Open cholecystectomy

INTRODUCTION — Cholecystectomy is one of the most frequently performed surgical procedures in the United States with roughly 700,000 completed annually. As the use of laparoscopy has increased, the incidence of open cholecystectomy has steadily decreased. Familiarity with this procedure has declined in training programs. However, open cholecystectomy is still used when laparoscopy is contraindicated or technically impossible. In addition, it is often employed during other hepatobiliary and gastrointestinal operations.

The purpose of this review is to highlight some important differences in the techniques and review the treatment of the more common postoperative complications of open cholecystectomy. The techniques and complications of laparoscopic cholecystectomy are discussed in other topics:

●(See "Laparoscopic cholecystectomy".)

●(See "Complications of laparoscopic cholecystectomy".)

●(See "Managing the difficult gallbladder".)

INDICATIONS — Gallstones are the primary reason a patient requires cholecystectomy in the United States; however, many patients with cholelithiasis will remain asymptomatic and therefore do not have a need for cholecystectomy. Other indications include gallbladder polyps greater than or equal to 10 mm, gallstone pancreatitis, or functional gallbladder disease. Cholecystectomy is also performed for the suspicion of gallbladder cancer or as a prophylactic procedure for this cancer in endemic countries such as Chile and India. Lastly, cholecystectomy is routinely performed concomitantly with other procedures such as pancreaticoduodenectomy or major anatomic liver resections, including hemihepatectomies.

Although laparoscopy is the most common approach for cholecystectomy, certain conditions may require conversion to open procedure. Conversion rates have been reported to be between 5 to 15 percent and should not indicate a failure on the part of the surgeon [1,2]. The most frequent indications for conversion include significant inflammation or adhesions leading to difficulty in identification of anatomy, particularly in patients who have had previous surgery.

Contraindications to cholecystectomy include significant coagulopathy, inability to tolerate general anesthesia, or severe sepsis causing hemodynamic instability. In the presence of these factors, nonoperative management with percutaneous cholecystostomy tubes or endoscopic transduodenal gallbladder decompression can be entertained [3]. (See "Treatment of acute calculous cholecystitis", section on 'Gallbladder drainage'.)

Relative contraindications to open surgery can include cirrhosis with portal hypertension, severe cardiopulmonary disease, and pregnancy. Cirrhosis can be challenging due to concerns over the ability to retract a fibrotic liver, presence of pericholecystic and portal varices, and subsequent risk of bleeding (see "Managing the difficult gallbladder", section on 'Cirrhosis'). Liberal use of energy sealing devices, hemostatic agents, and an argon beam coagulator in addition to correction of coagulopathy can allow for a safe cholecystectomy in this population for the right indication. Cholecystectomy during pregnancy is discussed elsewhere. (See "Gallstone diseases in pregnancy", section on 'Cholecystectomy during pregnancy'.)

The timing of cholecystectomy can vary, but acute cholecystitis should proceed to the operating room as early as possible, ideally within 48 hours of admission. Patients suffering from mild gallstone pancreatitis benefit from cholecystectomy at the time of the index admission [4]. However, surgery for severe pancreatitis should be delayed to allow time for peripancreatic fluid collections to resolve or mature prior to cholecystectomy [5]. (See "Treatment of acute calculous cholecystitis", section on 'Timing of cholecystectomy' and "Management of acute pancreatitis", section on 'Cholecystectomy'.)

STANDARD TECHNIQUES

Incision — The traditional incision used for an open cholecystectomy is a right subcostal or Kocher incision (figure 1). This incision is made 2 centimeters below the right costal margin and extends from the midline laterally to the desired length but usually across the rectus muscle. It can be extended superiorly along the midline to the xiphoid process for further exposure. Often, open incisions are performed due to conversion from laparoscopy by connecting the epigastric and right upper quadrant port sites (figure 2). An open cholecystectomy can also be safely performed via an upper midline incision in those undergoing a concomitant abdominal or pelvic procedure.

Exposure and placement of retractors — Exposure during open cholecystectomy is critical to performing the procedure safely, particularly in the presence of inflammation, infection, or adhesions from previous operations. The ligamentum teres can be divided between ties or an energy device in order to release the liver from the abdominal wall. The attachments from the falciform ligament to the liver are incised with cautery for several centimeters cephalad again to gain exposure for retraction.

