Table of Contents
Gallbladder diseases are a subset of a spectrum of pathologies of the biliary system and are a particularly common etiology of abdominal pain encountered in modern medicine. These pathologies most often share a similar underlying mechanism of disease: obstruction of a portion of the biliary tree by cholelithiasis, or gallstones. Gallstones are initially formed in the gallbladder. Risk factors include a wide variety of conditions both pathologic and physiologic, including hyperlipidemia, hemolysis, and pregnancy. The resulting obstruction creates a state of biliary stasis, eventually leading to inflammation, pain, and an increased risk of infection. The anatomical location of the obstruction contributes greatly to both the clinical presentation and the ultimate treatment of the disease. A hallmark of the treatment of gallbladder disease, ranging from simple biliary colic to life-threatening emphysematous cholecystitis, is the cholecystectomy. In modernized countries, this procedure is almost invariably performed laparoscopically. However, in certain clinical scenarios, such as when a patient cannot tolerate the pneumoperitoneum associated with laparoscopic surgery or when the procedure takes place in a developing country with limited access to laparoscopic capabilities, an open approach is preferred.
The history associated with gallbladder disease is consistent with the presentation of abdominal pain localized to the right upper quadrant or epigastrium that may radiate to the back and/or the right shoulder. Characteristics of the pain vary depending on the underlying pathology. For example, the pain of biliary colic is classically described as relapsing/remitting and lasting less than six hours. In contrast, the pain of acute cholecystitis is characterized by abrupt onset, constant and unrelenting severity, and duration of greater than four to six hours. In addition, patients with acute cholecystitis are generally acutely ill and febrile. In both disease states, the pain is typically provoked or worsened by the consumption of fats, which stimulates gallbladder contraction and bile release. Patients are typically overweight, middle-aged females; however, gallbladder disease can affect patients of every demographic.
Most patients with gallbladder pathology will present with tenderness to palpation and voluntary guarding of the right upper abdominal quadrant and epigastrium on a physical exam. The vast majority of patients presenting with acute cholecystitis will also have a positive Murphy sign, which is described as an involuntary arrest of inspiration on deep palpation of the right upper quadrant due to pain. While these physical exam findings may be supportive of a diagnosis of gallbladder disease, no single physical exam finding is considered specific enough for confirmation.
Laboratory studies in patients with gallbladder diseases are relatively nonspecific but may support the diagnosis. Patients that suffer from biliary colic are unlikely to show any derangements in their lab values that can be directly attributed to their disease. In contrast, patients presenting with acute cholecystitis will often show leukocytosis on a complete blood count and normal liver enzymes on a complete metabolic panel, although the absence of leukocytosis in these patients should not exclude the diagnosis.1 Patients presenting with acute cholangitis due to choledocholithiasis are also commonly found to have leukocytosis on CBC; however their lab work would also be expected to reveal derangements in liver enzymes and evidence of biliary obstruction – namely increased AST, ALT, conjugated bilirubin, and Alkaline phosphatase – due to involvement of the main biliary tree.
Imaging is a hallmark of the diagnosis of gallbladder disease in modern medical practice. By far the most common first-line imaging modality used is ultrasonography.1 Ultrasound imaging of the right upper quadrant has excellent sensitivity and specificity for both the detection of gallstones and the diagnosis of acute cholecystitis.2 Gallstones >3 mm can be visualized directly with ultrasound imaging. In addition to the presence of gallstones, ultrasound findings supportive of a diagnosis of acute cholecystitis include gallbladder wall thickening >5 mm and the presence of pericholecystic fluid.
If ultrasound imaging is suboptimal or inconclusive, cholescintigraphy may be performed. Also known as a hepatic iminodiacetic acid (HIDA) scan, it is performed by injecting the patient with technetium-labeled HIDA, which is absorbed by hepatocytes and excreted with the bile. X-ray imaging is then obtained revealing good visualization of the gallbladder in patients without the obstruction of the cystic duct. If an obstruction is present, such as in patients with acute calculous cholecystitis, technetium-tagged bile will not be secreted into the gallbladder, and the organ will be poorly visualized on imaging. Cholescintigraphy has a sensitivity for the detection of acute cholecystitis that is >95%.3
The natural history of gallbladder disease is highly variable but classically progresses through a period of biliary colic secondary to the formation of gallstones that may last months to years. It is important to note, however, that the majority of patients that develop gallstones will never experience symptoms.4 Should medical or surgical intervention be delayed or refused, symptomatic patients are at an increased risk for the development of complicated gallstone disease such as acute calculous cholecystitis, empyema of the gallbladder, acute cholangitis, gallstone pancreatitis, cholecystoduodenal fistula, etc, due to persistent occlusion of the cystic duct and/or migration of gallstones.5 Gallbladder disease may initially present similarly to many other intra-abdominal pathologies, and patients presenting with abdominal pain that is exacerbated by food consumption should receive a thorough surgical evaluation to determine the underlying cause.
