Open Cholecystectomy
Author: William W Hope, MD; Chief Editor: Kurt E Roberts, MD
Approximately 700,000 cholecystectomies are performed annually in the United States. Most are performed to address symptoms related to biliary colic from cholelithiasis, to treat complications of gallstones (eg, acute cholecystitis and biliary pancreatitis), or as incidental cholecystectomies performed during other open abdominal procedures.
Currently, most cholecystectomies are done via the laparoscopic approach (see Laparoscopic Cholecystectomy); however, the open technique is sometimes required,[1] though perhaps with decreasing frequency as senior surgeons retire.[2] Accordingly, it is still important for surgeons to be exposed to this technique during training.[3, 4]
Indications for cholecystectomy, either open or laparoscopic, are usually related to symptomatic gallstones or complications related to gallstones. The most common of these indications are the following:
Biliary colic
Biliary pancreatitis
Choledocholithiasis
Other indications include the following:
Biliary dyskinesia
Gallbladder cancer
Prophylactic cholecystectomy during various intra-abdominal procedures (controversial)
Prophylactic cholecystectomy at the time of a splenorenal shunt has been proposed on the basis of the acute pain syndrome that these patients can develop postoperatively, which is often related to gallbladder symptoms, as well as the high likelihood of the formation of gallstones in this subset of patients with liver disease.
The procedure of choice for most of these indications has shifted from an open approach to a laparoscopic approach. However, some situations still require a traditional open cholecystectomy. Depending on the clinical situation, the procedure can either begin as an open operation or be converted to an open procedure from a laparoscopic one.
Some indications for forgoing laparoscopy and proceeding with an open operation are as follows:
Suspected or confirmed gallbladder cancer
Type II Mirizzi syndrome (cholecystobiliary fistula)
Gallstone ileus
Severe cardiopulmonary disease
When gallbladder cancer is suspected or confirmed preoperatively or intraoperatively, an open cholecystectomy should be performed with consultation from an experienced hepatobiliary surgeon if the primary surgeon is not comfortable with liver resections and hepatobiliary surgery. If the necessary expertise is not available, the patient can be referred to a hepatobiliary surgeon for reexploration, given that prior exploration, either laparoscopic or open, does not appear to adversely affect long-term survival.[5]
The recommendation for open cholecystectomy for gallbladder cancer, however, remains somewhat problematic, in that most gallbladder cancers are discovered incidentally during surgery or in the specimen.[6, 7]
Open cholecystectomy should also be considered in patients with cirrhosis and bleeding disorders, as well as pregnant patients. In patients with advanced cirrhosis and bleeding disorders, potential bleeding may be difficult to control laparoscopically, and an open approach (or a percutaneous cholecystostomy tube) may be more prudent. Also, patients with portal hypertension often have a recannulized umbilical vein, and placing ports in these patients may cause significant hemorrhage.
Although laparoscopic cholecystectomy has been proved to be safe in all trimesters of pregnancy, as well as possibly associated with fewer maternal and fetal complications,[8] an open operation should be considered for pregnant patients, especially in the third trimester, because laparoscopic port placement and insufflation may be difficult.
Open cholecystectomy is also indicated, albeit infrequently, in patients who have trauma to the right upper quadrant and in the rare cases of penetrating trauma to the gallbladder.
A propensity score–matched analysis by Babb et al, using data from the Kids' Inpatient Database (1997-2012), found that even though laparoscopic cholecystectomy is accepted as the gold standard for many conditions affecting the gallbladder, open cholecystectomy continues to be offered as the initial approach in a relatively high percentage of pediatric cases.[9]
Most open cholecystectomies result from conversion of a laparoscopic procedure, often because of bleeding complications or unclear anatomy. Conversion rates for laparoscopic cholecystectomy vary widely, with a reported range extending from as low as 1% to as high as 30%.[10] However, most series report the incidence of conversion to be lower than 10%, and some series report figures closer to 1-2%.[11, 12, 13, 14, 15]
In a study by Ibrahim et al, predictors of conversion to open cholecystectomy included age greater than 60 years, male sex, weight exceeding 65 kg, the presence of acute cholecystitis, previous upper abdominal surgery, the presence of diabetes and high glycosylated hemoglobin levels, and a less experienced surgeon.[16]
In a study by Licciardello et al,[17] risk factors for conversion on univariate analysis included increased age; acute cholecystitis; comorbidities; elevated white blood cell count; and increased levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), gamma glutamyl transpeptidase, C-reactive protein (CRP), and fibrinogen. On multivariate logistic regression analysis, acute cholecystitis and age greater than 65 years were found to be independent predictive factors for conversion.
