Evidence - Cholecystectomy, open

  1. Literature summary

    Several international consensus conferences have defined laparoscopic cholecystectomy as the gold standard in symptomatic cholecystolithiasis. Currently, most surgeons explore all patients this way, leaving themselves the option of converting to open surgery.

    The current meta-analysis of randomized trials comparing both techniques demonstrates identical complication rates for laparoscopic cholecystectomy, with a mean shortening of the hospital stay of 3 days and the recovery of 3 weeks. This is also reflected by cost analyses which saw 18% lower inpatient costs for laparoscopic cholecystectomy compared with open cholecystectomy. And the comparison of the current complication rates with historic figures favors laparoscopic over open cholecystectomy as well (biliary leakage 0.4 – 1.5%, wound infection 1.3 – 1.8%, pancreatitis 0.3%, bleeding 0.2 – 1.4%).

    While in 1996 an extensive meta-analysis still saw a tendency toward higher rates of bile duct injuries, today the rate of bile duct injuries in cholecystectomy is low (0.2 – 0.4%), irrespective of the surgical technique.

    In manifest portal hypertension and cirrhosis of the liver Child A/B, laparoscopic cholecystectomy may be superior to the open procedure, while for Child C patients – but possibly also for patients with a MELD score of 8 – the complication rate in cholecystectomy is rather high.

    In case of strongly suspected (advanced) gallbladder cancer, the primary procedure of choice should be open cholecystectomy.

    If the presence of a Mirizzi syndrome has been confirmed preoperatively, this does not constitute a contraindication for the laparoscopic procedure; however, particularly when dealing with Mirizzi II (fistula between gallbladder and hepatic duct), the surgeon should readily convert to open surgery.

    The randomized trials comparing laparoscopic cholecystectomy and minilaparotomy cholecystectomy (laparotomy incision < 8 cm) did not find any differences between both techniques regarding complication rate, length of hospital stay and length of recovery. Access in open cholecystectomy is via the standard right oblique subcostal (Kocher) incision or right upper transverse incision.

    In patients with very wide thoracic aperture, i.e., particularly in men, a somewhat superiorly convex transverse incision is recommended.

    The upper transverse incision offers the following benefits compared with the right oblique subcostal access: Nerves remain (almost) completely untouched; the incision may be extended to the left at any time.

    Sometimes the gallbladder is so heavily adherent to the liver bed because of chronic inflammation, that complete resection cannot avoid injury to the hepatic parenchyma. In these cases, it is recommended to leave the posterior wall in the liver bed and coagulate the remaining mucosa with the electrocautery.

    Once the anatomical situation in Calot’s triangle has been clarified completely, subserous retrograde resection of the gallbladder from the liver bed is recommended. Antegrade resection toward the infundibulum should be reserved for special cases, since this technique increases the intraoperative complication rate.

    It is not necessary to suture the liver bed.

  2. References

    Pre-incisional analgesia with intravenous or subcutaneous infiltration of ketamine reduces postoperative pain in patients after open cholecystectomy: a randomized, double-blind, placebo-controlled study. Safavi M, Honarmand A, Nematollahy Z. Pain Med. 2011 Sep;12(9):1418-26. doi: 10.1111/j.1526-4637.2011.01205.×. Epub 2011 Aug 3

    What necessitates the conversion to open cholecystectomy? A retrospective analysis of 5164 consecutive laparoscopic operations. Genc V, Sulaimanov M, Cipe G, Basceken SI, Erverdi N, Gurel M, Aras N, Hazinedaroglu SM. Clinics (Sao Paulo). 2011;66(3):417-20.

    Open mini-invasive cholecystectomy in high risk elderly. A review of 121 consecutive procedures.

    Amato G, Salamone G, Romano G, Agrusa A, Saladino V, Gulotta G. G Chir. 2010 Nov-Dec;31(11-12):518-22.

    An analytical review of vasculobiliary injury in laparoscopic and open cholecystectomy.

    Strasberg SM, Helton WS. HPB (Oxford). 2011 Jan;13(1):1-14. doi: 10.1111/j.1477-2574.2010.00225.×. Epub 2010 Nov 15. Review.

    Trends, outcomes, and predictors of open and conversion to open cholecystectomy in Veterans Health Administration hospitals. Kaafarani HM, Smith TS, Neumayer L, Berger DH, Depalma RG, Itani KM. Am J Surg. 2010 Jul;200(1):32-40.