The mainstay of management of gallbladder disease is surgical intervention, most commonly via a cholecystectomy. Patients with symptomatic biliary colic who are good surgical candidates should be offered an elective cholecystectomy, which serves to relieve their symptoms as well as reduce or eliminate their future risk of developing complicated gallstone disease. Patients that suffer from biliary colic who are not good surgical candidates or who refuse surgical intervention should be advised on lifestyle modifications to minimize their symptoms.
Patients presenting with acute cholecystitis are generally acutely ill and require urgent cholecystectomy in addition to intravenous antibiotic therapy in an inpatient setting. In patients with calculus or acalculous cholecystitis who are poor surgical candidates, drainage of the gallbladder is achieved via cholecystostomy tube placement via either a percutaneous or open approach under local anesthesia.6 This procedure is generally considered to be a bridging therapy to eventual cholecystectomy once the patient is deemed to be able to tolerate the procedure.6
The goals of treatment in patients who suffer from gallbladder disease vary depending on the disease in question. Surgical management of biliary colic serves to relieve patients of their symptoms as well as reduce their risk of developing complicated gallbladder disease. In patients who have already developed complicated gallbladder disease, surgical management via either cholecystectomy or percutaneous drainage is performed in order to prevent the development of further complications, including severe sepsis and death.
In patients presenting with suspected gallbladder malignancy, laparoscopy is often performed initially in order to evaluate the surrounding abdominal wall and viscera for evidence of metastatic disease that would indicate unresectability. If evidence of unresectability is encountered, such as peritoneal seeding or other evidence of distant spread of disease, biopsies are taken of the suspected metastases for pathological analysis, and the cholecystectomy is aborted. In contrast, if no evidence of metastatic disease is encountered, the procedure should be converted to an open cholecystectomy with en bloc resection of the gallbladder and a portion of the liver, as well as regional lymph node dissection; an approach that serves to reduce the risk of gallbladder perforation and subsequent peritoneal and abdominal wall seeding during removal.8
Surgical history of multiple previous laparotomy incisions is considered a relative contraindication for the performance of laparoscopic surgery. Large laparotomy incisions commonly result in extensive intraabdominal adhesions that make laparoscopic procedures technically challenging to perform. If a cholecystectomy is indicated, a primary open approach is appropriate in these patients.9 In addition, while laparoscopic surgery has been proven safe in pregnancy, primary open cholecystectomies are preferred during the third trimester due to the practical difficulties of inducing appropriate pneumoperitoneum and the significant technical difficulty associated with the use of laparoscopic instruments in pregnant women with a large, gravid uterus.8
Absolute contraindications for laparoscopic or open cholecystectomy are consistent with contraindications for any surgical procedure requiring general anesthesia, including a patient who is medically unstable or unable to tolerate general anesthesia. In such populations, percutaneous drainage of the gallbladder, performed under local anesthesia, is recommended in lieu of surgery.6
Since the very first cholecystectomy was performed in the 19th century by Dr. Carl Langenbuch, it has become one of the most common abdominal surgical procedures performed today.10 In the United States alone, more than half a million cholecystectomies are performed each year. 11
For over a century, surgeons were trained to perform cholecystectomies exclusively via an open approach. As seen in our case, this approach involves making an incision 2–3 cm inferior to the right subcostal margin extended laterally. After exposure and division of the rectus abdominis muscle, the peritoneum is carefully entered, and the gallbladder is identified. Adequate exposure of the gallbladder and surrounding anatomy is an essential aspect of this procedure to avoid accidental injury to the surrounding organs and vasculature. The duodenum and hepatic flexure of the colon are packed with wet lap sponges and retracted to optimize visualization. Next, the critical structures that comprise the Triangle of Calot should be identified; namely the cystic and common bile ducts. The cystic artery characteristically crosses this space and should be identified and ligated with the cystic duct. After the cystic duct and artery are carefully ligated and divided, the gallbladder must then be dissected away from the liver. Most surgeons prefer the “top-down” approach