Continuing Education Activity

Gallbladder removal, also known as cholecystectomy, is one of the most common procedures in the United States, with more than 1.2 million cholecystectomies done annually. Before 1991, an open technique was the standard procedure for cholecystectomy. This usually included performing an intraoperative cholangiogram, and patients usually had a postoperative stay between 2 and 6 days. With the advent of laparoscopic cholecystectomy in the early 1990s, the laparoscopic approach has become the gold standard for cholecystectomy. Today, 92 percent of cholecystectomies are done laparoscopically. However, laparoscopic cholecystectomy is associated with a higher incidence of bile duct injuries. This activity reviews the indications, contraindications, and technique involved in performing an open cholecystectomy and highlights the role of the interprofessional team in the preoperative and postoperative care of patients undergoing this procedure.

Objectives:

• Describe how an open cholecystectomy is performed.
• Review the indications for open cholecystectomy.
• Outline the complications of open cholecystectomy.
• Explain some interprofessional team strategies for enhancing care coordination and communication to advance the role of open cholecystectomy in the management of biliary tract stones, improving patient outcomes.

Introduction

Gallbladder disease is one of the most common procedures done in the United States with more than 1.2 million cholecystectomies done annually. Before 1991, an open technique was the standard procedure for cholecystectomy. This usually included performing an intraoperative cholangiogram, and patients usually had a 2 to 6-day postoperative in-house stay. With the advent of laparoscopic surgery and laparoscopic cholecystectomy in the late 1980s, the gold standard for cholecystectomy has changed to a laparoscopic approach[1]. This method showed a 30% increase in the overall performance of elective cholecystectomies. Today, 92% of all cholecystectomies are done laparoscopically, although open cholecystectomies remain more common in many less affluent settings[2]. With the advent of laparoscopic cholecystectomies in the 1990s, common bile duct (CBD) injuries increased by three to ten times. The injury rate dropped to 0.3% but has remained the same despite better training, preventative maneuvers, and equipment. Laparoscopic CBD injuries are typically more complex.[3] There are several indications to perform open cholecystectomies, and this procedure remains an important part of training for the general surgery resident.

Anatomy and Physiology

The anatomy of the biliary tree remains one of the most variant areas of the body[4][5]. The gallbladder is a pear-shaped organ affixed to the undersurface of segments IVB and V of the liver. It has no capsule. There is a slight outpouching of the distal gallbladder called Hartman's pouch, which tapers distally to the cystic duct, which contains Valves of Heister. The cystic duct joins the bile duct at the confluence of the common hepatic (proximal) and common bile (distal) ducts. The common bile duct empties into the duodenum at the Ampulla Vater. The sphincter of Oddi controls the flow of bile into the duodenum. The proximal common hepatic duct branches into the left and right hepatic radicals in the liver. These radicals eventually branch into smaller intrahepatic ducts. There may be small ducts that traverse directly into the gallbladder from the gallbladder bed of the liver, called the ducts of Luschka, that may result in postoperative bile leaks if not identified and addressed at the time of surgery[6].

The blood supply to the gallbladder is from the cystic artery, which usually branches from the right hepatic artery, which branches from the common hepatic artery. There is no formal venous structure associated with the gallbladder. A commonly used landmark is the triangle of Calot. There are two definitions of this anatomical landmark. The original description uses the cystic duct, the cystic artery, and the liver. The more commonly used description of Calot's triangle is the cystic duct, the common hepatic duct, and the undersurface of the liver. The latter description helps identify the cystic artery that lies within the triangle beneath the lymph node of Calot. The portal vein lies just below the common bile duct. The surgeon must always be aware of the high incidence of the diversity of this area of the body, and there, in fact, is no such thing as standard biliary anatomy. There are many anatomical variances such as choledochal cysts, fusiform gallbladders, accessory ducts, intrahepatic gallbladders, and duplications.

