Gallstone disease is one of the most common disorders affecting the digestive tract. Most individuals with gallstones are asymptomatic and do not require treatment. For symptomatic patients, however, cholecystectomy is recommended. Cholecystectomy is one of the most common abdominal surgeries performed worldwide. Indications include moderate-to-severe symptoms, stones obstructing the bile duct, gallbladder inflammation, large gallbladder polyps and pancreatic inflammation due to gallstones. Here, we report the case of a 53-year-old man with stones in his biliary duct. Despite having uncomplicated disease, the patient was treated with a primary open cholecystectomy because laparoscopy was not available.
Gallstones are solid masses formed by bile precipitates and form in the gallbladder or bile ducts. The prevalence of gallstones is related to many factors, including diet, age, gender, BMI, and ethnic background. Women are more likely to develop gallstones than are men, and first-degree relatives of patients with gallstones are at increased risk, possibly indicating a genetic predisposition. There are two main types of gallstones: cholesterol and pigment.1 Cholesterol stones account for 80% of all gallstones and are formed from supersaturation of bile with cholesterol. Pigment stones are typically formed in conditions of stasis. Most individuals with gallstones remain symptom free; however, if a gallstone lodges in a duct and causes obstructions, there may be symptoms such as right upper quadrant or epigastric pain, nausea, vomiting, bloating, and fever. Ultrasonography or computed tomography are used to visualize the stones in the gallbladder, while magnetic resonance cholangiopancreatography or endoscopic retrograde cholangiopancreatography can better visualize stones within the bile ducts.
Focused History of the PatientA 53-year-old male presented with a 1-year history of recurrent right upper quadrant pain that radiated to the back. Ultrasound revealed a non-thickened gallbladder with presence of intraluminal stones. The liver was normal and biliary ducts were not dilated. Surgical removal of the patient’s diseased gallbladder and stone was indicated because of recurrent bouts of biliary colic.
Classic biliary colic is characterized by constant right upper quadrant or epigastric pain lasting 20 minutes to 3 hours. Up to 60% of patients with biliary colic complain of pain that radiates to the right shoulder pain or back, as in our patient. Typical time of onset is more than 1 hour after eating, often at night. The pain is not relieved by position changes or by evacuation of the bowels.1
The imaging modality of choice is transabdominal ultrasound, which has a sensitivity as high as 89% and a specificity of 99%.2 If there is a discrepancy between the clinical diagnosis of acute cholecystitis and the ultrasound findings, scintigraphy of the biliary tract may be performed using technetium-labeled hydroxy iminodiacetic acid. Scintigraphy is more sensitive than ultrasound (97% vs 89%) and has equivalent specificity.
Regardless of whether the patient has symptoms, between 1% and 3% of individuals with gallstones will experience complications. These include acute and chronic cholecystitis, choledocholithiasis, acute cholangitis, acute pancreatitis, empyema in the gallbladder, obstructive jaundice, choledochoduodenal fistula, and gallbladder perforation.1
Options for Treatment
Patients with symptomatic gallstones are usually treated surgically, whereas those with asymptomatic disease may be treated expectantly. Laparoscopic cholecystectomy is the procedure of choice in places in the developed world. Primary open cholecystectomy is performed in areas of the world where laparoscopic procedures are not often performed, because of lack of availability of proper equipment or because of costs, as was the case with our patient.
Rationale for Treatment
The primary reason to perform cholecystectomy is to prevent the complications referenced above. A secondary rationale is prevention of recurrent bouts of biliary colic, as was the case with our patient. Most patients with histories of biliary pain are likely to experience recurrences.
The contraindications to open cholecystectomy are limited to severe physiological derangements or conditions that preclude administration of general anesthesia.
We present a patient who had right upper quadrant pain radiating to the back lasting more than a year. On ultrasound, the patient was noted to have gallstones and an open cholecystectomy was performed because he lives in the rural Philippines and cannot afford the more expensive laparoscopic procedure that could be performed in an urban area.