to gallbladder dissection when performing an open cholecystectomy, as demonstrated in our case where we begin our dissection at the gallbladder fundus and progress down to the neck and the cystic duct. This is in contrast to laparoscopic cholecystectomy, in which a “bottom-up” approach is generally preferred. Once the gallbladder is dissected away from the liver, it is removed in its entirety and the abdomen is inspected for any evidence of bile leak or hemorrhage. After the surgical site is irrigated and hemostasis assured, the tissues are closed in a layered fashion, just as they were entered. The routine placement of intra-abdominal drains after an uncomplicated cholecystectomy is not a recommended practice due to an increased risk of postoperative infections and longer hospital stays.12
Since the development of the laparoscopic technique for cholecystectomy in the 1980s, this technique has become the gold standard for the treatment of gallbladder disease in most clinical scenarios.13 Benefits of the laparoscopic technique include better cosmetic results, less postoperative pain, and reduced postoperative complications when compared with the open approach.13 With that stated, the traditional open cholecystectomy still has a role in this age of laparoscopic procedures. Most open cholecystectomies in modern countries are performed as conversions from laparoscopic procedures.13 This conversion may be undertaken for a variety of reasons, first and foremost being due to suboptimal visualization of the relevant anatomy, increasing the risk of damage to the common bile duct and regional vasculature.14 Recent studies place the rate of conversion from a laparoscopic to open cholecystectomy at approximately 2.0–10.0%.13,14
While the laparoscopic cholecystectomy has several benefits over the open approach, researchers have noted an increase in the overall incidence of bile duct injuries in laparoscopic cholecystectomies.15,16 The incidence of common bile duct injuries in laparoscopic cholecystectomy is approximately 0.2–3.4%, which is significantly higher than the 0.1–0.2% risk associated with open cholecystectomies.16 While these injuries remain uncommon overall, this data supports the adoption of the open approach in more difficult cholecystectomies when a laparoscopic approach is challenging to perform safely.
A primary open approach to cholecystectomy has several important indications. A common indication seen in underdeveloped countries, and notable in our case, is simply the inability to perform laparoscopic surgery. Laparoscopic procedures require specialized equipment that, while increasing in availability worldwide, remains scarce in much of the developing world. A 2016 study from Rwanda determined that while laparoscopic cholecystectomies may be a more effective approach for the treatment of patients with gallbladder disease overall, it remains too expensive to be cost-effective in many low- and middle-income countries.17 Open cholecystectomies remain a more practical approach in this setting and can be performed safely and efficiently, as seen in our case. However, as the cost of equipment required for laparoscopic procedures decreases and their availability increases, adoption of the laparoscopic approach to cholecystectomy is expected to increase in these countries.16,17 Additional notable indications of a primary open cholecystectomy, as discussed in the “Special Considerations” section above, include patients that present with complicated gallbladder disease in the third trimester of pregnancy as well as patients with a past surgical history of multiple laparotomy incisions likely resulting in extensive intraabdominal adhesions.9
In patients presenting with complicated gallbladder disease who are poor candidates for cholecystectomy, interventions should be pursued via drainage of the gallbladder through either a percutaneous or open approach. While traditionally viewed as a bridging therapy to definitive treatment via cholecystectomy, recent studies suggest that as many as 50% of patients who are treated with a percutaneous cholecystostomy never undergo a subsequent cholecystectomy.18 More research is needed to determine if percutaneous or endoscopic drainage of the gallbladder is a viable alternative to surgery in patients with complicated gallbladder disease.
In addition to a standard surgical tray, electrocautery is essential and ample lighting is required for good visualization of the anatomy. A harmonic scalpel is particularly useful to reduce blood loss, albeit a luxury.
Nothing to disclose.
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.
1. Trowbridge RL, Rutkowski NK, Shojania KG. Does this patient have acute cholecystitis? [published correction appears in JAMA. 2009 Aug 19;302(7):739]. JAMA. 2003;289(1):80-86. doi:10.1001/jama.289.1.80.
2. 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;154(22):2573–2581. doi:10.1001/archinte.1994.00420220069008.