Fifteen percent to 20% of patients will have altered anatomy. One of the most dangerous situations is a short cystic duct with the accompanying short cystic artery. The common bile duct may be mistaken for the cystic duct and be at risk for transection. A short cystic artery may lead to injury or transection of the right hepatic artery. Ten percent to 15% of people have a replaced right hepatic artery with the origin from the superior mesenteric artery (SMA).[7]

Indications

With the advent of laparoscopic cholecystectomies, the indications to perform an open cholecystectomy have decreased. The most common instance (2% to 10%) that an open cholecystectomy is performed is when converting from a laparoscopic to open cholecystectomy. This change is made for a variety of reasons. Any time there is a question of the anatomy, surgeons may change to an open technique. Extensive inflammation, adhesions, anatomical variances, bile duct injury, retained bile duct stones, and uncontrolled bleeding are all indications to convert to an open procedure. The need for a common bile duct exploration also can be a reason to convert to an open procedure, as laparoscopic bile duct exploration can be difficult. A planned open cholecystectomy may be performed in cases of cirrhosis, gallbladder cancer, extensive upper abdominal surgeries with adhesions, and other comorbid conditions (notably, diabetes melitis) [8][9][8]. Situations of critically ill patients also may necessitate the need for a planned open cholecystectomy, as an open procedure may be less stressful in critically ill patients, thereby avoiding the physiologic changes associated with a surgical pneumoperitoneum (e.g. decreased cardiac return and higher ventilation pressures).

Poor visualization and unclear anatomy are typically the reason to convert from laparoscopic to open procedure. Conversion to open cholecystectomy should not be viewed as a complication or a failure but just the opposite. It is showing good judgment to complete the operation in the safest manner possible.[10]

Contraindications

There are no contraindications in performing an open cholecystectomy versus laparoscopic cholecystectomy. However, the preferred method is to complete the procedure using the laparoscopic technique as this can be done outpatient and reduces the recovery time from several weeks to about one week. General contradictions for any surgery, in general, apply to open cholecystectomy. Severe comorbid conditions such as shock, advanced cardiac and respiratory disease, anticoagulation, a recent neurologic event, and other life-threatening ailments are relative contraindications to laparotomy. Additionally, if there is a concern for possible gallbladder cancer, resection should not proceed until a thorough workup has been completed, including potential depth of invasion and metastases[11].

Equipment

Surgeons work in an appropriate operating room and use a general anesthetic. They use standard laparotomy equipment. Fluoroscopy and cholangiogram catheters need to be available in case an intraoperative cholangiogram is needed. A colonoscope and instrumentation to perform a possible common bile duct exploration should also be available. Bile duct baskets, graspers, and Fogarty catheters are also required to do extractions of common bile duct stones. An array of T- tubes are also required if performing bile duct exploration. Often cultures are also done in cases of acute cholecystitis or obvious infections.

Self-retaining retractors, such as a Bookwalter, may be of some benefit depending on the operative setting. If a cholangiogram is needed, either a flat plate x-ray or C arm fluoroscopy is helpful. [12]

Personnel

An experienced surgeon who is comfortable performing open cholecystectomies is the most important person. In modern times, residents have less experience with open cholecystectomies than surgeons who trained before the 1990s[13]. A capable anesthesiologist is needed to administer the appropriate general anesthesia. An experienced first assistant is also needed. This is usually a senior surgery resident. A scrub technician and circulating nurse round out the personnel needed to complete an open cholecystectomy. In cases where an intraoperative cholangiogram is indicated, a radiology technician with fluoroscopy is also needed.

Preparation

A thorough diagnostic workup needs to be completed to make the diagnosis of gallbladder disease. This workup includes a gallbladder ultrasound and possibly, an abdominal CT scan, Hida scan, and blood work. The decision to perform a scheduled open cholecystectomy needs to be made by the surgeon. A laparoscopic procedure can always be converted to an open procedure if needed[14]. The surgeon must evaluate the risks versus the benefits before attempting a laparoscopic cholecystectomy. Patients must be hemodynamically stabilized and resuscitated if needed. Appropriate permits and information must be discussed with the patients, including all risks, benefits, and options. Standard pre-operative preparation, such as nothing by mouth, possible antibiotics, and deep vein thrombosis prophylaxis, must be instituted.