A plastic wound protector can be placed in order to reduce surgical site infections, as supported by randomized controlled trials [6]. A retractor system such as a Thompson or Bookwalter can be applied to the table in order to secure the abdominal wall open for the procedure. Mechanical body wall retractors are placed on the superior edge of the incision, one medially and one laterally, and secured to the retractor system (figure 1). Moist sponges are used to pack the bowel out of the operative field inferiorly, typically with a bladder blade. A malleable-type retractor is then placed on the undersurface of the liver to the left of the gallbladder in order to retract the quadrate lobe and expose the porta hepatis.

Dissection — The gallbladder can be dissected retrograde (bottom-up) or anterograde (top-down) depending on patient anatomy (figure 3) and surgeon preference.

Retrograde cholecystectomy — This is the traditional method performed during laparoscopic cholecystectomy; however, it can be more difficult in the open setting without the aid of magnification. Regardless of approach, the same basic principles, including achieving the critical view of safety (CVS), must be achieved prior to removing the gallbladder from the liver (figure 4) [7].

The fundus is grasped with a Kelly or similar clamp, and the gallbladder is retracted superiorly and laterally in order to expose the triangle of Calot. The peritoneum overlying the infundibulum is incised to enter the fibrofatty tissue between the cystic duct, cystic artery, and porta hepatis. The incision is then extended along the medial and lateral gallbladder, being careful to stay close to the edge of the gallbladder but not entering it to prevent spillage of its contents. Once all fibroadipose tissue is cleared from the hepatocystic triangle, only two structures should be seen entering the gallbladder from the anterior and posterior perspective. In addition, the bottom third of the cystic plate has to be cleared in order to complete the CVS (figure 4). Any stones palpated within the cystic duct are gently pushed back into the gallbladder. The cystic artery can be doubly ligated with either clips or sutures, then divided. If cholangiography is indicated, it is performed at this time by making a lateral cystic ductotomy via a 2 to 3 mm incision for insertion of a cholangiocatheter. Ligation and division of the cystic duct can be completed after cholangiography, typically with a combination of a suture ligature and a clip.

The gallbladder is then dissected off the cystic plate sharply using cautery. The dissection plane is kept close to the gallbladder to avoid violating the cystic plate and entering the liver parenchyma and without puncturing the gallbladder to avoid bile or stone spillage. Brisk bleeding from liver parenchyma can be controlled by holding pressure over the affected area or using the argon beam coagulator. Hemostatic agents may also be applied, and, if these techniques fail, deep hemostatic sutures can be placed. However, care must be taken to avoid deeper dissection into the liver given the proximity of the terminal end of the middle hepatic vein that runs in the gallbladder fossa (figure 5).

Antegrade cholecystectomy — Antegrade cholecystectomy is an alternate and sometimes preferred technique for an open cholecystectomy. A Kelly clamp is used to grasp the fundus of the gallbladder; another clamp (eg, right-angle) is used to grasp the peritoneum on the liver edge. An incision is made in the gallbladder serosa a few millimeters from the liver edge with cautery. A plane is created between the gallbladder wall and the cystic plate. The dissection is continued medially and laterally toward the gallbladder neck. An energy device can be used in the presence of large vessels to minimize bleeding.

Once the gallbladder is completely free from the cystic plate, exposure of the cystic artery and duct can begin. The fibrofatty tissue encircling the infundibulum is cleared, and the cystic artery is ligated and transected as it enters the gallbladder wall. This is followed by the cystic duct, which should be the only remaining structure entering the gallbladder. There is no need to dissect more than 1 centimeter of the cystic duct in order to place clips or ties, as further dissection to its connection to the common bile duct risks a biliary injury.

Note that chronic inflammation can tether the gallbladder to the hilar structures; a small, contracted intrahepatic gallbladder may be indicative of this possibility [8]. If difficulty is encountered separating the lower third of the gallbladder from the cystic plate due to severe inflammation, the antegrade approach should be abandoned and an alternate technique (eg, subtotal cholecystectomy) considered. Persistent attempts at forcing dissection in this space may lead to inadvertent entry into the hilar plate and the biliary bifurcation, resulting in a high bile duct injury. This method of cholecystectomy was previously popularized due to the ability to encircle the cystic structures with an Endoloop or division of the infundibulum with a stapler. These maneuvers are now discouraged due to the increased risk of major vasculobiliary injury in the presence of dense inflammation. (See 'Partial or subtotal cholecystectomy' below.)