3. Fink-Bennett D, Freitas JE, Ripley SD, Bree RL. The sensitivity of hepatobiliary imaging and real-time ultrasonography in the detection of acute cholecystitis. Arch Surg. 1985;120(8):904-906. doi:10.1001/archsurg.1985.01390320028004.
4. Thistle JL, Cleary PA, Lachin JM, Tyor MP, Hersh T. The natural history of cholelithiasis: the National Cooperative Gallstone Study. Ann Intern Med. 1984;101(2):171-175. doi:10.7326/0003-4819-101-2-171.
5. Cho JY, Han H, Yoon Y, Ahn KS. Risk Factors for Acute Cholecystitis and a Complicated Clinical Course in Patients With Symptomatic Cholelithiasis. Arch Surg. 2010;145(4):329–333. doi:10.1001/archsurg.2010.35.
6. Bakkaloglu H, Yanar H, Guloglu R, et al. Ultrasound-guided percutaneous cholecystostomy in high-risk patients for surgical intervention. World J Gastroenterol. 2006;12(44):7179-7182. doi:10.3748/wjg.v12.i44.7179.
7. Jones MW, Genova R, O'Rourke MC. Acute Cholecystitis. [Updated 2020 May 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459171/.
8. McAneny D. Open cholecystectomy. Surg Clin North Am. 2008;88(6):1273-ix. doi:10.1016/j.suc.2008.08.00.
9. Bowers S.P., Hunter J.G. (2006) Contraindications to Laparoscopy. In: Whelan R.L., Fleshman J.W., Fowler D.L. (eds) The Sages Manual. Springer, New York, NY. https://doi.org/10.1007/0-387-29050-8_4.
10. Traverso LW. Carl Langenbuch and the first cholecystectomy. Am J Surg. 1976;132(1):81-82. doi:10.1016/0002-9610(76)90295-6.
11. Jones MW, Deppen JG. Open Cholecystectomy. [Updated 2020 Apr 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448176/.
12. Gurusamy KS, Samraj K, Mullerat P, Davidson BR. Routine abdominal drainage for uncomplicated laparoscopic cholecystectomy. Cochrane Database Syst Rev. 2007;(4):CD006004. Published 2007 Oct 17. doi:10.1002/14651858.CD006004.pub3
13. El Nakeeb A, Mahdy Y, Salem A, et al. Open Cholecystectomy Has a Place in the Laparoscopic Era: a Retrospective Cohort Study. Indian J Surg. 2017;79(5):437-443. doi:10.1007/s12262-017-1622-2.
14. Sultan AM, El Nakeeb A, Elshehawy T, Elhemmaly M, Elhanafy E, Atef E. Risk factors for conversion during laparoscopic cholecystectomy: retrospective analysis of ten years' experience at a single tertiary referral centre. Dig Surg. 2013;30(1):51-55. doi:10.1159/000347164.
15. Wu YV, Linehan DC. Bile duct injuries in the era of laparoscopic cholecystectomies. Surg Clin North Am. 2010;90(4):787-802. doi:10.1016/j.suc.2010.04.019.
16. Ayandipo O, Afuwape O, Olonisakin R. Laparoscopic cholecystectomy in ibadan, southwest Nigeria. J West Afr Coll Surg. 2013 Apr;3(2):15-26. PMID: 25453017; PMCID: PMC4220472.
17. Silverstein A, Costas-Chavarri A, Gakwaya MR, et al. Laparoscopic Versus Open Cholecystectomy: A Cost-Effectiveness Analysis at Rwanda Military Hospital. World J Surg. 2017;41(5):1225-1233. doi:10.1007/s00268-016-3851-0.
18. Stanek A, Dohan A, Barkun J, et al. Percutaneous cholecystostomy: A simple bridge to surgery or an alternative option for the management of acute cholecystitis?. Am J Surg. 2018;216(3):595-603. doi:10.1016/j.amjsurg.2018.01.027.