Part of the workup needs to include a thorough history and physical exam. Other specialties may be involved, such as gastroenterology or interventional radiology, to help in the workup and preparation in cases where preop endoscopic retrograde cholangiopancreatography or cholecystostomy tube is needed.

Technique or Treatment

Once the patient is appropriately anesthetized and prepped, a right subcostal (Kocher) incision or upper midline incision is made. Adequate exposure is gained by using packs and retractors. It is important to obtain good visualization of the gallbladder, triangle of Calot, and bile ducts. Care must be taken to avoid liver injury from the retractors. Once the surgeon has adequately identified all of the structures of the porta hepatis, the gallbladder is grasped with clamps and manipulated to facilitate the best visualization. The decision is made to remove the gallbladder from the top-down or classically from the triangle of Calot up. The cystic duct is first identified and divided between hemoclips, as is the cystic artery. Definitive identification of these structures is crucial. The gallbladder then can be removed from the gallbladder bed of the liver using either electrocautery or a harmonic scalpel. Inspection of the gallbladder bed is done to identify and address any bleeding or bile leaks from the duct of Luschka. Operative cholangiogram or common bile duct exploration is dependent on factors associated with common bile duct stones such as elevated bilirubin and dilated common bile duct (over 8 mm)[15]. The abdomen is then closed in a standard multilayer fashion.

There are times where the gallbladder is tense and distended from inflammation that may need to be drained with a decompression needle prior to starting the case. As in laparoscopy, the technique is based on surgeon experience and comfort. With either procedure, the surgeon should strive to gain an excellent critical view of safety before clipping or cutting. Some cases may present with a great deal of inflammation, or Hartmann's pouch is so fibrotic that "bailout" maneuvers are needed; these may consist of a cholecystostomy tube, partial cholecystectomy, or at times of necrosis leaving the back wall [16][17]. Closed suction drains can be placed at the discretion of the surgeon.[12]

Complications

When the procedure is done using an open technique, the implication is that it is not a typical cholecystectomy situation. Therefore, the complication rate associated is higher than a routine laparoscopic cholecystectomy (16% versus 9% in a recent study)[18][19]. Because the incision is larger than that required for laparoscopic surgery, there is a higher incidence of hernia formation, wound infection, and hematoma. Open surgery is usually more painful than a laparoscopic procedure. Bile leaks and bile duct injury, as well as retained bile duct stones, are all complications associated with this surgery.

There is typically an increased direct and indirect cost associated.  This is usually a reflection of the additional time the patient spends in the hospital. Also, the complication rate is higher and may result in issues requiring additional procedures and/or medication, especially if a bile duct injury occurred during the operation. The longer recovery time may keep people out of work for an extended period.[20]

Clinical Significance

Although the gold standard for gallbladder surgery is a laparoscopic cholecystectomy, it is imperative that surgeons are also comfortable doing open cholecystectomies. Certain conditions mandate a planned open technique as the initial surgery. However, in laparoscopic cases, the surgeon must be prepared to convert to the open technique during an operation.

There is no substitute for experience and using appropriate clinical judgment in tough cases. Preparation is key, and asking for help when the situation arises should not be forgotten or looked down upon. There is no substitute for safety. Residents should never pass up the chance to scrub an open chole. They are not very common anymore. The reason the case is open typically is preceded by some difficult issue that forces this technique.[21]

Enhancing Healthcare Team Outcomes

The standard treatment of choice for gallbladder disease is laparoscopic cholecystectomy. Complete knowledge of all cholecystectomy techniques and indications is mandatory for a competent surgeon. Being able to convert from laparoscopic surgery to an open technique is part of the modern surgeon's arsenal. Indications from gallbladder cancer to poor visualization to indistinguishable anatomy are all reasons to convert cases to open. Preoperative preparation will also allow the experienced surgeon to prepare for the possibility of conversion to an open technique. These possibilities must also be thoroughly discussed with each patient, along with all possible risks and outcomes.