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GALLSTONES
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We prefer to encourage trainees to perform all the initial dissection around
the cystic duct and artery without diathermy as this rarely causes bleeding and
prevents inadvertent cautery injury. It is often stated that Calot’s triangle
should be displayed but the popular description of this triangle is erroneous
(Rocko et al ., 1981 ). Jean-Francis Calot’s triangle was described by him (in
translation ‘The triangle is not exactly equilateral: the superior and inferior
sides, represented by the cystic duct, are equal and slightly longer than the side
of the triangle made up by the hepatic duct’) in his doctoral thesis ‘De la chole-
cystectomie’ submitted to the University of Paris in 1891 (Calot, 1891 ). It is the
triangle bounded by the cystic duct, common hepatic duct, and cystic artery.
To say this area should be displayed also suggests that the bile duct should
always be visualized, which is unnecessary and potentially dangerous. It is a
definition which is less useful in the laparoscopic era than the ‘cholecstectomy
triangle’. This is really the quadrangle defined by the by the gallbladder, cystic
duct, bile duct, and the inferior surface of the liver, but with traction becomes
triangular. The important manoeuvre is widely opening the space above
the gallbladder and below the liver to ensure that there are no additional or
aberrant structures.
We prefer to do this by keeping as close to the gallbladder wall as possible
and will separate about half the gallbladder from its bed before we consider it
is safe to address the cystic duct and artery ( Figs. 4.3 and 4.4 ).
Fig. 4.2 Peritoneum between liver and cystic duct incised.
GALLBLADDER
214
Fig. 4.3 Dissection without diathermy is used initially to define the space.
Fig. 4.4 Once cystic artery and duct are clearly seen, diathermy can be used with care.
GALLSTONES
215
The dissection of the gallbladder can safely be done with a diathermy hook
pulling tissue away from the gallbladder before diathermy is applied to prevent
damage to the wall with the potential for spillage of bile or stones. When the
space is widely opened, the cystic artery and cystic duct are further dissected in
preparation for clipping. It is at this point during the dissection that confusion
may arise and certain rules must be followed.
The most important thing is to have a strategy that enables the operator to
realize that the anatomy is abnormal and then define it rather than try and
memorize all the possible variations and have separate approaches for them.
◆
Abnormally large structures should always be treated with caution and
must not be ligated until the anatomy is clear
◆
‘Aberrant or accessory’ structures do occur but structures diffi cult to iden-
tify or in unusual positions generally turn out to be neither and usually
mean that the anatomy has been misinterpreted
◆
A very short cystic duct (or ‘apparently’ very short cystic duct) is an indica-
tion to convert to open surgery
◆
Inability to clearly defi ne the anatomy or open the space below the liver is
an indication for open surgery
◆
Confusing biliary anatomy can usually be clarifi ed by continuing the gall-
bladder dissection laterally or adopting a fundus fi rst approach (which may
require an extra port for counter traction). Biliary anatomy can usually be
delineated when the gallbladder is completely free even if rare variations
such as a cystic duct draining to the right hepatic duct or the gallbladder
being a diverticulum of the right hepatic duct are present ( Fig. 4.5 ).
Using this approach, injuries are avoided and although conversion to open
operation may be necessary occasionally, it is a very safe approach. When the
anatomy is defined and the operator is confident that the cystic artery and duct
are sufficiently well mobilized, then we initially ligate the cystic artery with two
metal clips proximally and one distally and then divide it ( Fig. 4.6 ).
This allows further dissection of this and ensures that the area between the
cystic duct, infundibulum of the gallbladder, and the inferior surface of the
liver is very widely displayed. Only at this point do we divide the cystic duct,
placing two metal clips and one or two lockable absorbable clips proximally
(depending on the length of the duct that can be safely displayed) and a metal
clip distally ( Fig. 4.6 ). The procedure is completed by removing the gallbladder
from the gallbladder bed with a diathermy hook ( Fig. 4.7 ).
This is done as far as possible with a ‘hooking motion’ lifting the peritoneum
upwards before activating the diathermy rather than the use of the back of the
hook which frequently results in perforation of the gallbladder and consequent
GALLBLADDER
216
Fig. 4.5 a) Abnormal right hepatic duct giving origin to the gallbladder. b) Right
sectoral duct entering the gall bladder c) Short cystic duct.
