Open Cholecystectomy for Gallbladder Disease

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, for the most part, form initially in the gallbladder with the exception of primary common bile duct (CBD) stones that form primarily in the CBD. 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 4–6 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 acute cholecystitis will present with tenderness to palpation, voluntary guarding of the right upper abdominal quadrant and epigastrium, and 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 intra-abdominal 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 19^th 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.

A retractor set is important for having adequate visualization.

There are different options for ligating the cystic duct and artery. Clips were used in this patient, but there are many other options, including simple suture ligation in resource-limited settings.

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.