Perioperative management - Cholecystectomy, open

Note: The laparoscopic cholecystectomy is considered the gold standard! Therefore, there must always be special reasons for an open procedure.

General Indications

• Symptomatic cholecystolithiasis
• Choledocholithiasis with or without biliary pancreatitis
• Cholecystitis
• Gallbladder empyema and gangrene
• Cystic duct obstruction
• Benign and malignant gallbladder tumors
• Mirizzi syndrome
• Chronic Salmonella carriers

Special Indications

• Extensive previous operations in the upper abdomen
• Unclear anatomical conditions
• Abscesses and larger empyemas
• Patients who, due to their condition, cannot tolerate a capnoperitoneum
• Choledocholithiasis that cannot be treated endoscopically
• Confirmed malignancy

Severe comorbidity is not a reason not to operate in the case of a vital indication.

• History: Colicky pains(> 15 minutes) in the right upper abdomen/epigastrium, jaundice and fever are among the leading symptoms of gallbladder and bile duct diseases.
• Clinical examination: Typical symptoms of acute cholecystitis are right-sided upper abdominal pains, Murphy's sign (localized pain over the gallbladder on direct pressure), elevated inflammatory markers and fever.
• Laboratory: CBC, CRP, transaminases, bilirubin, amylase, lipase, in case of suspicion of malignancy possibly tumor marker CA 19-9, before surgery if necessary coagulation, electrolytes, creatinine.
• Abdominal ultrasound examination: Detection of stones, wall thickening or triple layering of the gallbladder wall as well as sonographic-palpable Murphy's sign in acute cholecystitis.
• If there are no indications for choledocholithiasis (clinical, laboratory and ultrasound), further imaging can be dispensed with.
• An ERCP (endoscopic retrograde cholangiopancreatography) should only be performed with therapeutic intent. In case of doubt, precede with endosonography or MRCP.
• Endosonography has the highest sensitivity for the detection of stones in the CBD.
• CT, MRCP/MRI in case of unclear ultrasound findings or suspicion of tumor.
• Choledochoscopy only for specific questions, suspicion of malignancy or unclear findings, especially for clarification of bile duct pathologies.
• Gastroscopy, if the clinical picture is not clear and the complaints could also come from the stomach.

• In acute cholecystitis or choledocholithiasis: perioperative antibiotic therapy
• In elective cholecystectomy: Discontinuation of Metformin, switch from phenprocoumon to low-molecular-weight heparin
• Otherwise optional perioperative single-shot antibiotic prophylaxis

General: 

Thrombosis, Embolism, Pneumonia, Keloid formation, Scar hernias, Injury to skin nerves, Intolerance to medications, Wound infection, Secondary bleeding, Hematoma formation, Seroma

Specific: 

Injury to abdominal organs such as colon and small intestine, stomach, liver
Injury or severance of the draining bile ducts with their sometimes significant consequences
Possible lifelong change in dietary and bowel habits
Bile fistulas
Pancreatitis

Note: 

Injuries to the bile ducts are complications with significant morbidity and mortality.