Cholecystectomy, open

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  • Anatomy

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    General anatomy

    The bile duct drains bile from the liver into the duodenum. This way, bile aids in the digestion of lipids in the food. The intrahepatic biliary tract comprises the right and left hepatic duct (ductus hepaticus dexter et sinister) which descend from the liver. Their union forms the common hepatic duct (ductus hepaticus communis). Along its course to the duodenum it is joined by the cystic duct (ductus cysticus) from the gallbladder (vesica biliaris). The union of the common hepatic duct and the cystic duct forms the common bile duct (ductus choledochus) which drains into the duodenum. The major duodenal papilla (papilla of Vater) is a sphincter muscle controlling the bile flow from the common bile duct into the duodenum.

    Specific anatomy

    In 75% of cases, the sole arterial blood supply for the gallbladder is a single cystic artery, arising from the right hepatic artery which courses posterior to the right hepatic duct (see figure above). In all other cases, the cystic artery arises from other branches of the hepatic arteries, and even the gastroduodenal artery, and courses anterior to the common hepatic duct, or the gallbladder is supplied by several arterial branches. Many times, hemorrhage obscuring the view of the surgical field can be controlled by compressing the hepatic artery within the hepatoduodenal ligament or by clamping of the hepatic pedicle (Pringle maneuver). Persistent bleeding may be indicative of an accessory hepatic artery arising from the superior mesenteric artery!

    While anomalies of the cystic duct are less common than vascular variants, their impact in terms of injuries to the common bile duct is more severe. The cystic duct may join the biliary tree at any point, including the duodenal papilla. Therefore, the length of the cystic duct may vary significantly, from being very short to complete absence, and it may spiral anterior or posterior to the common hepatic duct or may even share a common wall (duplicated common bile duct). In addition, accessory bile ducts from the liver may drain into the cystic duct, gallbladder or right hepatic duct. Whenever the anatomy of the cystic duct is in doubt, there is always the option of opening the gallbladder and probing the cystic duct from within the gallbladder. Option: In case of doubt perform intraoperative cholangiography!

    Injuries of the common bile duct are mostly due to anatomic anomalies or disease-induced tissue changes. Excessive traction on the cystic duct may result in knuckling of the common duct and applying the forceps too low, thereby catching and ligating part of the edge of the common duct. This will result in stenosis or even complete transection of the common duct.

  • General anatomy

    The bile duct drains bile from the liver into the duodenum. This way, bile aids in the digestion of lipids in the food. The intrahepatic biliary tract comprises the right and left hepatic duct (ductus hepaticus dexter et sinister) which descend from the liver. Their union forms the common hepatic duct (ductus hepaticus communis). Along its course to the duodenum it is joined by the cystic duct (ductus cysticus) from the gallbladder (vesica biliaris). The union of the common hepatic duct and the cystic duct forms the common bile duct (ductus choledochus) which drains into the duodenum. The major duodenal papilla (papilla of Vater) is a sphincter muscle controlling the bile flow from the common bile duct into the duodenum.

  • Specific anatomy

    In 75% of cases, the sole arterial blood supply for the gallbladder is a single cystic artery, arising from the right hepatic artery which courses posterior to the right hepatic duct (see figure above). In all other cases, the cystic artery arises from other branches of the hepatic arteries, and even the gastroduodenal artery, and courses anterior to the common hepatic duct, or the gallbladder is supplied by several arterial branches. Many times, hemorrhage obscuring the view of the surgical field can be controlled by compressing the hepatic artery within the hepatoduodenal ligament or by clamping of the hepatic pedicle (Pringle maneuver). Persistent bleeding may be indicative of an accessory hepatic artery arising from the superior mesenteric artery!

    While anomalies of the cystic duct are less common than vascular variants, their impact in terms of injuries to the common bile duct is more severe. The cystic duct may join the biliary tree at any point, including the duodenal papilla. Therefore, the length of the cystic duct may vary significantly, from being very short to complete absence, and it may spiral anterior or posterior to the common hepatic duct or may even share a common wall (duplicated common bile duct). In addition, accessory bile ducts from the liver may drain into the cystic duct, gallbladder or right hepatic duct. Whenever the anatomy of the cystic duct is in doubt, there is always the option of opening the gallbladder and probing the cystic duct from within the gallbladder. Option: In case of doubt perform intraoperative cholangiography!

    Injuries of the common bile duct are mostly due to anatomic anomalies or disease-induced tissue changes. Excessive traction on the cystic duct may result in knuckling of the common duct and applying the forceps too low, thereby catching and ligating part of the edge of the common duct. This will result in stenosis or even complete transection of the common duct.