Cholecystectomy is the removal of a diseased gallbladder, performed through an open or laparoscopic approach. Open cholecystectomy is performed through an incision on the right side under the rib cage. Open cholecystectomy was first performed in 1882 by Carl August Langenbuc.3 It used to be the mainstay of treatment of gallstones; however, there has been a gradual shift in the treatment since the introduction of laparoscopic cholecystectomy, which was first performed by Philippe Mouret in Lyon, France.4-6 Laparoscopic cholecystectomy is currently considered the gold standard treatment for gallstones because of reduced pain, faster return to activity and shorter length of hospital stay.7 However, patients with hemodynamic instability, uncontrolled coagulopathy, frank peritonitis, severe obstructive pulmonary disease or congestive heart failure may not tolerate the increased intra-abdominal pressures of pneumoperitoneum; these are contraindications that may require open cholecystectomy. Acute cholecystitis, gangrene and empyema of the gallbladder used to be relative contraindications to laparoscopic cholecystectomy; however, they are now considered risk factors for a potentially difficult cholecystectomy and do not preclude an attempt at laparoscopy.
In the laparoscopic era, primary open cholecystectomy for uncomplicated gallbladder disease may be becoming a lost art. Nevertheless, surgeons should become familiar with the technique, particularly for treatment of patients with contraindications to laparoscopic procedures.
Nothing to disclose.
Statement of Consent
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
World Surgical Foundation
- Ibrahim MO, Sarvepalli SH, Morris-Stiff G, et al. Gallstones: Watch and wait, or intervene. Clevel Clin J Med. 2018;85:323-31. doi:10.3949/ccjm.85a.17035.
- Shea JA, Berlin JA, Escarce JJ, et al. Revised estimates of diagnostic test sensitivity and specificity in suspected biliary tract disease. Arch Intern Med. 1994;:2573–2581. doi:10.1001/archinte.1994.00420220069008.
- Gadacz TR, Talamini MA. Traditional versus Laparoscopic Cholecystectomy. Am J Surg. 1999;161:336-8. doi:10.1016/0002-9610(91)90591-Z.
- McSherry CK. Open Cholecystectomy. Am J Surg. 1993;165:435-9. doi:10.1016/s0002-9610(05)80936-5.
- Ji W, Li LT, Li JS. Role of Laparoscopic Subtotal Cholecystectomy in the treatment of complicated cholecystitis. Hepatobilpancreat Dis Int. 2006;5(4):584-9.
- Cuschieri A. Laparoscopic Cholecystectomy. J R Coll Surg Edinb. 1999;44:187-92.
- Strasberg SM. Clinical practice acute, calculus cholecystitis. N Engl J Med. 2011;358(26):2804. doi:10.1056/NEJMcp0800929.
Table of Contents
All right, so, we were presented with a 53-year-old male, who was complaining of right upper quadrant pains, beginning since last year. Now the pain was recurrent, and was radiating to the back. From his history, it seems that the problem involving- is involving your hepatobiliary area, so we… Workup was done, specifically an ultrasound, which revealed intraluminal gallstones. The liver was normal, intrahepatic ducts were not dilated, the gallbladder was particularly not thickened. So, we had a case of- acute cholecystitis, and when we received the patient, the patient was in a remission state. The- recommended procedure for this patient- treatment is to- have your gallbladder removed. It's the gall bladder that are- it's the organ that made the gallstones, and if we only take out the gallstones, the gallbladder will continue producing gallstones. So removal of the gallbladder is the standard operative procedure of choice. Now the- standard procedure nowadays involves open cholecystectomy where you- cut the abdomen from the right upper quadrant, and we have another procedure, which we call laparoscopic. The approach is different since we have smaller incisions- you can have 2, 3 or 4 small incisions, but the procedure remains the same, you still take out the entire gallbladder. In the urban areas, urban setting- most patients are exposed to these offers, but in the rural setting, some centers do not have these equipment, the laparoscopic machines, and also, it's quite costly. So, people living in the rural areas could really not afford to have these more expensive procedures done. At any rate, like I mentioned earlier, the procedure is still the same, you end up with a removed gallbladder.
All right. Cutting. Welcome everyone, for today we'll be discussing a case of open cholecystectomy. So, I am Dr. June Soledad, surgeon is Dr. Enrico Jayma, and with us, is our first assist- sorry, second assist, Dr. Ted Carpio.