Sutcliffe et al, using data from a prospective UK database of 8820 patients, developed a validation risk score designed for preoperative identification of patients at high risk for conversion from laparoscopic to open cholecystectomy.[18] This score was derived from the following six significant predictors: age, sex, indication for surgery, American Society of Anesthesiologists (ASA) score, thick-walled gallbladder, and common bile duct (CBD) diameter. A score higher than 6 identified patients likely to require conversion.
In a retrospective analysis of 1950 cases at a single tertiary center, Kara et al found that the the main reasons for conversion from laparoscopic to open cholecystectomy were significant inflammation, inadequate dissection of the Calot triangle because of fibrotic adhesions, and adhesions due to previous surgery.[19] The rate of conversion was significantly high in men and in elderly patients.
Finally, in lower-income countries, open cholecystectomy may be more cost-effective than the laparoscopic equivalent and may therefore be preferred on that basis.[20]
Absolute contraindications for proceeding with an open cholecystectomy are few. Such absolute contraindications are limited to severe physiologic derangement or cardiopulmonary disease that prohibits general anesthesia.
In cases of terminal illness, temporizing procedures such as percutaneous transhepatic cholangiography or percutaneous cholecystostomy should be considered in lieu of cholecystectomy.
Periprocedural Care
Equipment for open cholecystectomy includes instruments common to a major instrument tray, as follows:
Kelly clamps, Kocher forceps, needle holders, scissors, clips, suctions, knife/knife handles, forceps, retractors, right-angle clamps, Kitner dissectors, and electrosurgical devices should be assembled
Balfour retractors, Bookwalter retractors, or other self-retaining retractors can be used, according to the surgeon's preference
Sutures or clips can be used to control the cystic duct and artery, depending on the surgeon's preference and the size of the structures (see Technique); long instruments may be needed, depending on the body habitus of the patient
A headlight worn by the operating surgeon or assistant is often valuable in open cholecystectomy for improving visualization.
Several types of cholangiography catheters are available if cholangiography is to be performed.
Patient Preparation
Most open cholecystectomies are performed with general anesthesia. Less commonly, the procedure is done with regional (epidural or spinal) anesthesia; in rare instances, it is done with local anesthesia.
Patients are positioned supine with the arms extended. Placing a folded blanket or bump underneath the patient's right back or inverting the table may be beneficial.
In general, open cholecystectomy can be performed via either of two different approaches: retrograde or anterograde.
The more traditional retrograde ("top-down") approach starts with dissection at the gallbladder fundus and proceeds toward the portal triad and the triangle of Calot. This strategy facilitates sure identification of the cystic duct and artery, because they are the only two remaining attachments to the gallbladder. (See the video below.)
Retrograde technique for open cholecystectomy.
With increased experience and expertise in the laparoscopic technique, surgeons often feel more comfortable with the anterograde approach, in which dissection begins at the triangle of Calot with dissection and ligation of the cystic artery and duct. This is followed by dissection of the gallbladder from the liver bed, starting usually from the infundibulum up. Dissection from the fundus down can also be used. (See the video below.)
Anterograde technique for open cholecystectomy.
Place the patient under general anesthesia, supine, with arms extended. Place a Foley catheter and sequential compression devices before the operation begins, and, if indicated, administer preoperative anticoagulation. If indicated, administer preoperative antibiotics within 60 minutes of skin incision.
The surgeon stands on the patient's left with the assistant opposite. The operating room and table should be oriented so that cholangiography can be performed if necessary.
Incision
A right subcostal (Kocher) incision is the most often used incision and allows excellent exposure of the gallbladder bed and cystic duct. Alternatively, an upper midline incision can be used when other concomitant operations are planned and a wider exposure is needed. Typically, the midline incision remains above the umbilicus, still allowing adequate exposure of the gallbladder with appropriate retraction. A right paramedian incision is another option but is not often used at present.
Start the subcostal incision approximately 1 cm to the left of the linea alba, about two fingerbreadths below the costal margin (~4 cm). Extend the incision laterally for 10-15 cm, depending on the patient's body habitus.
Incise the anterior rectus sheath along the length of the incision, and divide the rectus and lateral muscles (external oblique, internal oblique, and transversus abdominis) with the electrocautery. Then, incise the posterior rectus sheath and peritoneum and enter the abdomen.
To the extent possible, perform a thorough manual and visual inspection to evaluate for concomitant pathology or anatomic abnormalities. Place a retracting device (eg, Balfour retractor, Bookwalter retractor, or wound protractor retractor) as needed for adequate exposure. (See the videos below.)