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  • Indication

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  • Contraindication

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  • Preoperative diagnostic work-up

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  • Specific preparation

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  • Informed consent

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  • Anesthesia

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  • Positioning

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  • Operating room setup

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  • Special instruments and fixation systems

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  • Postoperative management

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date of publication: 23.01.2012
  • Klinikum Merheim

    Dr. Johannes Volland

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  • Access

    104-4

    The preferred access is an upper transverse incision. Whenever needed the incision may be extended to the left as far as necessary. Before laparoscopic cholecystectomy became the gold standard, the recommended access was the right oblique subcostal (Kocher) incision (se figure above).

    Following the skin incision, sharply take down the subcutaneous tissue to the anterior lamina of the rectus sheath. Open up the fascia and transversely transect the rectus abdominis by electrocautery. Bluntly running a Kocher guide probe under the rectus abdominis helps prevent thermal injuries to the posterior structures. Transect the external and internal oblique muscles and the transversus abdominis at the lateral part of the incision. Carefully open up the exposed posterior rectus sheath/transverse fascia together with the peritoneum, sparing the intraabdominal structures.

    Note:

    Pararectal incisions are obsolete.

    The length of the incision depends on the patient’s individual situation.

    Never transect along the costal arch because this will not leave enough tissue for proper wound closure.

    In case of a markedly enlarged liver make the incision markedly more inferior.

  • Exploration, subserous antegrade resection of the gallbladder

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    After exploring the abdomen, particularly the hepatocystic (Calot) triangle, take down any adhesions of the gallbladder, mostly with the transverse colon and duodenum.

    Now put traction on the gallbladder with the organ holding forceps. In case of a tense gallbladder, initial needle aspiration may be indicated. With standard scissors, scalpel, electrocautery or bipolar scissors incise the serosa at the fundus close to the liver. From experience electrocautery is the modality of choice here because it substantially reduces any tendency for bleeding (in antegrade resection the blood supply of the gallbladder is intact until the arterial blood supply is finally obstructed by ligation of the cystic artery) Gently increased traction on the gallbladder will expose the almost avascular plane between the gallbladder and liver. Keeping up this traction while transecting the serosa will mobilize the gallbladder from the liver bed. Care should be taken not to injure small accessory bile ducts, which sometimes course directly from the liver to the gallbladder and must be ligated separately.

    Note: Open gallbladder surgery today prefers antegrade cholecystectomy, i.e., dissecting from the fundus toward the hepatic pedicle. The reason for this is that in unclear anatomy with initially unidentifiable structures in Calot’s triangle, this type of exposure offers safety if the dissection strictly adheres to the wall of the gallbladder. Drawback: More pronounced bleeding tendency, since the artery has not been ligated yet.

  • Cystic artery ligation

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    Expose the artery in Calot’s triangle (bile duct – inferior liver aspect – gallbladder neck). Transect the artery between Overholt forceps. Simple ligature with absorbable material, e.g., Vicryl 3/0.

    Note: Usually, the cystic artery originates from the right branch of the hepatic artery proper. Since there are any number of anatomical variants, iatrogenic ligation of the right branch is possible. For this reason, the cystic artery must always be identified directly at the gallbladder, and in case of doubt followed medially until the anatomy has become evident.

  • Ligation of the cystic duct

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    Expose the cystic duct together with the cystic artery in Calot’s triangle. At this point the anatomy must behave become crystal clear! The duct must be clearly exposed from the neck of the gallbladder until its union with the common bile duct. To prevent any leakage of the cystic duct stump, double ligate it with an extended absorption monofilament suture, e.g., PDS 3/0, employing a suture ligature together with a simple ligature.

    Note: Since the cystic duct has numerous known anomalies, here, too, the iron-clad rule must be to clearly identify the anatomy before transecting the cystic duct. Leave a long enough stump for the cystic duct (0.5 cm) which will 1. prevent any stenosis of the common duct, and 2. ensure a secure ligature. Furthermore, if the stump is long enough this permits cholangiography without any significant risks.

  • Checking for any bleeding

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    Mild oozing can be stopped by electrocautery; however, often it is enough to apply brief compression with a moist abdominal pack. Persistent bleeding from individual visible vessels calls for directed suture ligation; in case of diffuse persistent bleeding, coagulation may be achieved with a hemostatic agent. Suturing the liver bed with deep bites or use of an argon beamer is rarely called for.

    For the final check of the liver bed push a white sponge against it. To rule out bile leakage, check the sponge for any bile-like discoloration.

    Whether to drain is left to the surgeon.

  • Wound closure

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    Close the abdominal wall with a running suture PDS 2 encompassing the fascia, transverse fascia and peritoneum. Spare the muscle as much as possible because otherwise this will only result in muscular necrosis and subsequent infections. After optional closure of the subcutaneous layer with, e.g. Vicryl 2/0, close the skin. For this we recommend a rapidly absorbable subdermal running suture with, e.g., Monocryl 4/0. Optionally, close the skin with a standard subcuticular suture, interrupted sutures or skin staples.

    As a final step, the surgeon should open the gallbladder and inspect it for anatomical anomalies!

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  • Intraoperative complications

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  • Postoperative complications

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