We are presented with a 53-year-old male, with a 1-year history of recurrent right upper quadrant pains. On workup- abdominal ultrasound was done, which revealed presence of intraluminal stones in his gallbladder. There were no evidence of thickened walls and dilated ducts, intrahepatic and otherwise. Since the pain has been recurrent, he's advised to undergo removal of the gallbladder. So we begin the procedure by cutting through the right upper quadrant, making an oblique incision. So from the skin, we pass through the subcutaneous fat layer. We are now at the level of your anterior rectus sheath. Beneath that is your rectus abdominis muscle. So we will be accessing the abdominal cavity through the right upper quadrant. We are presently dissecting, and separating, or cutting away the part of your rectus abdominis muscle. Depending on the patient's habitus and lifestyle, the rectus abdominis muscle can be thick or thin. Since we are- we have a male patient, we expect this to be somewhat muscular, as you can very well see. Beneath this muscle is your posterior rectus sheath, and then your internal oblique muscle. Now, the trick is to open the abdomen from the medial most end of the incision. That way you will be accessing your falciform ligament and preventing or avoiding possible injuries to the internal organs as you begin the penetration into the cavity. Mosquito. Here you see the cavity, it has already been opened, this is your falciform ligament, your internal oblique muscle. The incision is made around one to two fingerbreadths from the rib cage or subcostal margin. Debakey. On initial inspection, you see the liver edge here, the sharp border of the liver, you have her gallbladder beneath it with the fundus looking out. And inferior to that would be parts of your omentum and the end colon. So, we'll be pushing the colon caudally, and we'll keep it away using a wide Beaver or you can also use a malleable for- in this case. We shall also be retracting the duodenum towards the medial aspect or towards the midline. Now, here is your gallbladder, fat-laden gallbladder. The liver appears to be healthy with no nodulations, the surface is smooth. Narrow Beaver.
With the use of a narrow Beaver, we retract your duodenum towards the medial aspect that- Ted, could you hold? So, the goal is to initially find your cystic artery and ligate it. The procedure is less bloody when you dissect the gallbladder from the liver. We are now dissecting the area of your cystic duct and common bile duct, about the Hartmann's pouch. The cystic artery is a branch off your right hepatic artery in… The cystic artery is accessed about the area of your cystic duct. Debakey. There you go. Pickup. We have just clamped your cystic artery, and we're about to divide and ligate it. So, the cystic artery is the blood supply of your gallbladder. Release. Yes.
Now once this is done, we can begin- dissecting your gallbladder from the liver bed. So the trick also lies in the proper application of your retractors. This is your gallbladder fundus- as defined, it's the area of the gallbladder that is- peeking out of- from the liver edge. It's approximate location is at the midclavicular line, on the right. Well, similar to all the other abdominal organs, your gallbladder is surrounded by a peritoneum, except at a certain area where it is directly intimately, or intimately related to the liver and we call that the bare area. Now Dr. Jayma is now dissecting the peritoneal covering of your gallbladder. So, at this point, we're just taking down the gallbladder, transferring from the medial to the lateral aspect, back and forth. Now, this can be very difficult sometimes, especially if you have an acutely inflamed gallbladder. Now, if the cystic artery has not been litigated initially, this procedure can be- sometimes be bloody, you might encounter a certain amount of hemorrhaging. Sometimes when the gallbladder is too distended, like in cases of hydrops, we sometimes drain what's inside- initially. So the gallbladder is decompressed. So as you can see, we encounter less hemorrhaging, since we were able to initially ligate the cystic artery. This posterior side of the gallbladder is what we call the bare area, it's this part, which is intimately related to your liver, directly attached to it, occupying the gallbladder fossa of the liver. Now we are about to finish dissecting the gallbladder from the liver, just a few more peritoneal attachments. Mosquito. Now, this is quite an easy procedure for Dr. Jayma as he has done many open cholecystectomies before. Now, we will be keep on- we'll keep on dissecting until the gallbladder is left hanging by the cystic duct.
Buzz. Debakey. Mixter. That is your cystic vein, and we shall be ligating it also. Metz. Tie. So Dr. Jayma is now just peeling off- the adipose tissue surrounding the cystic duct and Hartmann's pouch. Good, good. Buzz. All right. So this is now the fundus, the body, you have here your, your Hartmann's pouch, and beyond that would be your cystic duct. Your common bile duct is hidden away by this adipose tissue.
So Dr. Jayma is now looking for an area where he can clamp the cystic duct and take out the gallbladder. Now, once he's- once he's satisfied with his clamp, he can now remove the gallbladder. Now that is your gallbladder, we shall be inspecting the organ after the patient has been closed. He's not applying ligature to the cystic duct. Before completely cutting the final ligature, Dr. Jayma will be inspecting the area of the cystic artery to make sure- that the vessel is- completely litigated. If there are doubts, he can apply a final ligature to that.
Now before we close the patient, we do a final inspection of the operative site. Make sure there are no bleeders from the liver bed, from the gallbladder fossa and from the area of the cystic duct. So, careful hemostasis is applied by electrocautery. Now, washing with... is optional, we mostly perform that if we encounter spillages during dissections.