Exposure for open cholecystectomy.
Anatomy, exposure, and beginning of dissection for retrograde technique of open cholecystectomy.
Palpate and inspect the liver, and admit air into the subphrenic space to displace the liver inferiorly and better expose the inferior surface. If additional downward displacement is needed, laparotomy pads can be placed above and lateral to the liver to facilitate exposure (see the video below). Retract the duodenum inferiorly to expose the porta hepatis.
Anatomy and exposure for an open cholecystectomy. Placing packs above liver for improved visualization.
Palpate the gallbladder for stones or masses. The porta hepatis can be assessed by inserting the left index finger into the foramen of Winslow and using the thumb to palpate anteriorly on the porta hepatis/common bile duct (CBD) for stones or tumors.
Grasp the dome of the gallbladder with a Kelly clamp, and elevate it superiorly. Adhesions to the undersurface of the gallbladder from the transverse colon or duodenum are typically encountered; these can be lysed with sharp dissection or judicious use of the electrocautery.
Dissection of the gallbladder can be performed in two ways. Traditionally, as previously noted, dissection in open cholecystectomy is performed with a "top-down" or retrograde technique, whereby the fundus is mobilized toward the porta hepatis. This technique differs from the anterograde technique, in which dissection begins at the porta hepatis and extends up to the fundus (as is done in laparoscopic cholecystectomy).
Retrograde approach
In the retrograde approach, incise the visceral peritoneum overlying of the gallbladder fundus approximately 1 cm from its attachment to the liver. Grasp the fundus of the gallbladder with a Kelly clamp. Using a right-angle clamp or suction device, develop the plane on both the lateral and the medial side of the gallbladder, and carry the incision along the gallbladder parallel to the liver. This dissection ensures complete mobilization of the gallbladder from the liver bed before dissection within the triangle of Calot. (See the videos below.)
Beginning of dissection for retrograde technique of open cholecystectomy.
Dissecting gallbladder off liver bed in retrograde technique.
Completion of dissection of gallbladder off of liver bed in retrograde technique.
The dissection plane is typically avascular, with only small cholecystic veins that must be divided. Occasionally, more prominent veins may be encountered that must be ligated, especially in the presence of portal hypertension or gallbladder distention. If significant bleeding occurs, the dissection has likely been too deep entering the liver parenchyma.
Anterograde approach
In the anterograde approach, attention is initially directed to the porta hepatis. Grasp the fundus of the gallbladder, and elevate it superiorly while the neck of the gallbladder is mobilized away from the liver laterally to expose the triangle of Calot. Dissect the cystic artery and cystic duct, with careful attention to the potential for anatomic variations.
Once the cystic duct and cystic artery are completely dissected and identified entering directly into the gallbladder (the so-called critical view popularized by Strasberg[21] ), the structures can be divided if cholangiography is not being performed. Before division of the cystic duct, "milk" the duct from proximal to distal to deliver stones that reside in the cystic duct into the gallbladder lumen. After dividing the cystic artery and duct, dissect the gallbladder away from the liver bed as described in the retrograde technique.
Ligation of cystic duct and artery
When the cystic duct and artery are correctly identified and completely dissected, they are ligated. Various techniques for ligation have been described, including using suture, staplers, and clips. (See the videos below.)
Ligation of cystic duct and artery in retrograde technique of open cholecystectomy.
Completion of retrograde technique of open cholecystectomy showing ligated cystic artery and cystic duct.
Nonabsorbable sutures are acceptable for use on the cystic duct stump; however, they are not recommended for biliary-enteric anastomosis or choledochotomy suture lines, because they can be lithogenic and incite a chronic inflammatory reaction. Absorbable sutures, such as polyglactin 910 or polydioxanone, are traditionally used for ligation of the cystic duct. Metallic (titanium) clips or locking (Weck) clips can also be used.
If the cystic duct is large and inflamed, mechanical staplers may be used, as well. The cystic artery can be ligated with ties (absorbable or nonabsorbable), suture ligature, or clips. Mechanical staplers are rarely necessary for ligation of the cystic artery.
A blunt Kitner (peanut) dissector aids in dissection of the cystic duct and artery, but it is best to proceed toward the portal structures so as to avoid avulsion of the blood supply of the CBD or avulsion of the cystic duct. The blood supply to the CBD courses on the medial and lateral side of the duct at the 3 o'clock and 9 o'clock positions. Knowledge of the anatomy and careful dissection on the lateral edge (9 o'clock) position avoids inadvertent injury and ischemia to the CBD.
