Juan Sanabria

Introduction

Removal of the gallbladder is one of the most common surgeries performed in United States. More than 650,000 cholecystectomies are done each year, with the majority accomplished by laparoscopic techniques. Indications for cholecystectomy include benign and malignant processes. By far the most frequent indication for cholecystectomy is symptomatic gallstone disease.

Gallbladder Anatomy

The gallbladder is an ovoid bag located in the gallbladder fossae of the liver capable of storing up to 50 mL of bile. The gallbladder has a fundus, body, and infundibulum, and it continues by the cystic duct to join the common hepatic duct (CHD) and form the common bile duct (CBD) (Fig. 12-1).

The right hepatic artery passes behind the CHD, where the cystic artery originates, and reaches the gallbladder at the cystic node level. This represents the most common anatomic variation but is present in only 50% to 70% of patients. The surgeon must be aware of all anatomic variations of the biliary tree and hepatic artery to avoid injury to the CBD and vascular structures (Figs. 12-2 and 12-3).

Symptomatic Gallstones: Clinical Manifestations

Although more than 60% of adults older than 60 have gallstones in Western countries, only 20% become symptomatic. The hallmark of symptomatic gallstone disease is abdominal pain, usually in the right upper quadrant (RUQ), with radiation to the back, right shoulder, or epigastrium (Fig. 12-4). Pain classically occurs 30 minutes to 2 hours after the ingestion of a fatty meal and varies in severity. Pain typically is not constant and may be associated with nausea and vomiting. This presentation as biliary colic could progress to an acute inflammatory state promoted by the impaction of a stone in the neck of the gallbladder (see Fig. 12-1).

Patients with acute cholecystitis have constant RUQ pain, tenderness at deep palpation (a surrogate of Murphy sign), hyperthermia, and elevated white blood cell count (Fig. 12-4). The stone may pass to the CBD, causing obstruction and development of jaundice. A patient with RUQ pain, fever, leukocytosis, and jaundice, with or without mental changes and hemodynamic compromise, has cholangitis, a true surgical emergency. Other stones produce distal obstruction of the CBD and pancreatic duct, causing an acute episode of pancreatitis. However, most stones that reach the CBD pass into the duodenum, to be passed without consequence.

In another complication of gallstone disease, gallstone ileus, the stone erodes through the gallbladder wall and passes into the duodenum or colon. If the stone becomes impacted in the duodenum, it manifests as gastric outlet syndrome (Bouveret syndrome). More often, if it becomes stuck in the terminal ileum, the stone manifests as small bowel obstruction with pneumobilia.

Laparoscopic Approach

Indications for laparoscopic cholecystectomy include biliary colic, acute and chronic cholecystitis, cholangitis, and gallstones pancreatitis. The author recommends starting the planned procedure laparoscopically, but with a low threshold for conversion to open cholecystectomy in patients with suspected Mirizzi syndrome, gallbladder cancer, or unusual anatomic variation and patients with severe portal hypertension. The surgeon is positioned on the left side of the patient with a camera assistant at the surgeon’s side and a second assistant on the right side.

Conversion to Open Cholecystectomy

Open cholecystectomy is performed most commonly through a right subcostal incision (Kocher incision), but it can also be approached through an upper midline incision. The dissection starts exactly as described for the laparoscopic approach until the critical view is achieved (see Fig. 12-5). Caution should be exercised if vigorous traction of the cystic duct is performed, because it may result in avulsion of the cystic duct from the CBD or inclusion of the CBD during placement of the cystic duct clamp, as illustrated in Figure 12-7.

An alternative approach, used when severe inflammation is encountered at Calot’s triangle, is to start the dissection at the fundus of the gallbladder and dissect toward the infundibulum, keeping the dissection as close as possible to the gallbladder wall. The fundocystic approach also has been suggested as a safer technique in difficult laparoscopic cholecystectomies. In exceptional cases where anatomic planes of dissection are not found because of severe inflammation or portal hypertension, the gallbladder can be drained of bile and stones, and the dissection could be carried down to the infundibulum following the mucosal lining. Such cases merit IOC to document proper identification of the anatomy.

Special Circumstances

Acute cholecystitis in the older population and in patients with diabetes can result in necrosis of the gallbladder wall or perforation and bile peritonitis. If the patient is unfit for surgery, resuscitation and percutaneous drainage can arrest the systemic inflammatory response to allow for an elective approach later. In these populations the acute inflammation of the gallbladder could be the result of stone pathology or ischemia (acalculous cholecystitis).

Symptomatic gallstone disease is a common surgical consultation in pregnant women. In general, surgery should be avoided during the first and last trimesters if possible. A laparoscopic approach is not contraindicated.

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