Common bile duct exploration — If cholangiography confirms the presence of common bile duct stones and postoperative endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction is not a likely option (eg, Roux-en-Y gastric bypass, prior failed ERCP, lack of local expertise), common bile duct exploration and removal of stones will be necessary. The procedure of common bile duct exploration is discussed in detail elsewhere. (See "Surgical common bile duct exploration".)

Closure — After the gallbladder is removed, a closed suction drain may be placed through a separate stab wound after a difficult cholecystectomy, especially if there is evidence of residual bile leakage from the liver bed. However, drains are not a substitute for adequate hemostasis and cannot be relied upon to indicate the extent, or the absence, of postoperative hemorrhage [9]. The subcostal (Kocher) incision is typically closed in two layers.

ALTERNATE TECHNIQUES FOR DIFFICULT CASES — When a severely inflamed gallbladder is encountered at the time of operation, it may not be possible to achieve the critical view of safety (CVS). Fibrosis and inflammation can cause the cystic duct to shorten and fuse with the common bile duct, leading the surgeon to mistake the common bile duct for the cystic duct (figure 6) [10]. In these cases, it may be best to use an alternate technique to avoid significant bile duct injury. (See "Managing the difficult gallbladder", section on 'Management'.)

Cholecystostomy tube drainage — If difficulty of the operation is encountered at the time of exploration and the gallbladder has not been violated, a cholecystostomy tube may be placed, and surgery may be postponed until a period of medical management and optimization has transpired.

To place a cholecystotomy tube, a pursestring suture is placed into the fundus of the gallbladder, through which an 18 F balloon catheter (inflated once inside the gallbladder) or mushroom catheter is introduced after making a stab incision within the confines of the pursestring suture. The pursestring suture is drawn up and tied to secure the catheter. The catheter should be brought out of the abdomen through a site separate from the abdominal incision. The gallbladder wall is sutured to the peritoneum where the catheter exits the abdomen. If the gallbladder cannot be brought up to the abdominal wall, the space between the gallbladder and abdominal wall should be buttressed with omentum and closed suction drains placed.

The cholecystostomy tube is placed to gravity drainage and should be irrigated as needed. After one week, cholangiography can be performed through the cholecystostomy tube. The cholecystostomy tube can be clamped in two to three weeks, and if tolerated, the tube can be removed one month after placement, provided there is no ongoing need for the tube.

Partial or subtotal cholecystectomy — Should the surgeon determine it is best to proceed with removal of the gallbladder, a partial or subtotal cholecystectomy should be performed. This is typically accomplished by removing the anterior portion of the gallbladder while leaving behind the posterior wall attached to the liver [11].

The gallbladder is entered purposefully superiorly in a safe location with cautery, and its contents are suctioned. This incision is extended down to the gallbladder neck without dissecting the cystic duct or artery. The anterior wall of the gallbladder is then completely removed, leaving the posterior wall attached to the cystic plate (picture 1).

The cystic duct orifice may be seen from inside the gallbladder; however, it also may be obliterated by severe inflammation from the cholecystitis. If bile is encountered or cholangiography desired, a catheter may be placed into the orifice and images obtained. This can be particularly useful if distal stones are suspected. After removal of the catheter, the orifice can be closed with a pursestring absorbable suture to prevent a bile leak and avoid a nidus for further stone formation.

At this point, the surgeon has a choice whether to leave the gallbladder open or "fenestrated" or to attempt to close the remainder of the gallbladder wall, thereby performing a "reconstituting" remnant (figure 7) [12]. Both approaches offer some benefits and drawbacks. While the fenestrated approach may be prone to bile leaks if the cystic duct closure is not complete, the reconstituting method may leave the patient susceptible to recurrent cholecystitis of the pouch. The choice of the procedure is determined by surgeon preference and patient anatomy. Regardless of technique, a closed gravity or suction drain is typically left in the gallbladder bed to diagnose and control postoperative leaks. The remnant mucosa is then coagulated with either cautery or argon beam to prevent accumulation of epithelial secretions.

