Cholecystectomy

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Cholecystectomy

Cholecystectomy is surgical removal of the gallbladder. It is one of the most common abdominal operations performed worldwide - over 750,000 are performed annually in the United States alone. Carl Langenbuch performed the first successful open cholecystectomy in 1882; Philippe Mouret introduced the laparoscopic approach in France in 1987, which quickly became the gold standard.

Schwartz's Principles of Surgery, 11th ed., p. 1438-1442
Bailey and Love's Short Practice of Surgery, 28th ed., p. 1270-1271

Indications

Indication	Details
Symptomatic cholelithiasis	Biliary colic, recurrent attacks
Acute cholecystitis	Calculous or acalculous
Chronic cholecystitis	Repeated episodes of inflammation
Choledocholithiasis	CBD stones (with or without ERCP)
Biliary pancreatitis	Same-admission for mild/interstitial disease
Biliary dyskinesia	Gallbladder EF <35% on HIDA scan; 90% symptom improvement
Gallbladder polyps	>1 cm, or symptomatic
Gallbladder carcinoma	Where technically resectable

Contraindications

Absolute:

Haemodynamic instability
Uncontrolled coagulopathy
Frank peritonitis (relative to laparoscopic approach)
Severe COPD or severe cardiac failure (EF <20%) - inability to tolerate pneumoperitoneum

Formerly absolute, now relative (risk factors for difficult cholecystectomy):

Acute cholecystitis, empyema/gangrene of gallbladder
Biliary-enteric fistula, Mirizzi's syndrome
Morbid obesity, cirrhosis, prior upper abdominal surgery
Pregnancy, ventriculoperitoneal shunts, portal hypertension

Preoperative Assessment

Full blood count, liver function tests, coagulation screen, renal function
Chest X-ray and ECG if clinically indicated
Abdominal ultrasound (assess stones, gallbladder wall, CBD diameter)
CBD stone risk stratification (Table below)
DVT prophylaxis: LMWH + antiembolic stockings
Antibiotic prophylaxis: second-generation cephalosporin at induction of anaesthesia
Informed consent (including risks of bile duct injury, conversion to open, bleeding, retained stones)

CBD Stone Risk Assessment (Bailey & Love):

Risk	CBD Stone Risk	History	LFTs	CBD Diameter	Action
Low	2-3%	No cholangitis/pancreatitis	Normal	≤6 mm	None
Medium	20-40%	Cholangitis or pancreatitis	2x normal	8-10 mm	MRCP ± ERCP
High	50-80%	Jaundice + cholangitis	2x normal	≥10 mm	MRCP ± ERCP

Laparoscopic Cholecystectomy - Technique

Laparoscopic cholecystectomy steps: trocar placement, retraction, critical view of safety, clipping, cholangiography, and division of cystic duct and artery

Figure: Laparoscopic cholecystectomy. (A) Trocar placement. (B) Fundus retracted cephalad to expose the hepatoduodenal ligament. (C) Intraoperative photo showing the Critical View of Safety with cystic artery, cystic plate, and cystic duct. (D) Clip on cystic duct. (E) Cholangiogram catheter insertion. (F) Division of cystic duct and artery. - Schwartz's Surgery

Port Placement (Standard 4-port)

Camera port - supraumbilical (5 or 10 mm), 30° laparoscope
Working port - epigastric (10-12 mm), surgeon's right hand
Mid-clavicular port - right mid-clavicular (5 mm), surgeon's left hand
Lateral port - right flank (5 mm), assistant retraction

Key Operative Steps

1. Pneumoperitoneum

Established with CO2 via Veress needle (closed) or Hasson technique (open cut-down, preferred when prior surgery). Intra-abdominal pressure typically 12-15 mmHg.

2. Patient Positioning

Supine, reverse Trendelenburg with left lateral tilt. Surgeon stands at patient's left (or between legs in split-leg position).

3. Retraction - Critical First Step

Fundus grasped and retracted towards the patient's right shoulder (cephalad, over liver edge)
Infundibulum retracted inferolaterally towards the right iliac fossa
This opens the hepatocystic triangle, increases the cystic duct-CBD angle, and limits dissection above Rouvière's sulcus

4. Calot's Triangle Dissection

Peritoneum on both anterior and posterior aspects of the hepatocystic triangle is divided
Fat and fibrous tissue are cleared
Dissection is kept close to the gallbladder wall

5. Critical View of Safety (CVS) - Mandatory Safety Step Three criteria must ALL be met:

Hepatocystic triangle cleared of all fat and fibrous tissue
Lower one-third of the gallbladder separated from the liver to expose the cystic plate
Only two structures seen entering the gallbladder (cystic duct and cystic artery)

CVS is the most important safety step - if it cannot be achieved, the surgeon must stop, consider alternatives (subtotal cholecystectomy, drain and refer, intraoperative cholangiogram), and not clip or divide any structure.