Table of Contents
- 1. Introduction
- 2. Surgical Approach
- 3. Incision and Access to the Abdominal Cavity
- 4. Abdominal Exploration and Gallbladder Exposure
- 5. Dissection of Calot's Triangle
- 6. Clipping and Division of Cystic Duct and Artery
- 7. Separate Gallbladder from Liver Bed
- 8. Final Check for Hemostasis
- 9. Closure
- 10. Post-op Remarks
- Division of the Rectus Abdominis Muscle
- Incision of the Posterior Rectus Sheath and Peritoneum
Hi, my name is Peter Rovito. I'm a general surgeon. What you're about to see is an open cholecystectomy. This is about a 50-year-old Honduran male who's had a long history of gallbladder disease, chronic pain - so, we're here, we're going to do an open cholecystectomy on him. This is the way gallbladders used to be taken out for years and years and years, open through incisions. Now we do them more laparoscopically, especially in the states, you know, in higher-tech countries like that. Places like this, they don't have the opportunity to have it taken out that way. So a lot of them were done open, the old fashioned way. And what do you do? You make an incision under the ribs, then you go in, you find the gallbladder and take it out. Key steps of the procedure - the main thing with an open cholecystectomy is exposure. You have to be able to see it, okay? You know, you make an incision in the patient, there's fatty tissue, there's other organs in the way. You have to pack those away so you can see what you have to do. The important thing is - you have to be able to see, you can't injure anything else that's in there that's not coming out. Okay, you find the gallbladder. The gallbladder has an artery that's going to it, and the duct to the gallbladder joins the main bile duct. We have to clip the duct of the gallbladder and cut it, clip the artery and cut it, and then take it off the liver. The gallbladder, of course, hangs from the liver. And the main thing you can't do is hurt the common bile duct because it's hard to fix. It's just a very unforgiving organ. So that's the key steps that you have to be able to define where the gallbladder duct, cystic duct, joins the common duct, clip and control it and get the artery, and then you take the gallbladder off the liver bed, and then you're finished with the procedure. You don't want to injure any other organs in there. And then when you're done with the procedure, you close the belly and the patient should do well.
We're doing an open cholecystectomy on this man. Okay? He has gallbladder disease and needs it out. So we're in a third world, and we tend to do a lot of these open, the old fashioned way because we don't have the technology to do it like we do in the- in the United States, which has everything. So, you have to make an incision, old fashioned surgery. Okay, go ahead, you want to go for like here… So what are the anatomic marks that you normally use? So this is the edge of the ribs, okay, so you go about 2 fingerbreadths below that, you make your incision through the skin, and then the muscle, and then you get in the abdominal cavity, then you see the liver and the gallbladder, and we'll talk about that once we get there. So, let's just do it.
That's good. Yeah, make it a little bit bigger. That's it. Good. Hemostat please? Yeah, just open it. Sometimes the tension in the wound makes them bleed a little bit more. Mm hmm Uh huh. Mm hmm, good. This is just normal fatty tissue, which he doesn't have much of. Go ahead, whack through it. So this is the muscle fascia, which is covering the muscle, which we have to get through to get through the belly. We're trying to do this through a relatively small incision. This is the rectus abdominis muscle, which is like the washboard ab-type muscle that people talk about, but rarely have. I know I don't have it. Uh huh. His is nice and developed. I'm going to keep going slow, all right? Mm hmm. Absolutely. You're the doctor. Let's just do this for a second. Okay. Well just do this, that's good. We used to do hundreds of these in the old days in the states. But now with laparoscopy, we don't do them this way too often. Uh huh, good. Okay. So this is the peritoneum or the posterior sheath of the rectus muscle, and you have to get through this to get into the belly. Hemostat, Mosquito? Do you have the knife? That's great.
Keep cutting, keep cutting, keep cutting. Boom! Mm hmm, good. Now, that's enough. Hemostat? That's great, that was lovely. I don't know - it might be in the way, but no - it's good. Mm hmm. Mm hmm. Oh lordy, I love it. Let's cut the rest of this peritoneum out of the way. So this is the liver we'll see. As soon as we get in, we'll kind of tell you what's going on. Go ahead, cut this. He's thin, I mean, you know… Okay, now what's bleeding here?
So the object of the game here is to identify the gallbladder, which happens to be right here. Nice. This is the liver, just like - liver you see in the supermarkets. And when people have attacks, gallbladder attacks, they develop adhesions to the surrounding structures, fatty tissue, other organs. Uh huh, so that's what this is. There you go, right there's your adhesion. That's where you can see it. I think, yeah, right here. Uh huh. Ere to the gallbladder because it's coming out, so it doesn't matter. So the main thing you have to do in a gallbladder when you're taking the gallbladder out, it has a blood supply, so it'd be nice to find the blood supply before you start cutting the gallbladder. I think you're in the serosa a little bit, but - I think it's out here, but it's okay, you can use the Bovie if you want, I don't care. And then there's the gallbladder duct that delivers bile to the intestine to help you absorb fatty food. That's what the gallbladder does. Kelly?
