Cholecystectomy: Approaches and Technique

Definition and Surgical Anatomy

Definition

Cholecystectomy is the surgical removal of the gallbladder, which can be performed using either an open or a laparoscopic method.

Anatomy

Gallbladder:

• Bile-filled sac located in a fossa on the inferior aspect of the liver beneath the junction of hepatic segments Ⅳb and Ⅴ
• 7–10 cm in length, average capacity 30–50 mL
• Anatomic divisions:
  • Fundus (most superior aspect)
  • Corpus (body)
  • Infundibulum (round, blind end extending below the liver margin)
  • Neck (connects with cystic duct)
• Cystic duct connects the gallbladder to the biliary tree and contains the spiral valves of Heister.
• Blood supply: cystic artery, usually a branch of the right hepatic artery (90% of cases)
• Gallbladder wall layers:
  • Mucosa, composed of columnar cells with microvilli
  • Lamina propria
  • Muscular layer (not arranged in distinct layers)
  • Serosa
  • Lacking muscularis mucosae
  • Rokitansky–Aschoff sinuses: invaginations of mucosae extending through the muscular layer

Biliary tree:

• The right and left hepatic ducts join to form the common hepatic duct.
• The cystic duct joins the common hepatic duct to form the common bile duct.
• Cystic duct length is highly variable.

Calot’s (hepatobiliary) triangle:

• Borders:
  • Medial: the common hepatic duct
  • Lateral: the cystic duct
  • Superior: inferior edge of the liver 
• Contents:
  • Right hepatic artery
  • Cystic artery
  • Lymph node of Lund
  • Lymphatics

Anatomic variants

• Cystic duct:
  • Low junction between cystic duct and common hepatic duct 
  • Cystic duct adherent to common hepatic duct
  • High junction between cystic and common hepatic ducts
  • Cystic duct drains into right hepatic duct.
  • Long cystic duct that joins the common hepatic duct behind the duodenum 
  • Absence of a cystic duct
  • Cystic duct crosses posteriorly to common hepatic duct and joins it anteriorly.
  • Cystic duct crosses anteriorly to common hepatic duct and joins it posteriorly.
• Cystic artery:
  • From right hepatic artery (most common)
  • From the right hepatic artery arising from the superior mesenteric artery
  • 2 cystic arteries: from the right hepatic and common hepatic artery
  • 2 cystic arteries: from the right and left hepatic arteries
  • From the right hepatic artery and running anterior to the common hepatic duct
  • 2 cystic arteries from the right hepatic artery

Indications and Contraindications

Indications

• Symptomatic cholelithiasis without cholecystitis:
  • Gallstones within the gallbladder
  • Stones are predominantly made up of cholesterol and, sometimes, bilirubin.
• Cholecystitis (acute and chronic): inflammation of the gallbladder caused by cystic duct obstruction (most often by stones)
• Biliary dyskinesia: physiologic dysfunction of the gallbladder characterized by abnormal emptying of bile
• Choledocholithiasis and gallstone pancreatitis
• Gallbladder polyps > 0.5 cm
• Porcelain gallbladder (calcification of the gallbladder)
• Gallbladder cancer: radical cholecystectomy; includes lymphadenectomy and resection of the adjacent liver parenchyma
• Emergent indications:
  • Gangrenous gallbladder
  • Emphysematous gallbladder
  • Gallbladder perforation

Contraindications

• Absolute: uncontrolled coagulopathy
• Relative:
  • Chronic obstructive pulmonary disease (COPD)
  • Severe cardiac disease:
    • Congestive heart failure
    • Recent myocardial infarction (within 6 months)
    • Severe aortic stenosis
  • Cirrhosis
  • Portal hypertension
  • Sepsis/hemodynamic instability: If there are no strict indications for emergent cholecystectomy (e.g., perforation, emphysema), alternative approaches can be tolerated better.
• Alternative approaches to cholecystitis when surgery is contraindicated:
  • Acute cholecystitis can initially be managed with antibiotics while the patient is stabilized and coagulopathy corrected.
  • If a patient remains a poor surgical candidate, a percutaneous drain can be placed into the gallbladder to provide source control.
  • The drain will remain in place for 6–8 weeks, after which time the patient is reevaluated for cholecystectomy.

Procedure

The goal of surgical treatment is to remove the gallbladder and the stones it contains, while ensuring that no stones remain within the ductal system. The goals are the same for both the laparoscopic and the open approach.