Subtotal cholecystectomy can be performed both open and laparoscopically, the latter potentially decreasing the need for conversion [13]. However, as expected, there may be a higher risk of postoperative complications with subtotal cholecystectomy compared with standard cholecystectomy, such as a biloma or abscess. One study found the relative risk of bile leak after subtotal cholecystectomy was as high as threefold, especially with the fenestrated approach [14]. A systematic review and meta-analysis of 1231 subtotal cholecystectomies demonstrated a higher rate of postoperative bile leakage but overall comparable morbidity rates, including bile duct injury, when compared with complete cholecystectomy [15]. (See "Managing the difficult gallbladder", section on 'Subtotal cholecystectomy'.)

POSTOPERATIVE MANAGEMENT

Routine care — The majority of patients who undergo open cholecystectomy require postoperative admission for pain control and diet advancement.

●Patients are allowed a clear diet after recovering from anesthesia and then advanced as tolerated to a regular diet without any specific restrictions.

●If the operation is planned, patients may have a transverse abdominis plane (TAP) block or epidural analgesia placed prior to surgery. Incisional pain is common and treated with oral narcotics, but many can use over-the-counter pain medications.

●Antibiotics postoperatively are not necessary, except in unusual circumstances (eg, ongoing sepsis). (See "Treatment of acute calculous cholecystitis", section on 'Antibiotic therapy'.)

Routine follow-up in clinic typically occurs between one and four weeks after surgery unless complications develop. To reduce the likelihood of hernia formation, heavy lifting (anything over ten pounds) is not recommended for four to six weeks after an open procedure.

Complications of cholecystectomy

Bile leak — The incidence of bile leak after cholecystectomy has been estimated at 1 to 4 percent for the open and laparoscopic approaches, respectively [16]. The majority of bile leaks arise from two sources: the cystic duct stump and the aberrant branches of hepatic ducts directly from the liver to the gallbladder, known as the ducts of Luschka [17].

Patients with postoperative bile leaks typically present with abdominal discomfort, fever, and jaundice. Bilious drainage from operative drains can also suggest the diagnosis. The initial diagnostic test should be an abdominal ultrasound to check for fluid accumulation and dilated bile ducts. If present, subsequent computed tomography of the abdomen and percutaneous drainage should be performed to better characterize the anatomy. In addition, hepatobiliary cholescintigraphy (generally referred to as a HIDA scan) may also be performed when other studies are equivocal.

Fortunately, the majority of leaks that occur with open cholecystectomy are from small ducts in the cystic plate rather than major bile ducts. Most such leaks are self-limiting or can be managed with drainage alone. In refractory cases, endoscopic sphincterotomy via endoscopic retrograde cholangiopancreatography (ERCP) and stent placement can reduce the pressure downstream and divert the preferential flow of bile into the duodenum with success rates ranging from 90 to 100 percent. (See "Endoscopic management of postcholecystectomy biliary complications", section on 'Bile leak'.)

Bile duct injury — Bile duct injury (BDI) is a rare but most feared complication of cholecystectomy, occurring between 0.08 to 0.25 percent. This is because it can result in significant long-term morbidity and decreased lifespan for the patient. Large database studies from experienced biliary repair centers have determined that the 30 day mortality rate is 2 percent [18]. A mean survival of 17.6 years following BDI along with decreased quality of life has also been reported in prospective cohort studies [19].

Intraoperative cholangiography has been purported to reduce iatrogenic BDI; however, some studies have demonstrated an increased incidence of BDI when intraoperative cholangiogram is performed. This is due to the fact that cholangiography is used more frequently during more difficult cases [20]. In addition, in order for cholangiography to prevent BDI, correct identification and interpretation of the images is necessary. (See "Repair of common bile duct injuries", section on 'Role of intraoperative cholangiography'.)

Inflammation of the gallbladder as seen in complicated cholecystitis increases the risk of BDI [21]. The injury occurs when the common bile duct is mistaken for the cystic duct and ligated distally by excessive lateral retraction of the gallbladder. In this scenario, the cystic duct lies parallel to the common bile duct, and there is an illusion that the latter is the only structure entering the gallbladder. When dissection is carried proximally to free the remaining gallbladder, the common hepatic duct is typically divided by cautery, resulting in a high biliary injury (figure 8) [22].

