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Surgical Approach
Laparoscopic cholecystectomy is performed under general
anesthesia with the patient in supine position (Table 1).
Access to the abdomen is generally obtained inferior to the
umbilicus via open Hassan or closed Veress needle
technique. Pneumoperitoneum is established and a 30degree laparoscope inserted. Two additional operating
ports are inserted in the RUQ and one in the subxiphoid
epigastrium. Reverse Trendelenburg and tilting the
operating table to the patient’s left facilitate displacement
of the small bowel and omentum out of the operative field.
The fundus of the gallbladder is grasped and retracted
cephalad over the edge of the liver via the lateral subcostal
port. A thick-walled, tightly distended or hydropic
gallbladder may be extremely difficult to grasp. Needle
aspiration of gallbladder contents facilitates grasping the
gallbladder for retraction. The remainder of the operation is
conducted through the subxiphoid and medial right
subcostal ports. Any adhesions to the gallbladder are taken
down to reveal the triangle of Calot. The infundibulum is
retracted laterally to open the triangle, separating the cystic
duct from the common hepatic duct. The overlying
peritoneum is incised and the triangle of Calot is cleared of
soft tissue. Dissection continues until the cystic duct and
artery are the only remaining structures in the triangle and
can be seen di rectly entering the gallbladder. This
constitutes the “critical view of safety” (Figure 5). Opening
the peritoneal reflections over the gallbladder and elevating
the distal gallbladder off of the liver with electrocautery may
facilitate this portion of the operation. This technique is
particularly helpful in the setting of acute cholecystitis with
dense inflammation of the gallbladder and surrounding
structures. Once the critical view of safety is achieved, the
cystic duct and artery are doubly clipped and divided. The
gallbladder is di ssected off of the liver with electrocautery,
placed into a specimen bag, and removed from the
abdomen. After hemostasis is assured,
pneumoperitoneum is released, all port sites are closed,
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and the patient is allowed to emerge from anesthesia.
TABLE 1. Key Technical Steps and Potential Pitfalls in Laparoscopic
Cholecystectomy
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FIGURE 5 • The critical view of safety. The triangle of Calot has been neatly
cleared of all tissue except the cys tic artery and cystic duct. These two
remaining structures are seen directly entering the gallbladder and may be
safely divided. (From Mulholland, M., Greenfield’s Surgery, 5th ed.
Lippincott Williams & Wilkins, 2011)
Special Intraoperative Considerations
Approximately 10% of attempts at laparoscopic
cholecystectomy for acute cholecystitis result in conversion
to an open operation. The primary indication for conversion
is an inability to clearly define the anatomy of the biliary
tract. Failure to establish the critical view of safety
mandates conversion. Other indications include significant
inflammation, failure to make satisfactory progress, any
suspicion of injury to ductal or vascular structures, and
concern for gallbladder cancer (Table 2).
TABLE 2. Indications for Conversion to Open
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Intraoperative cholangiography (IOC) may be used
routinely in cholecystectomy or reserved for select
circumstances (Table 3). Direct imaging of the biliary tree
may demonstrate choledocholithi asis in patients suspected
of having common duct stones due to biliary dilatation,
elevated liver enzymes, or pancreatitis (Figure 6). Stones
may be removed via CBD exploration or ERCP, either
during the operation or postoperatively. Additionally, IOC
may aid in delineating bi liary anatomy or identification of
biliary injury.
TABLE 3. Indications for Intraoperative Cholangiogram
FIGURE 6 • IOC with choledocholithiasis. This intraoperative
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cholangiogram revealed stones stacked within the CBD.
Patients with severe inflammation pose a particular
challenge. Needle decompression of a tense gallbladder
allows for more effective retraction. IOC may be necessary
to define ductal anatomy. Occasionally, it is not possible to
definitively attain the critical view of safety due to unclear
anatomy or inflammation, which would render further
dissection unsafe. Frequently in these circumstances, the
operation may be safely completed with conversion to
open. In select cases, however, the patient may be better
served with a partial cholecystectomy. The gallbladder is
elevated off of the liver bed starting proximally with the
fundus. It is then transected at the level of the gallbladder
neck or infundibulum without complete dissection of the
triangle of Calot. Remaining stones can then be removed
through the gallbladder lumen. The distal gallbladder can
then be oversewn with absorbable suture. Drains should be
left in place, given the risk of a bile leak from the oversewn
gallbladder. If partial cholecystectomy is performed, care
must be taken to remove almost all of the gallbladder and
any remaining stones. Otherwise, the patient could develop
recurrent cholecystitis. If this approach is also ill-advised
due to severe inflammation and/or anatomical distortion, a
cholecystostomy tube may be placed laparoscopically.
Prior abdominal operations are not an absolute
contraindication to an attempt at laparoscopic
cholecystectomy, but may necessitate deviation from
standard port placement. The initial access to the abdomen
should be obtained in a location remote from prior
operations where possible to minimize the risk of visceral
injury. The left subcostal region is often an excellent
location. In cases where this is not practical, an open
approach to placement of the first port allows direct
visualization of any adhesion to the abdominal wall.
Alternate port placement may also be considered in
patients with indwelling mesh from a prior herniorrhaphy.
The camera port and the right subcostal ports may often be
placed lateral and superior to the anticipated margins of
the mesh. Placing a port directly through indwelling
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synthetic mesh is technically possible but carries a risk of
contamination of the prosthetic and subsequent infection,
and may compromise the integrity of the hernia repair.