    Open cholecystectomy without intraperitoneal drainage. Ali SA, Tahir SM, Soomoro AG, Siddiqui AJ, Memon AS. J Ayub Med Coll Abbottabad. 2010 Apr-Jun;22(2):29-31.

    Prediction of conversion of laparoscopic cholecystectomy to open surgery with artificial neural networks. Gholipour C, Fakhree MB, Shalchi RA, Abbasi M. BMC Surg. 2009 Aug 21;9:13.

    Conversion after laparoscopic cholecystectomy in England. Ballal M, David G, Willmott S, Corless DJ, Deakin M, Slavin JP. Surg Endosc. 2009 Oct;23(10):2338-44. Epub 2009 Mar 6.

    Open cholecystectomy. McAneny D.

    Surg Clin North Am. 2008 Dec;88(6):1273-94, ix. Review.

    Surgical outcomes of open cholecystectomy in the laparoscopic era. Wolf AS, Nijsse BA, Sokal SM, Chang Y, Berger DL. Am J Surg. 2009 Jun;197(6):781-4. Epub 2008 Oct 16.

    [Prevention of iatrogenic injury of the extrahepatic ducts and vessels and diagnosis of choledocholithiasis during open and laparoscopic cholecystectomy]. Nychytaĭlo MIu, Shapryns’kyĭ VO, Vorovs’kyĭ OO, Karyĭ IaV, Babiĭchuk IuV, Kapitanchuk IuA, Serhiĭchuk OL. Klin Khir. 2008 Feb;(2):18-21. Ukrainian.

    Error traps and vasculo-biliary injury in laparoscopic and open cholecystectomy. Strasberg SM.

    J Hepatobiliary Pancreat Surg. 2008;15(3):284-92. Epub 2008 Jun 6. Review.

    Open cholecystectomy in the laparoendoscopic era. Visser BC, Parks RW, Garden OJ.

    Am J Surg. 2008 Jan;195(1):108-14. Review

    Preoperative findings predict conversion from laparoscopic to open cholecystectomy. Lipman JM, Claridge JA, Haridas M, Martin MD, Yao DC, Grimes KL, Malangoni MA. Surgery. 2007 Oct;142(4):556-63; discussion 563-5.

    Comparison of major bile duct injuries following laparoscopic cholecystectomy and open cholecystectomy. Kaman L, Sanyal S, Behera A, Singh R, Katariya RN. ANZ J Surg. 2006 Sep;76(9):788-91.

    Conversion from laparoscopic to open cholecystectomy. Gouma DJ.

    Br J Surg. 2006 Aug;93(8):905-6. No abstract available.

    Conversion of elective laparoscopic to open cholecystectomy between 1993 and 2004. Ishizaki Y, Miwa K, Yoshimoto J, Sugo H, Kawasaki S. Br J Surg. 2006 Aug;93(8):987-91.

    Open cholecystectomy for all patients in the era of laparoscopic surgery – a prospective cohort study.

    Leo J, Filipovic G, Krementsova J, Norblad R, Söderholm M, Nilsson E. BMC Surg. 2006 Apr 3;6:5.

    Bile duct injuries associated with laparoscopic and open cholecystectomy: an 11-year experience in one institute. Diamantis T, Tsigris C, Kiriakopoulos A, Papalambros E, Bramis J, Michail P, Felekouras E, Griniatsos J, Rosenberg T, Kalahanis N, Giannopoulos A, Bakoyiannis C, Bastounis E. Surg Today. 2005;35(10):841-5.

    Laparoscopic cholecystectomy in the elderly: increased operative complications and conversions to laparotomy. Kauvar DS, Brown BD, Braswell AW, Harnisch M. J Laparoendosc Adv Surg Tech A. 2005 Aug;15(4):379-82

    Conversion from laparoscopic to open cholecystectomy. Bhattacharya K. J Postgrad Med. 2005 Apr-Jun;51(2):153; author reply 153. No abstract available.

    Risk factors for conversion of laparoscopic cholecystectomy to open cholecystectomy. Simopoulos C, Botaitis S, Polychronidis A, Tripsianis G, Karayiannakis AJ. Surg Endosc. 2005 Jul;19(7):905-9. Epub 2005 May 4.

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