A good anatomic landmark to prevent BDI is the sulcus of Rouviere or fissure of Ganz [23]. This is the anatomic location of the right posterior pedicle to segments 6 and 7 of the liver. Dissection of the gallbladder and cystic structures should be maintained above this location, which has been dubbed the "line of safety" to be used in conjunction with the CVS (picture 2) [24].

If a BDI is identified during the course of the operation, the surgeon should try to evaluate the scope of the injury while gauging their own experience as well as the patient's condition and hospital resources (eg, advanced endoscopy, interventional radiology). If the operating surgeon is inexperienced with BDI repair, a hepatobiliary surgeon should be contacted to discuss the situation either in person or via telephone consultation. When immediate repair is not possible, placement of a drain near the porta hepatis, closure of the patient, and transfer to a center with hepatobiliary expertise is the best course of action. Attempts at continued removal of the gallbladder should be avoided in order to minimize the extent of the injury [22]. (See "Repair of common bile duct injuries".)

Spilled stones — Every attempt should be made to recover inadvertent stones that fall out of the gallbladder during cholecystectomy. This can be particularly challenging in cases where they fall above or lateral to the liver. If left in situ, they can also sometimes lead to erosion into the chest through the diaphragm.

Pigmented stones contain bacteria and may cause postoperative infection if left in the abdomen after spillage of gallbladder contents. These can lead to complications, including intra-abdominal and abdominal wall abscesses. A study examining outcomes after accidental gallbladder spillage suggests that it may cause more postoperative pain, ileus, and infection when compared with cases where spillage does not occur [25].

Remnant gallbladder and cystic duct stones — Recurrent stone formation in the remnant gallbladder or cystic duct is rare but can occur in reconstituting subtotal cholecystectomies. Patients can present with biliary colic symptoms from 4 months to 25 years after the initial operation [26]. A confirmatory diagnosis can be achieved by magnetic resonance cholangiopancreatography (MRCP) or ERCP. Other modalities, such as endoscopic ultrasound (EUS), can also be useful in obtaining a diagnosis of retained stones [27].

Resection of a remnant gallbladder from a prior reconstituting operation via completion cholecystectomy can be performed laparoscopically but more often will require an open approach [28].

Cystic duct stones may be amenable to endoscopic retrieval or lithotripsy. However, failure of these techniques may require an operative intervention to open the cystic duct and tie it closer to the common bile duct to clear the stone [29].

Postcholecystectomy syndrome — Postcholecystectomy syndrome (PCS) is a complex of heterogeneous symptoms, including persistent abdominal pain and dyspepsia, that recur or persist after cholecystectomy. Since most cholecystectomies are performed laparoscopically, PCS is much more common after laparoscopic than open cholecystectomy. PCS is discussed in more detail elsewhere. (See "Laparoscopic cholecystectomy", section on 'Postcholecystectomy syndrome'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Gallbladder surgery".)

SUMMARY AND RECOMMENDATIONS

●Indications – Although not performed as frequently anymore, the technique of open cholecystectomy is one that surgeons should be comfortable performing when gallbladders are not amenable to laparoscopic resection or when cholecystectomy is combined with other abdominopelvic procedures. (See 'Indications' above.)

●Standard techniques – One must be familiar with the open exposure and retraction of the liver, duodenum, and other abdominal structures to perform a safe gallbladder removal via laparotomy. This can be completed with an antegrade or retrograde approach. (See 'Standard techniques' above.)

When performing both open and laparoscopic cholecystectomy, the principles of the critical view and line of safety must be followed to avoid a bile duct injury.

●Alternate techniques for difficult gallbladders – In the presence of severe inflammation or when complete gallbladder removal is not possible, the surgeon should consider use of cholecystostomy tubes or a subtotal cholecystectomy. (See 'Alternate techniques for difficult cases' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Daniel T Dempsey, MD, FACS, Major Kenneth Lee IV, MD, PhD, and Shefali Agrawal, MD, FACS, who contributed to earlier versions of this topic review.