6. Clipping and Division

Cystic duct and cystic artery are each double-clipped proximally and single-clipped distally, then divided
Gallbladder dissected off the liver bed (cystic plate left on liver to prevent bile leak and bleeding)

7. Extraction

Gallbladder extracted via umbilical port in a retrieval bag (prevents port-site contamination/seeding)

Intraoperative Cholangiogram (IOC)

Routine vs. selective: remains debated; routine IOC detects CBD stones in ~7% of patients and helps delineate anatomy
Selective indications: abnormal LFTs, history of jaundice or pancreatitis, dilated CBD on preoperative US, large CBD stones, failed preoperative ERCP, uncertain ductal anatomy
ICG fluorescence cholangiography: real-time biliary tree visualisation using indocyanine green with special laparoscopic systems - reduces bile duct injury risk
Technique: clip placed on proximal cystic duct; small incision on anterior surface; catheter secured; contrast injected under live fluoroscopy

Difficult Cholecystectomy - Red Flag Signs (Bailey & Love)

When these appear, stop and reassess before proceeding:

Failure of timely progression of dissection
Anatomical disorientation
Difficulty in visualisation

Risk factors for difficult cholecystectomy include: Male sex, age >65, acute cholecystitis with >72-96 hours since onset, contracted or thickened gallbladder wall (>4-5 mm), distended gallbladder with impacted neck stone, gangrenous gallbladder, Mirizzi's syndrome, cirrhosis/portal hypertension, previous upper abdominal surgery.

Options when CVS cannot be achieved:

Subtotal (partial) cholecystectomy: remove as much mucosa as possible, close cystic duct stump, wide drainage
Cholecystostomy (drain the gallbladder, defer definitive surgery)
Convert to open
Obtain a cholangiogram to clarify anatomy

Open Cholecystectomy

Performed when laparoscopic approach is contraindicated or conversion is required. Incision options: upper midline, short subcostal (Kocher), or right upper transverse incision over the lateral rectus border.

Approach:

Packs placed on hepatic flexure of colon, duodenum, and lesser omentum
Artery/Duval forceps on infundibulum to put peritoneum over Calot's triangle under stretch
Peritoneum divided close to gallbladder wall; fat cleared from Calot's triangle
Cystic artery and duct identified, ligated, divided
Gallbladder dissected from liver bed

"It is the left hand of the assistant that does all the work" - Moynihan (on retraction during open cholecystectomy)

Conversion to Open

Elective setting: ~5% conversion rate
Emergency/complicated gallstone disease: 10-30% conversion rate
Conversion is not a failure - it is sound surgical judgment
Must always be discussed with the patient preoperatively

Indications for conversion:

Inability to tolerate pneumoperitoneum
Complication not correctable laparoscopically
Failure to identify key anatomical structures
No progress over a defined period

Complications

Complication	Detail
Mortality	~0.1% for laparoscopic cholecystectomy
Bile duct injury	Most feared complication; historically higher with laparoscopic approach, now comparable to open with modern technique and CVS
Bile leak	From cystic duct stump or ducts of Luschka; presents with biloma/pain/fever post-op
Retained CBD stones	Managed with ERCP post-operatively
Haemorrhage	From cystic artery or liver bed
Wound infection	Less frequent than open surgery
Port-site hernia	Especially at 10/12 mm ports
Visceral injury	Bowel, liver, duodenum
Post-cholecystectomy syndrome	Persistent or recurrent symptoms after surgery

Special Situations

Biliary Pancreatitis:

Mild/interstitial pancreatitis: same-admission cholecystectomy recommended (reduces recurrence from 18% at 6 weeks to near zero; no increase in conversion rate)
Moderately severe/necrotizing pancreatitis: interval cholecystectomy after inflammation resolves and fluid collections stabilize (at least 6 weeks)
If patient cannot undergo surgery: biliary sphincterotomy prevents further AP but does not prevent biliary colic or acute cholecystitis

Biliary Dyskinesia:

Diagnosed by HIDA scan with gallbladder EF <35%
Cholecystectomy improves or resolves symptoms in up to 90% of cases

Acalculous Cholecystitis (ICU patients):

Cholecystectomy when patient stable; percutaneous cholecystostomy as bridge to definitive surgery in critically ill patients

Single-port laparoscopic cholecystectomy:

Improved cosmesis and possibly less postoperative pain
But systematic reviews show higher failure rate, longer operative time, and increased blood loss versus standard 4-port approach

Key Anatomical Landmarks

Triangle of Calot (hepatocystic triangle): Bounded by the cystic duct (inferiorly), common hepatic duct (medially), and inferior border of the liver (superiorly). Contains the cystic artery.
Rouvière's sulcus: Hepatic fissure on the right lobe surface - dissection should remain anterior/inferior to this landmark
Cystic plate: Connective tissue between gallbladder and liver bed; exposing its medial third confirms CVS

Sources: Schwartz's Principles of Surgery 11th ed.; Bailey and Love's Short Practice of Surgery 28th ed.; Sleisenger and Fordtran's GI and Liver Disease

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