After complete counting, we now close the patient layer by layer, starting from the peritoneum and the internal oblique muscle. Kelly. The first layer would involve your peritoneum, you're internal oblique, and your posterior rectus sheath. Mayo. We anchor the suture at the medial coroner or medial end. You can also apply a wet sponge over the abdominal organs to avoid hitting them. Dr. Jayma is using absorbable suture. With continuous, interrupted method of the suturing. We've just acknowledged that the OS count is complete. One more. We're almost done with the first layer of closure. Now, the second layer to be closed is your rectus abdominis muscle. Now this layer involves- the anterior rectus sheath, and your rectus abdominis muscle. Again, the continuous interrupt- continuous interlocking technique of suturing is employed by Dr. Jayma. Dr. Jayma will now be approximating the subcutaneous layer- in preparation for the subcuticular closure. Just a few interrupted stitches will suffice. Mayo. The skin is closed finally, using an absorbable suture, applying subcuticular technique. The wound is expected to dry up in around 24 hours, and healed by around 1 to 2 weeks. Now part of the advice- that we instruct the patients is some recurring pains emanating from the operative sites, specifically the scarred area. And this is usually felt when the patient shivers or- have, involuntary contractions of the muscle, most notedly during cold temperatures. So we expect them to happen around November to February, and this is quite expected or normal.
So, for this patient, when we opened him up, we noted that the ultrasound findings were fairly accurate, the liver was normal, the bowels were normal, the gallbladder was moderately dilated, it's physiologic. The walls were thickened, the intrahepatic ducts were also- not dailated, as well as the common bile duct. So after careful dissection, the gallbladder was eventually removed. The entire operative course was- quite uneventful, we did the procedure in under an hour, we did not encounter any bleedings during the procedure. Now, postoperatively, the patient is expected to be fed immediately, and allowed to ambulate and to walk around. He is restricted from performing heavy activities for about 6 to 8 weeks, that is to take care of your incisional area and prevent incisional hernias from occurring. Follow up is usually recommended and suggested after a week, just to check on the wound. The patient can be sent home with antibiotics and painkillers. It is very important that painkillers be- given to these patients, because open cholecystectomies tend to be quite painful postoperatively, but it's not really that painful in, in the manner that you- it can be controlled by your painkillers. So, we have a lot of painkillers in the market. We can use any one of them, it can work for the patient. After about 6 to 8 weeks, the patient is now allowed to perform your heavy activities, he can even perform marathons, do weightlifting, get into active sports again. In the long run, the patients will, experience some bouts of pain about the area of your operative site. This could only be due to your involuntary muscle contractions during cold environments. Physiology-wise, there is really- no- discrepancy with the- in- between a patient without a gallbladder and a patient with an intact gallbladder. You see the gallbladder is just a storage organ for your bile, it's your liver that produces your bile, the bile's primary function is to digest fats in your diet. When we take in food, we take in carbohydrates, proteins, and fats. The pancreas and pancreatic juices in the bile usually takes care of your fat digestion, while your, your gastric juices and your small intestinal juices takes care of digesting your proteins and carbohydrates. So, if you take out the gallbladder, you only take out the storage organ, but the source of the bile still comes from- remains to be the liver. As I understand, based on statistics, as of today, gallbladder still runs ahead- from the- from appendicitis case, so, it's- we encounter more, our gallbladder stone cases, even compared to appendicitis cases. So it's not really a rare condition, the procedure is not really rare, you know, a lot of surgeons rapidly perform more gallbladder surgeries compared to other procedures. Patients come in and ask us if- what could they do to prevent gallstones from occurring? It's actually a metabolic thing, if you are a stone-former, you will really form stones, it's in the way your gallbladder digests and metabolizes fat and cholesterol. If you are a stone-former, you can't really avoid- having stones formed. But the thing is, mere presence of stones, does not really- it's not really mandatory for a surgical removal of your gallbladder. It's when your gallbladder becomes diseased, that's when- that's the only time when surgeons recommend removal of your gallbladder. So it can be diseased if it becomes inflamed from obstruction. So it doesn't really- matter whether you have a few stones, or a lot of stones, or a solid-type of stone, it doesn't really matter whether you have small stones or big stones. What matters is if your gallbladder becomes diseased due to these stones. So, complications arise if you're a gallbladder- causes obstruction in your cystic duct, preventing bile from coming out of the gallbladder, or if small stones accidentally passes through the cystic duct into the common bile duct and causes obstruction in that area.