Perioperative management - Cholecystectomy, open

Note:  Today, laparoscopic cholecystectomy is regarded as the gold standard! Open procedures therefore require special indications.

General indications

• Symptomatic cholecystolithiasis
• Choledocholithiasis with/without biliary pancreatitis
• Cholecystitis
• Empyema or gangrene of the gallbladder
• Cystic duct obstruction
• Benign and malignant tumor of the gallbladder
• Mirizzi syndrome
• Chronic salmonella carrier

Specific indications

• Extensive previous upper quadrant surgery
• Unclear anatomy
• Abscesses and larger empyemas
• Patients with conditions unable to tolerate pneumoperitoneum
• Choledocholithiasis not amenable to endoscopic treatment
• Confirmed malignancy

In vital indications, severe comorbidity does not constitute grounds enough to forgo surgery.

• Patient history and clinical examination
• Lab panel: Red blood count, CRP, transaminases, bilirubin, amylase, lipase; in case of suspected malignancy possibly also tumor marker CA 19-9; before surgery possibly coagulation panel, electrolytes, creatinine
• Ultrasound study
• CT, MRCP, endoscopic ultrasound, ERCP; choledochoscopy reserved for special cases, suspected malignancy and unclear findings, particularly when working up bile duct pathology
• Gastroscopy when the clinical picture is ambivalent and the complaints might also arise from the stomach

• In acute cholecystitis and choledocholithiasis: Perioperative antibiotic regimen
• In elective cholecystectomy: Discontinue metformin; switch from phenprocoumon to low-molecular weight heparin
• Otherwise: Perioperative single-shot antibiotic prophylaxis

General: Thrombosis, embolism, pneumonia, keloid formation, incisional hernias, injuries to cutaneous nerves, drug intolerance, wound infection, secondary hemorrhage, hematoma, seroma

Specific: Injury to abdominal organs, e.g., colon, small intestine, stomach, liver

Injury to and transection of the extrahepatic bile ducts with at times massive consequences

Possible lifelong changes in dietary and bowel habits

Biliary fistula

Pancreatitis

Note: Biliary duct injuries are complications resulting in significant morbidity and mortality.