1. Introduction

2. Surgical Approach

a. Division of the Rectus Abdominis Muscle

b. Incision of the Posterior Rectus Sheath and Peritoneum

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

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.


<h4>CHAPTER 1</h4>

<p>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 are 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 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.</p>

<h4>CHAPTER 2</h4>

<p>We're doing an open cholecystectomy on this man.
Okay?
He has gallbladder disease and needs it out.
So we're in the 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.</p>

<h4>CHAPTER 3</h4>

<p>That's good.
Yeah, make it a little bit bigger. No, this way.
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.</p>

<p>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.
We'll 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?</p>

<p>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?</p>

<h4>CHAPTER 4</h4>

<p>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?</p>

<h4>CHAPTER 5</h4>

<p>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.</p>

<h4>CHAPTER 6</h4>

<p>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 artery.
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 Bovie this.
Yeah, 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.</p>

<h4>CHAPTER 7</h4>

<p>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. We're almost finished, Bear.
Okay.
Hold on a second.
Here, I'll take this.
You want to take the other one?
I think we're good.
So this is the 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.</p>

<h4>CHAPTER 8</h4>

<p>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 yet,
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.</p>

<h4>CHAPTER 9</h4>

<p>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.
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 under 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.
Oh - okay.
So this should go down here.
You see? Mm hmm.
Mm hmm, good.
Okay, Army-Navy?
Army?</p>

<h4>CHAPTER 10</h4>

<p>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.</p>


Watch this full-length, narrated surgical video of an open cholecystectomy performed during a surgical mission in Honduras with the World Surgical Foundation.

DOI
Publication Date	2023/10/24
Article ID	290.12
Production ID	0290.12
Volume	2023
Issue	290.12
https://doi.org/10.24296/jomi/290.12

Open Cholecystectomy for Gallbladder Disease

Procedure Outline

Table of Contents