Fig. 4.6 Cystic duct clipped with a proximal locking clip on the duct and three metal
clips on the artery (two proximally and one distally).
contamination from spillage of the contents ( Fig. 4.7 ). Accessory bile ducts
which, although uncommon, do occur can result in significant intra-abdomi-
nal biliary leakage and should always be clipped with a single metal clip.
The gallbladder is removed through the epigastric port (or an enlarged
umbilical port for a gallbladder full of stones). We use a retrieval bag if the
gallbladder is abnormally friable or has been perforated during dissection.
GALLSTONES
217
If desired it is reasonable to leave a small suction drain for the rest of the day
(or overnight if the patient stays in hospital) and then removing it, if it
contains no bile.
Open cholecystectomy ( Figs. 4.8 – 4.12 )
Open cholecystectomy remains a valuable procedure as an element in hepato-
biliary surgery. It may be mandated during a conversion of a laparoscopic
procedure or indicated by preoperative assessment which suggests additional
problems, particularly gallbladder pathology. While debate continues about
whether the better routine method is a fundus first approach or a pro-grade
dissection of the cholecystectomy triangle, the arguments are now somewhat
anachronistic. They developed in an era when long-standing gallstone disease
had produced advanced local disease and even routine open cholecystectomy
could be hazardous. Of course these cases still occur today and are responsible
for many of the laparoscopic cholecystectomies which have to be converted to
an open procedure. Conversion is frequently associated with abnormal anat-
omy (when biliary and vascular anomalies are both included only 40% of
patients can be described as having classical anatomy) or additional pathology,
either the suspicion of malignancy or dense fibrosis around the cystic duct. In
addition it should be remembered that a number of the better known and
described anomalies occur with the frequency of about 1 in 10 (see Fig. 3.12)
Fig. 4.7 Gall bladder dissected free from the liver with diathermy and removed (in
retrieval bag if necessary).
GALLBLADDER
218
(Healey and Schroy, 1953 ; Couinaud, 1957 ). An additional advantage that
accompanies an open procedure is the ability to open the gallbladder and
determine the anatomy (particularly of the cystic duct and bile duct conflu-
ence) safely from within the lumen of the gallbladder ( Fig. 4.10 ).
We employ an 8–10cm transverse incision ideally placed in the skin crease.
A larger incision may be needed in an obese patient and previous incisions for
upper abdominal surgery have to be considered and ‘tram-lining’ must be
avoided. After dividing any adhesions and identifying the gallbladder, hepa-
toduodenal ligaments, and duodenum, the small bowel and transverse colon
are packed away below the lower incision ( Fig. 4.8 ) and an appropriate self-
retaining retractor (such as a Goligher retractor with unequal blades so that
the smaller one can be employed to hold the wound superiorly and the larger
one the wound and packed off bowel inferiorly) or a second assistant should be
used to ensure an adequate exposure.
Irrespective of the approach adopted, dissection must always be performed
on the wall of the gallbladder. Straying from the wall is by far the most com-
mon cause of an injury. If the gallbladder and surrounding tissue are so
Fig. 4.8 Successful open cholecystectomy relies on excellent retraction. Medial and
inferior packing together with the retraction is vital. An assistant is always helpful.
GALLSTONES
219
diseased and fibrotic that identification of the plane is difficult, then the
approach must be altered until a starting point can be identified. If the plane
appears to be genuinely obliterated and no obvious perforation of the gallblad-
der (particularly into the liver) has occurred, then one should be suspicious of
xanthogranulomatous cholecystitis or gallbladder carcinoma, and the approach
changed.
In the usual circumstance with minimal to moderate gallbladder disease,
we prefer to begin the dissection by identifying and entering Calot’s triangle
and then developing this exposure to enter the cholecystectomy quadrangle
proper. During this dissection, the gallbladder is held with a suitable large
clip or sponge-holding forceps above the neck. While this allows tension
which aids dissection, it also produces distortion which must be considered
particularly during dissection of the cystic duct near its confluence with the
bile duct.