While laparoscopic cholecystectomy is technically possible
in many patients with prior abdominal surgery, primary
open cholecystectomy must also be considered. The
ultimate choice of surgical approach must be tailored to the
individual.
Postoperative Management
Most patients with acute cholecystitis are able to return
home the day after laparoscopic cholecystectomy. Regular
diet may be resumed immediately after surgery, and oral
pain medications usually provide ample analgesia.
Antibiotics are not indicated beyond the immediate
perioperative period. Some patients experience diarrhea
associated with altered bile salt storage after
cholecystectomy, but this is typically mild and temporary.
Persistent abdominal pain, fever, or hyperbilirubinemia
should prompt evaluation for retained CBD stone, biliary
leak, or biliary injury. US should be the initial imaging study
as it noninvasively demonstrates biliary dilation and fluid
collections. Similar information may be derived from
abdominal CT. Biliary dilation should be further evaluated
with ERCP to identify a retained CBD stone or biliary injury
causing obstruction. D uring the same procedure,
interventions such as stent placement, stone extraction, or
sphincterotomy may be accomplished (F ig u r e 7).
Postoperative fluid collections may represent hematoma,
biloma, or abscess. Percutaneous CT- or US-guided drain
placement allows for adequate drainage of the collection
as well as identification of its source. Return of bilious fluid
should prompt ERCP to pinpoint the leak. During ERCP,
an endobiliary stent may then be placed to encourage bile
flow through the biliary tree into the duodenum rather than
into the peritoneum.
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FIGURE 7 • ERCP with bile leak. Postoperative ERCP demonstrating a
cys tic duct stump leak. A wire is seen within the common hepatic duct,
which traverses the CBD and terminates in the duodenum. A stent is
placed across this wire to encourage bile flow into the duodenum rather
than through the leak.
Case Conclusion
The patient underwent laparoscopic cholecystectomy
for acute cholecystitis. Despite residual adhesions from
the patient‘s right hemicolectomy, the critical view is
achieved and the operation completed
laparoscopically. The patient recovers without incident
and is discharged on postoperative day 1. On
postoperative day 4, she returns to the ER with fever,
increasing abdominal pain, leukocytosis, and
hyperbilirubinemia. She is admitted to the hospital and
treated with antibiotics. US demonstrates a fluid
collection in the gallbladder fossa. A percutaneous
drain is placed with return of bilious fluid. ERCP
identifies a cystic duct stump leak, and a biliary stent is
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inserted endoscopically (Figure 7). The patient‘s
condition improves and she returns home 2 days later.
The volume of drain output decreases over the course
of several weeks, and the drain is subsequently
removed. The patient suffers no further complications
and no recurrence of her biliary symptoms.
TAKE HOME POINTS
Acute cholecystitis presents with RUQ pain, fever,
and leukocytosis.
RUQ ultrasound is the first-line diagnostic test.
Acute cholecystitis must be distinguished from other
biliary pathology such as biliary colic,
choledocholithiasis, cholangitis, or biliary
pancreatitis.
Urgent laparoscopic cholecystectomy is the treatment
of choi ce for most patients, even those presenting
after 72 hours.
During laparoscopic cholecystectomy, no structures
should be divided until the critical view of safety is
established.
Inability to achieve the critical view of safety
mandates conversion to open operation.
Intraoperative cholangiogram may be useful in
defining the patient’s biliary anatomy and identifying
choledocholithiasis or biliary injury.
Persistent postoperative pain, fever, or
hyperbilirubinemia are concerning for retained CBD
stone or biliary leak.
SUGGESTED READINGS
Csikesz N, Ricciardi R, Tseng JF, et al. Current status of surgical
management of acute cholecystitis in the United States. World J Surg.
2008;32(10):2230–2236.
Gurusamy KS, Samraj K. Early versus delayed laparoscopic
cholecystectomy for acute cholecystitis. Cochrane Database Sys t Rev.
2006;(4):CD005440.
Strasberg SM. Clinical practice. Acute calculous cholecys titis. N Engl J
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Med. 2008;358(26):2804–2811.
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24
Bile Duct Injury
CHRISTOPHER J. SONNENDAY
Presentation
A 38-year-old woman presents to the emergency room
with right upper-quadrant pain, nausea, emesis, and
subjective fever. She underwent a laparoscopic
cholecystectomy 4 days ago for acute cholecystitis.
Past medical history is notable for obesity and two
uncomplicated pregnancies.
On physical exam, the patient appears uncomfortable
and diaphoretic. She is alert and oriented. Vital signs
are notable for a temperature of 38.7°C, pulse of 110
beats per minute, blood pressure of 130/80, respiratory
rate of 18, and an oxygen saturation of 99%. Her
sclerae are anicteric. The abdomen is mildly distended
with diffuse tenderness to light palpation, and more
focal tenderness in the right upper quadrant. Her
laparoscopic port site incisions are dry and intact
without erythema or induration.
Differential Diagnosis
Abdominal pain following laparoscopic cholecystectomy,
particularly pain significant enough to require an
emergency room evaluation, should immediately prompt
evaluation for technical complications of the procedure.
Postoperative pain following laparoscopic
cholecystectomy, now often accomplished as an outpatient
operation, is generally moderate and should improve each
subsequent postoperative day. It is unusual for otherwise
healthy patients to require narcotic analgesics after the first
3 to 5 postoperative days. Patients who do not follow this
expected course should be evaluated thoroughly, as early
recognition and treatment of postcholecystectomy
complications are paramount to limiting the impact of these
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