 46,47
    • No Proven Benefit to Routine Use of IOC in Reducing Rates of Retained Stones
    • Treatment: ERCP
  • Spilled/Dropped Stone (Gallstone Expectoration)
    • Stones Serve as a Nidus for Infection and Can Cause Abscess 42
    • Risk Factors for Complications After Spilled Stones: 48
      • Infected Bile
      • Spillage of Pigmented Gallstones – High Likelihood of Harboring Bacteria
      • Multiple Stones (> 15)
      • Large Stones (> 1.5 cm)
      • Old Age
    • Surgeon Should Attempt to Retrieve All Spilled Stones at the Index Operation
    • Treatment of Abscess: Laparoscopic Drainage and Stone Removal
      • If Abscess is Drained Percutaneously, the Stone Should Be Eventually Retrieved Laparoscopically – High Risk of Recurrence if Left

Remnant Gallbladder

  • Risk: 0.18% 49
  • Present with Symptoms of Postcholecystectomy Syndrome
    • *See Above
    • May Arise Days-Years After Surgery
  • Diagnosis is Often Difficult to Make Due to Rarity
    • Options: US, CT, MRCP, or ERCP
  • Treatment: Completion Cholecystectomy
    • Can Be Performed Open or Laparoscopic 50
    • Surgery is Often Challenging Due to Complexity of the Reoperative Field – May Require a Subtotal Fenestrating Cholecystectomy if Unable to Safely Identify the Critical View to prevent Another Remnant Gallbladder 50

Non-Biliary Complications

  • Bleeding
    • Risk for Clinically Significant Bleeding: 0.1-1.9% 51
    • Sources of Bleeding: 52
      • Vessel Injury
      • Slippage of Clips/Ligatures Off the Cystic Artery
      • Liver Bed
      • Port Sites
    • Treatment Depends on Source
  • Bowel Injury
    • Risk: 0.07-0.7% 53
    • Burn/Thermal Injuries May Present in a Delayed Fashion
  • Pneumothorax
  • Surgical Site Infection/Abscess
  • Mortality
    • 30-Day Risk: 0.1-0.7% 54
    • Risk Factors: 54
      • Elderly
      • Underlying Comorbidity
      • Acute Surgery
      • Perioperative Complications

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