Preoperative preparation

• Initial supportive management:
  • Nothing by mouth
  • Pain control and nausea treatment
  • Fluid resuscitation with electrolyte correction
• Preoperative antibiotics:
  • In acute cholecystitis, antibiotics should be administered as part of treatment:
    • Gram-positive and gram-negative coverage
    • Cefazolin–metronidazole or ciprofloxacin–metronidazole
  • For other indications for cholecystectomy: Prophylactic antibiotics with the same coverage must be administered 30–60 minutes before incision.
• Anesthesia:
  • General anesthesia is administered for both laparoscopic and open approaches.
  • An orogastric or nasogastric tube should be placed to decompress the stomach.
• Foley catheter:
  • Optional
  • A Foley catheter should be placed if technical difficulties are anticipated (e.g., prior abdominal operations, underlying liver disease) because the procedure may last > 4 hours.

Procedure

Laparoscopic cholecystectomy is considered the gold standard, as it results in decreased postoperative pain, a shorter hospital stay, and an earlier return to work. Over 90% of cholecystectomies are performed laparoscopically. Conversion to an open approach is mandatory if anatomy is not clear.

Laparoscopic cholecystectomy:

1. A port incision is made at the umbilicus and a trocar is inserted.
2. Pneumoperitoneum is achieved by insufflating the abdomen with CO₂.
3. The laparoscope is inserted through the umbilical port.
4. The remaining ports are inserted under direct visualization with the laparoscope:
   • Epigastrium
   • Right anterior axillary line
   • Right midclavicular line along the costal margin
5. The patient is placed in a reverse Trendelenburg position.
6. The gallbladder fundus is retracted cephalad over the liver with a grasper for visualization.
7. A second grasper is used to retract the infundibulum laterally and expose Calot’s triangle.
8. Dissection is performed around the infundibulum to delineate Calot’s triangle.
9. The critical view of safety needs to be established:
   • Calot’s triangle is cleared of fibrous and fatty tissue.
   • The lower ⅓ of the gallbladder is mobilized from the liver bed.
   • Only 2 structures should be seen entering the gallbladder: cystic duct and artery
   • Cholangiography could be performed at this point, if there are doubts regarding ductal anatomy.
10. The cystic duct and artery are divided between clips.
11. The gallbladder is dissected off the inferior aspect of the liver using electrocautery.
12. The gallbladder is placed in a specimen bag and extracted through the umbilical port.
13. The CO₂ is let out the peritoneal cavity and the trocars are removed.
14. The incisions are closed.

Open cholecystectomy:

1. A right subcostal incision, 2 fingerbreadths below the costal margin (Kocher incision) is made and the surgeon advances through the layers of the abdominal wall until the peritoneal cavity is reached. 
2. The gallbladder is placed in the center of the operative field; retraction and exposure are key:
   • The liver and costal margin are retracted superiorly.
   • The small bowel, colon, and duodenum are carefully retracted inferiorly.
3. The gallbladder is dissected from the liver bed, usually with cautery:
   • Anterograde: from the cystic duct toward the fundus
   • Retrograde: from the fundus toward the cystic duct
4. The cystic duct and artery are ligated using ties or clips and then transected.
5. The gallbladder is removed, and hemostasis of the gallbladder is achieved with electrocautery.
6. The abdominal wall is closed in layers.

Postoperative care

• Diet:
  • Oral fluids after 4 hours
  • Quick transition to semisolid and solid food
• Early ambulation
• Incentive spirometry
• After laparoscopic cholecystectomy, up to 80% of patients can be discharged within 24 hours.
• After open cholecystectomy, patients typically remain in the hospital for 2–3 days for pain control, or longer if their condition warrants.

Complications

Cholecystectomy has a low-risk profile; however, like any other surgical procedure, it has inherent risks and complications. 

• Injury to the common bile duct (greater risk with laparoscopic approach):
  • If encountered intraoperatively:
    • Conversion to open cholecystectomy and immediate repair if a surgeon is skilled at these procedures
    • Otherwise, placement of a drain and immediate transfer to a higher-level facility with a hepatobiliary surgical service
  • If discovered postoperatively:
    • Significant injuries to the common bile duct will require operative repair.
    • Endoscopic retrograde cholangiopancreatography (ERCP) for possible stenting of injured duct may be an option in some cases.
    • Percutaneous drainage for biloma (bile collection) if present
• Cystic duct stump leak: 
  • More common when acute cholecystitis/severe inflammation is present
  • Most can be treated with ERCP and stent and drainage of biloma.
• Injury to the liver, duodenum, or colon
• Bleeding:
  • Due to vascular injury (right hepatic artery)
  • Due to clip coming off the cystic artery stump (classic manifestation is hypotension in the recovery room)
• Diaphragmatic injury 
• Gallbladder perforation and spillage of bile and stones: increases the risk of postoperative abdominal abscess