Cholecystectomy, open

The preferred access route is the transverse upper abdominal laparotomy on the right. This incision can be extended to the left as desired. Before laparoscopic surgery could become established, the right subcostal incision (Kocher) (see image above) was traditionally recommended.
After cutting through the skin, the subcutaneous fatty tissue is sharply divided up to the anterior leaf of the rectus sheath. Then the fascia is opened and the rectus abdominis is transversely divided with diathermy. By using a Kocher retractor, which is bluntly pushed under the muscle, thermal injuries to dorsal structures can be avoided. In the lateral part of the incision, the M. obliquus externus, internus, and M. transversus abdominis are divided. The then exposed posterior rectus sheath / transversalis fascia is carefully opened together with the peritoneum, sparing intra-abdominal structures.

Note:

Pararectal incisions are obsolete.
The length of the incision always depends on the individual circumstances.
Never cut directly at the costal margin, as in this case not enough tissue is available for wound closure.
In case of an enlarged liver, the incision can also be made significantly more caudal.

After exploration of the abdomen, particularly in the area of Calot's triangle, if necessary, release of adhesions of the gallbladder, usually with the transverse colon and duodenum.
Then tension the gallbladder with the organ grasping forceps. If the gallbladder is too tautly filled, prior puncture may be necessary. Incise the serosa at the fundus close to the liver with normal scissors, scalpel, diathermy or bipolar scissors. Based on experience, thermal methods should be preferred here, as this significantly reduces the tendency to bleed (in the anterograde procedure, the gallbladder initially remains perfused, the blood supply - ligation of the cystic artery – is only interrupted at the end). Then the traction on the gallbladder is carefully increased, whereby the almost vessel-free layer between the gallbladder and liver becomes visible. Thus, the gallbladder can be mobilized from the liver bed with simultaneous transection of the serosa. In this process, attention must be paid to accessory small bile ducts, which occasionally run directly from the liver into the gallbladder and must be ligated separately.

Note: 

Nowadays, in open gallbladder surgery, anterograde cholecystectomy, preparation from the fundus toward the hepatoduodenal ligament, is preferred. This is mainly because this type of preparation offers advantages in unclear anatomy and initially unidentifiable structures in the area of Calot's triangle, as long as one moves strictly along the gallbladder wall. Disadvantage: The tendency to bleed is higher, since the artery is not yet ligated.

Exposure of the cystic artery in Calot's triangle (bile duct – inferior liver surface – cystic neck). Division with the aid of Overholt clamps. Simple ligation with absorbable material e.g. Vicryl 2-0.

Note: 

The cystic artery usually arises from the right branch of the proper hepatic artery. There are relatively many anatomical variants, so that an accidental ligation of the right branch can occur. For this reason, the cystic artery must absolutely be identified directly at the gallbladder and, in case of doubt, traced centrally until the anatomy is clear.