There you go boss, peel that off. See through it? Mm hmm. Good. Yeah, that - that filmy - that's it. Nice. Uh huh, now pull that down again so you could… Yeah, just grab it and peel it off, nice and gentle, good. Uh huh Uh huh, uh huh - the stuff on top. Nice. Uh huh, good. Yep. Well, I think - your duct is around here. I think your artery is up here. Okay. You know, I think - I wouldn't touch that. That's your common duct. Okay. Yeah, yeah. You can do it - Metz? Scissors? Or you could just peel it away if you want. Yeah Uh huh, open. Okay, now I - that's enough, you don't have to be there. I think, so this is - I thought that was your artery there, but… Uh huh, now just spread nice and gentle. Once again, we're trying to find the duct, which is the important structure. Uh huh, how's it look? See, I think artery is above you there. And I think duct is where you're at. Do we have the clip? No, you're good man - don't force it. Uh huh. See, get this stuff off the top too. See that red stuff? Just kind of push it away - it should push away, but - see these gallbladder stuff, you can spread - that's it. That's nice, good. Good. Let me cut it. This looks like a vessel right here. Mr. Bovie? So this is the cystic duct, which is the gallbladder duct, and this is the main bile duct. So we can't hurt this, and this is what we want to clip and cut, right? This thing underneath this little blood vessel - this a blood vessel. This is your gallbladder. This is your liver. Mm hmm. Don't touch anything else. Scissors? Okay, now, get around this thing and let's clip it. Yeah, I'd go from known to unknown. Do you have the clip applier? Nice, okay. How's it look? Great. Uh huh, okay. I think you should be good.
Yeah, so gallbladder, cystic duct, common duct there, okay? Just to verify it before we cut it. I think I'm through. Yep. What's the deal? One for the road here. Here, let go. I'm going this way. Okay. Right Angle? Here, cut it. This thing is so huge, lordy! Okay, you want to cut up between those two. I don't know if I'm helping you. Pull the gallbladder a little bit toward you. That's it. Okay, great. Okay, now your artery should be here. That's what it used to be anyway, when we used to do these open in the old days. I think your artery is… It looks like this is the… Let's just see here. Let's just look up here for one second. I don't want to steal your case, but - I thought it was that little thing there, but… That looks like it right there. This thing here? Yeah. This right here. Yeah, why don't you clip it there? This thing - I have it, right? It's not this? Yeah. Or is it this? Hmm. See, I think we should cook this. I think it's this over here. We have such a big right angle clamp here. I think you should just put one clip on this. Clip it. Okay. So this is like a branch of the artery that we're getting. Okay, I can see the… I'd turn it the way around maybe. You want to stay on the inside, yeah. Yeah spin it around. Good. Nice. Okay? Yeah. All right, now… It's usually kind of up there, we used to do this to kind of get it. You want me to clip it? Yep. I can do that, you can clip above me. Uh huh, boom! Uh huh. Clip - the liver's behind it, that's good. No, we have to get both sides then - this is serious. So, you want to get high, and get another one there. There. Uh huh, good. And then get one here. Boom. Yep. Mm hmm, now let's just cut it. Nice, okay now - loosen it up, let's just cut this too. Where do we clip it, here? Yeah, let's clip it again. This little thing here. Wow, the clip just flies out, huh? Did we cut the other one? Yeah, we did. I think this is just stuff we can just take with Mr... - now what's bleeding there? Pick up. Just go over this. That's nice. From this one here. This thing here, our clips are like failing us. Go ahead. Uh huh - burn me please. I hate these suckers. I'm a pool suction kind of guy, but… Okay. It doesn't matter. Let me just cauterize this. No just - hit my thing. Uh huh, more. Now just cut that. Uh huh, okay. Is it still bleeding when I hold here? It is? No. Oh, it's not. I'm asking. No, I don't think so. It's on this side then. Somewhere on this side. Right here. So we've disconnected the gallbladder's duct and the artery so, theoretically, it's safe to take it out. Now the blood supply has been cut off, it shouldn't bleed too much.
