Overview
Definition:
Open cholecystectomy is the surgical removal of the gallbladder, performed through a larger abdominal incision
It is typically indicated for complicated gallstone disease, severe inflammation, or when laparoscopic surgery is not feasible.
Epidemiology:
Cholelithiasis (gallstones) affects approximately 10-20% of the adult population worldwide, with women and older individuals being more susceptible
Cholecystectomy is one of the most frequently performed general surgical procedures globally.
Clinical Significance:
Understanding open cholecystectomy is crucial for surgical residents as it remains a vital option for managing complex gallbladder pathology
Proficiency in its indications, technique, and potential complications ensures optimal patient outcomes, especially in resource-limited settings or challenging clinical scenarios
This procedure directly impacts the management of biliary colic, acute cholecystitis, choledocholithiasis, and gallbladder cancer.
Indications
Absolute Indications:
Acute cholecystitis unresponsive to conservative management
Gallbladder gangrene or perforation
Empyema of the gallbladder
Gallbladder polyps greater than 1 cm or those with suspicion of malignancy
Symptomatic cholelithiasis refractory to medical management or previous unsuccessful laparoscopic attempts
Acute cholangitis or gallstone pancreatitis when there is concomitant gallbladder disease.
Relative Indications:
Porcelain gallbladder
Gallbladder stones in patients with specific risk factors for malignancy
Unexplained right upper quadrant pain with confirmed gallstones
Obesity or previous abdominal surgeries that may render laparoscopy technically difficult.
Contraindications:
Absolute contraindications are rare but include severe coagulopathy that cannot be corrected
Relative contraindications may include advanced cardiopulmonary disease, pregnancy in the second or third trimester, or severe systemic illness that significantly increases operative risk.
Preoperative Preparation
Patient Assessment:
Thorough history and physical examination to assess for comorbidities like diabetes, hypertension, cardiac or pulmonary disease
Assess for jaundice, fever, or signs of sepsis
Evaluate for previous abdominal surgeries and their impact on surgical approach.
Laboratory Investigations:
Complete blood count (CBC) to assess for leukocytosis or anemia
Liver function tests (LFTs) to evaluate for cholestasis or hepatocellular injury, including bilirubin, AST, ALT, ALP, and GGT
Coagulation profile (PT/INR, aPTT) to assess for bleeding diathesis
Serum electrolytes and renal function tests
Amylase/lipase to rule out pancreatitis.
Imaging:
Abdominal ultrasound is the initial investigation of choice, confirming gallstones, gallbladder wall thickening, pericholecystic fluid, and assessing for ductal dilatation
CT scan or MRI may be used in select cases for better delineation of anatomy, complications, or suspected malignancy.
Anesthesia And Antibiotics:
General anesthesia is typically employed
Prophylactic broad-spectrum antibiotics (e.g., cefazolin or a cephalosporin with metronidazole) should be administered intravenously within 60 minutes before skin incision to reduce surgical site infections
For patients with penicillin allergy, alternatives like clindamycin and an aminoglycoside may be used.
Procedure Steps
Incision And Exposure:
A subcostal (Kocher) incision or a midline/paramedian incision is made, depending on patient factors and surgeon preference
The abdominal cavity is explored, and the gallbladder is identified
Adequate retraction of the abdominal wall is crucial for visualization.
Identification And Dissection Of Cystic Duct And Artery:
The peritoneum overlying the gallbladder fossa is incised
The hepatoduodenal ligament is dissected carefully to expose the cystic duct and cystic artery
These structures are meticulously dissected free from surrounding tissue to prevent injury to the common bile duct or hepatic vessels.
Cystic Duct And Artery Ligation:
Once clearly identified, the cystic duct and cystic artery are ligated with sutures or clips
Secure ligation is paramount to prevent bleeding or bile leak
Two ligatures on the cystic duct proximal and distal to the planned division are recommended.
Gallbladder Detachment:
The gallbladder is then dissected from its fossa on the liver bed using electrocautery or sharp dissection
Bleeding from the liver bed is controlled with cautery or pressure
Any stones within the gallbladder are removed carefully, and the gallbladder is sent for pathological examination.
Hemostasis And Closure:
Thorough inspection of the liver bed and surrounding structures for hemostasis
A drain may be placed in the gallbladder fossa if there is significant oozing or suspicion of bile leak, though this is debated
The abdominal incision is closed in layers using absorbable or non-absorbable sutures.
Postoperative Care
Pain Management:
Adequate analgesia is essential
Intravenous opioids (e.g., morphine, fentanyl) may be required initially, transitioning to oral analgesics (e.g., paracetamol, NSAIDs) as tolerated
Patient-controlled analgesia (PCA) can be an option.
Fluid And Electrolyte Balance:
Intravenous fluids are typically administered until oral intake is satisfactory
Monitor urine output, vital signs, and serum electrolytes to maintain hydration and correct imbalances.
Ambulation And Diet:
Early ambulation is encouraged to prevent deep vein thrombosis and pulmonary complications
Patients can usually resume a normal diet as tolerated, starting with clear liquids and progressing to solids
Fatty foods may be introduced gradually.
Monitoring For Complications:
Monitor for signs of infection (fever, wound redness, discharge), bile leak (jaundice, abdominal pain, fever, drainage), bleeding (hypotension, tachycardia), or bowel obstruction
Vital signs, abdominal examination, and laboratory tests (e.g., CBC, LFTs) are crucial.
Complications
Early Complications:
Bile leak from the cystic duct stump or liver bed
Bleeding from the cystic artery stump or liver bed
Wound infection
Injury to the common bile duct or hepatic artery
Retained common bile duct stones
Postoperative ileus
Deep vein thrombosis (DVT) and pulmonary embolism (PE)
Pneumonia.
Late Complications:
Postcholecystectomy syndrome (persistent abdominal pain, dyspepsia, diarrhea)
Bile duct strictures
Formation of new stones in the common bile duct
Incisional hernia
Adhesions.
Prevention Strategies:
Meticulous surgical technique with clear identification of the cystic duct and artery before ligation
Careful dissection to avoid injury to surrounding structures
Adequate hemostasis
Prompt management of retained stones with ERCP
Judicious use of prophylactic antibiotics
Early mobilization of the patient
Use of compression stockings or pneumatic compression devices for DVT prophylaxis.
Key Points
Exam Focus:
Indications for open vs
laparoscopic cholecystectomy
The critical view of safety during dissection
Management of common bile duct injuries
Postcholecystectomy syndrome
Management of acute cholecystitis and cholangitis.
Clinical Pearls:
When in doubt about anatomical structures, do not proceed with ligation
consider intraoperative cholangiography or conversion to laparoscopy/open surgery
Ensure adequate exposure by creating a generous incision
Always explore the gallbladder bed for bleeding and bile collections
Communicate effectively with the anesthetist regarding fluid status and blood loss.
Common Mistakes:
Ligating or dividing the common bile duct instead of the cystic duct
Inadequate dissection leading to incomplete visualization
Failure to control bleeding from the cystic artery or liver bed
Incomplete exploration of the gallbladder bed
Overlooking retained common bile duct stones
Delayed recognition of bile leaks or duct injuries.