No attempt should be made to mobilize the bile duct and dissection contin-
ues towards the liver keeping strictly on the gallbladder wall. We develop this
space (the cholecystectomy triangle) until the cystic artery is clearly identified,
and as in laparoscopic cholecystectomy, approximately half of the gallbladder
has been freed from the liver. Any bleeding at this stage must not be handled
blindly. Usually with suction and adequate exposure it is possible to identify
the source and allow it to be accurately addressed. If this is not possible, then a
Pringle manoeuvre ( Fig. 4.9 ) applied with fingers may reduce the bleeding and
allow the vessel to be identified and ligated or sutured with a small 4/0 or 5/0
suture (Pringle, 1908 ).
The bleeding area must never be under-run blindly. Damage to the bile duct
or common hepatic artery is then highly likely.
This style of dissection produces a very widely opened area but if any addi-
tional tubular structures are identified at this stage they should not be divided
but the procedure recommenced at the fundus. If this is necessary, the fundus
is grasped with a clamp and the peritoneum incised 5–10mm away from
its reflection onto the liver (this leaves a small cuff which can be usefully
approximated if necessary) with scissors. The peritoneum at the liver bed is
then held with a small clip and the gallbladder removed by dissection in this
plane. The two planes of dissection generally meet without incident and the
‘tubular structure’ can clearly be seen to be a very small accessory artery or bile
duct, or simply fibrous tissue, which can be safely divided. If this is not the case
then the anatomy can be clearly defined and the variant recognized so that the
most appropriate approach can be adopted.
We do not routinely employ cholangiography unless there are preoperative
indications (dilated CBD on ultrasound, pancreatitis, abnormal liver function
GALLBLADDER
220
tests, or known CBD pathology from MRCP), however when the anatomy is
unclear it is essential (Metcalfe et al ., 2004 ). The cystic duct is ligated as close
to the gallbladder as possible and the catheter (e.g. on umbilical vein catheter)
inserted through a small transverse incision ( Fig. 4.12 ). When the main right
and left hepatic ducts have been identified and there is no communication
with the ‘accessory tubular structure’ it can generally be safely divided. If it is
of significant calibre (> 2mm) additional cholangiography (using a Chevasseau
catheter which is wedged in to the orifice of the duct demonstrated by opening
the gallbladder) to exclude an aberrant sectoral duct is justified.
Occasionally when the cystic duct and bile duct junction is obscured
then dissection in this area is abandoned. The gallbladder should be opened,
a bile swab sent for culture (and antibiotics given), all stones removed,
and anatomy defined from within. This often allows the junction to be identi-
fied by showing where the wall of the gallbladder lies but if necessary, the
proximal centimetre or two of the gallbladder can be left in situ ( Figs. 4.10
and 4.11 ).
Fig. 4.9 A digital Pringle manoeuvre helps identify a bleeding point. Blind suture
must never be used.
GALLSTONES
221
Fig. 4.10 Digital examination of the gallbladder lumen often helps to determine the
position of the cystic duct.
Fig. 4.11 The gallbladder can be subtotally resected and the remnant treated by
adequate drainage.
GALLBLADDER
222
Most authors advocate simple drainage at this point postulating that the
cystic duct must be obliterated and that this is safer than trying to suture any
visible orifice, which may produce a ‘closed system’. This certainly does occur
depending on the exact anatomy of the junction between the cystic duct and
bile duct but is much more likely if the procedure produces a large remnant
due to an unrecognized very low insertion of the cystic duct.
With the biliary and arterial anatomy defined, the cystic artery is ligated and
divided and a final check of any residual tissue around the cystic duct made to
ensure that there is sufficient length for safe ligation.
The cystic duct is then ligated proximally and distally and divided and the
residual stump transfixed beyond the ligature (standard practice when dealing
with bile ducts to prevent bile leakage from the stitch holes). The gallbladder is
dissected free from the liver with diathermy and removed, the gallbladder bed
is checked for haemostasis, and after insertion of a small suction drain (which
is removed the following day) the wound is closed.
Possible bile duct stones ( Fig. 4.13 )
In patients who appear to be intermittently passing calculi, either from docu-
mented abnormalities of liver function or pancreatitis, the initial investigations
Fig. 4.12 Cholangiography is used selectively.