Uh huh. You can just… So this is the outside covering of the gallbladder, it's called the serosa, She's kind of cutting in here with this Bovie. This is a thing that cuts and stops the bleeding at the same time, it cauterizes things. It's an old-fashioned thing. There's nothing new and fancy about it, It's been around for years. Let me go back here. Mm hmm. This Mixter is just so marvelously large. Mm hmm. So anything you can do to help me get around this. That's it. Okay, now… Uh huh, good. Mm hmm. Almost finished, Bear. Okay. Here, I'll take this. You want to take the other one? I think we're good. So this is a liver up here. This is the end of the gallbladder. She's doing a marvelous job taking it off. Mm hmm, ah! How did that happen, huh? Here, let's just do this. That's a little bile. Okay, now - where's the suction? Let's get the rest of it out. Hemostat, please? I just want to grab this with a hemo. This is what's called a gallstone. There are a few gallstones here. Just kind of grab this and lift up. Pick up. Now clean that off and let's go. Let's get the rest out. Hemostat, please? Uh huh, good. Mm hmm. Mm hmm, Mm hmm, good. Beautiful. Uh huh. Okay, now let's just get the sponge stick there. Uh huh, good. You can see there what has to go. It's out, just about. Okay, it's out. So this is the little scallywag gallbladder. We made a little hole in it, which is not the end of the world. Some bile escapes and the occasional small gallstone, but we got most of it out.
Sponge? Now suck that out so we can see what the heck's going on. This thing actually working? I'd like to look at the liver bed to see what may or may not be bleeding. Let's just check it out. That looks pretty good. Right down here, Bear. That's good. Right there. Take that, Bear. And I'll suck that, and you point to what needs to be pointed to. So… Right there's the gallbladder duct. And then… And the artery is over there, that's great. Right here, so this is the cystic duct clips, artery clips, this is the common bile duct, which we're actually close to you know, it's kind of sitting there, and it - like I said, the last thing you want to do is hurt that because it's hard to fix in the states, and it's really hard to fix down here. So anyway, this is kind of it. Make sure there's no bleeding, get all the rest of the juice out, and close the belly. This is a pretty small incision for a chole, but we got away with it. You see any bleeding? I think it's good. I think it's good too. Okay, close time. No sponges in here? Yep. No sponges? Okay, we didn't even feel it, over the liver. He's got a pretty liver, this guy. He's got a great liver. No cirrhosis in that. You can do a sponge count while it's hot to make sure that you got all the sponges out. It's like we where never there. Kelly's. five Kelly's, two rakes and a Rich. Just kidding.
Kelly? One more Kelly, thanks. Okay, now here. Good. Here it is. Is it out? Make sure it's out because we have a 3-0 over there too. Yeah, it's out. That's good. Good. Just some muscle here. So we're closing the belly in layers because we opened it in layers. (coughs) God bless you, God bless you. They're all different these gallbladders, believe it or not. You know, the patients are different, the diseases - some is bad, some is not. Some are bigger and larger and deeper, and some are thin like this guy, so - he wasn't that difficult. That's just falciform ligament there. Ballooning out. That's it, there's your posterior sheath over there. Good. Mm hmm. Falciform just wants to come out to play. Breathing is important. I guess. There's your peritoneum. Okay. Just push the fat in. You can use the other end too if you want, but… It has teeth, and… That's it, nice, nice, beautiful. Mm hmm, just tie it. Lets you close it. Let's make sure there's no bleeding here. Let's look at this now. It's bleeding here. Is there something over here? That's it, yeah. Oh, right here. There it is, pumping away. Beautiful. You have something? No. Or you're just looking? No, I'm just looking. Okay. So this should go down here. You see it? Mm hmm. Mm hmm, good. Okay, Army-Navy? Army?
So this operation, we're just finished. It went very well, we were lucky the patient was a thin man. He had a lot of disease, but we - we got through it without any problem. Exposure was good. I mean, I was happy with the procedure. There was no excessive bleeding, we accomplished what we wanted to do: finding the duct, controlling the duct and cutting it, finding the artery, controlling the artery, we took it off. We did it through a relatively small incision because the patient was thin, you know, which is almost, you know, unheard of. Most of the time, they're kind of big, heavy, middle-aged females. This was a skinny guy. So, we were lucky.