Cholecystectomy

History

• 1882 - Carl Langenbuch performed the first successful open cholecystectomy
• 1987 - Philippe Mouret (France) introduced laparoscopic cholecystectomy, which rapidly replaced the open approach and rendered non-surgical gallstone therapies (e.g., lithotripsy, bile salt dissolution) largely obsolete

Indications

• Symptomatic gallstones (biliary colic)
• Acute cholecystitis
• Chronic cholecystitis
• Empyema or gangrene of the gallbladder
• Gallstone pancreatitis
• Biliary dyskinesia (acalculous)
• Gallbladder polyps >1 cm (malignancy risk)
• Porcelain gallbladder (selected cases)

Preoperative Preparation

• Full history (jaundice, previous biliary events) and fitness assessment
• Investigations: FBC, renal and liver function tests, prothrombin time; ECG/CXR if medically indicated
• Antibiotic prophylaxis: second-generation cephalosporin at induction of anaesthesia
• VTE prophylaxis: subcutaneous heparin + antiembolic stockings
• Informed consent (procedure, alternatives, specific risks)
• Bladder emptied before the operating room (avoids need for catheterisation)

Risk Stratification for CBD Stones

Laparoscopic Cholecystectomy (Gold Standard)

Patient Positioning & Access

• Supine; surgeon stands at patient's left (or between legs in split-leg position)
• Pneumoperitoneum with CO₂ via Veress needle (closed) or Hasson technique (open); typical pressure 12-15 mmHg
• Port placement:
  • Supraumbilical (camera, 5- or 10-mm, 30° scope)
  • Epigastric (10-12 mm, working port)
  • Right midclavicular line (5 mm)
  • Right flank (5 mm)

Step-by-Step Technique

1. Retraction: Assistant grasps gallbladder fundus and retracts it cephalad over the liver edge toward the right shoulder
2. Infundibulum exposure: Surgeon retracts gallbladder infundibulum posterolaterally to expose the hepatocystic triangle (triangle of Calot)
3. Dissection: Peritoneum, fat, and areolar tissue around the cystic duct-gallbladder junction are dissected off. The cystic duct and cystic artery are carefully defined
4. Critical View of Safety (CVS) - mandatory before any clipping:
   • Hepatocystic triangle cleared of fat and fibrous tissue
   • Lower one-third of gallbladder separated from liver to expose the cystic plate
   • Only two structures seen entering the gallbladder (cystic duct and cystic artery)
5. Cholangiogram (selective or routine): catheter inserted into cystic duct to image biliary tree
6. ICG fluorescence cholangiography (modern): real-time imaging with indocyanine green for better bile duct visualisation
7. Clipping and division: Two clips at the base, one on the gallbladder side for both cystic duct and cystic artery; then divide. For dilated cystic ducts - endoloop, laparoscopic stapler, or suture
8. Dissection from liver bed: Electrocautery; watch for aberrant posterior bile ducts or vessels
9. Final inspection: Check for bile leak, bleeding, clip placement
10. Specimen retrieval: Usually through epigastric port, in retrieval bag; port may need enlargement for large stones
11. Drain (optional): placed if severe inflammation, gangrene, or expected bile/blood accumulation

Safe Zones and Landmarks

• B - Bile duct
• S - Sulcus of Rouvière (safe zone is cephalad to line from Rouvière's sulcus to umbilical fissure = R4U line)
• A - Hepatic artery
• F - Umbilical fissure
• E - Enteric (duodenum)

Contraindications to Laparoscopic Approach

• Haemodynamic instability
• Uncontrolled coagulopathy
• Frank peritonitis
• Severe COPD or heart failure (EF <20%) - unable to tolerate pneumoperitoneum

• Male, >65 years, acute cholecystitis >72-96 hours, prior upper abdominal surgery, morbid obesity, cirrhosis, pregnancy, thick-walled gallbladder (>4-5 mm), empyema, Mirizzi syndrome

Open Cholecystectomy

• Right subcostal (Kocher) incision or midline laparotomy
• Dissection usually begins at fundus, working toward the hepatocystic triangle
• Same surgical principles apply - CVS, cystic duct and artery identification, ligation, division
• "Fundus-first" (retrograde) approach useful when severe adhesions prevent antegrade dissection
• Indicated when laparoscopic approach fails or is contraindicated

Conversion to Open

• Elective setting: ~5% conversion rate
• Emergent/complicated: 10-30% conversion rate
• Not a failure - always discussed preoperatively
• Indications: inability to tolerate pneumoperitoneum, uncontrolled intraoperative complication, inability to identify anatomy, no progress after set time period

Intraoperative Cholangiogram (IOC)

• Performed selectively when biliary anatomy is unclear, or when CBD stones are suspected
• Catheter inserted into cystic duct before division; fluoroscopic imaging of biliary tree
• Identifies unsuspected CBD stones and confirms anatomy to prevent bile duct injury

Complications

Difficult Cholecystectomy: Safety Steps

1. "Dome-down" (fundus-first) technique - when severe adhesions at Calot's triangle; start at fundus and work down
2. Partial/subtotal cholecystectomy - leave gallbladder base when complete removal is dangerous; oversew the remnant
3. Cholecystostomy - tube drainage as temporising measure in high-risk patients
4. Time-out concept - procedural pause when disoriented to recall and apply safety measures
5. Convert early - conversion to open is not a failure; hesitation increases risk

Post-operative Care

• Day-case or overnight stay for elective laparoscopic cases
• Early ambulation
• Diet resumed when tolerating oral intake
• Analgesics (paracetamol + NSAIDs; opioids if needed)
• Discharge instructions: wound care, activity restrictions, when to seek review

Recent Evidence