Thermal energy devices must be used with caution in dissecting in the triangle of Calot and are not recommended for working immediately adjacent to biliary structures.
Sudden bleeding from the porta hepatis can be alarming and should initially be managed with direct pressure to allow adequate exposure and provide sufficient time to call for assistance, if needed. Surgeons should avoid blind placement of sutures or clips in this area, as well as thermal energy devices. If bleeding cannot be controlled, a Pringle maneuver may be needed. Suture ligation of bleeding porta hepatis structures should be carefully and precisely carried out with 5-0 polydioxanone horizontal mattress sutures.
Although open cholecystectomy is generally a safe procedure with limited morbidity and mortality,[22] it does carry a risk of potential complications. Traditionally, the complication rate has been reported to be in the range of 6-21%,[23] though in the current era, it is probably somewhat lower.[10] For patients with Child-Pugh class A or B cirrhosis who are undergoing cholecystectomy for symptomatic cholelithiasis, laparoscopic cholecystectomy has decreased complication rates and increased recovery as compared with open cholecyestectomy.[24]
Bleeding and infection
Inherent to any surgical procedure are the risks of bleeding and infection. Potential sources of hemorrhage include the liver bed, the hepatic artery and its branches, and the porta hepatis. Most bleeding sources are recognized and addressed intraoperatively. However, occasional postoperative hemorrhage can result in substantial hemoperitoneum.
Infectious complications range from skin and soft-tissue infection to intra-abdominal abscess. The risk of infection is minimized by maintaining meticulous sterile technique, as well as avoiding leakage of bile into the abdominal cavity. Should significant bile or stone spillage occur, thorough irrigation can help decrease the risk of intra-abdominal infection. All spilled stones should be removed to prevent further abscess formation.[25]
Biliary complications
Complications related to the biliary system include bile leaks and CBD injuries, which can result in biliary strictures. Bile leaks can be caused by clips or ligatures slipping off the cystic duct stump, injuries to the bile ducts, or, most commonly, transected Luschka ducts. Patients may present with persistent abdominal pain, nausea, vomiting, and elevated liver function test (LFT) results. Once leakage is diagnosed, endoscopic retrograde cholangiopancreatography (ERCP) can help further characterize the leak, as well as provide therapeutic options.
Perhaps the most morbid complication related to open cholecystectomy is injury to the CBD. The incidence of bile duct injury—already a known complication during open cholecystectomy—increased twofold with the advent of laparoscopic cholecystectomy (one injury per 200-5000 cases).[10, 26, 27]
When a bile duct injury is recognized intraoperatively, consult an experienced hepatobiliary surgeon. If one is not available, strongly consider transferring the patient to a tertiary care center for definitive care. Delayed diagnosis of a bile duct injury can occur weeks to months after the initial operation with elevation of LFT results or, in some cases, cholangitis. As noted previously, these patients should be referred to experienced hepatobiliary centers for evaluation and definitive treatment.[28]
Postcholecystectomy syndrome
Postcholecystectomy syndrome can arise after open or laparoscopic cholecystectomy.[29]
William W Hope, MD Assistant Professor of Surgery, University of North Carolina at Chapel Hill School of Medicine; Director of Surgical Education, Department of Surgery, New Hanover Regional Medical Center/South East Area Health Education Center
William W Hope, MD is a member of the following medical societies: American College of Surgeons, North Carolina Medical Society, Society of American Gastrointestinal and Endoscopic Surgeons
Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Cr bard, WL Gore, Intuitive Surgical<br/>Received research grant from: CR bard, WL Gore<br/>Received income in an amount equal to or greater than $250 from: CR Bard, WL Gore, Intuitive surgical<br/>Received grant/research funds from CR Bard and WL Gore for consulting.
Daniel C Barzana, DO Resident, Department of Surgery, New Hanover Regional Medical Center
Daniel C Barzana, DO is a member of the following medical societies: American College of Surgeons, American Osteopathic Association
David A Iannitti, MD Clinical Associate Professor of Surgery, University of North Carolina at Chapel Hill School of Medicine; Chief, HepatoPancreaticoBiliary Surgery, Department of General Surgery, Division of Gastrointestinal and Minimally Invasive Surgery, Program Director, HepatoPancreaticoBiliary Surgical Fellowship, Carolinas Medical Center
David A Iannitti, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, International Hepato-Pancreato-Biliary Association, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Surgical Oncology, Americas Hepato-Pancreato-Biliary Association, American Society of Clinical Oncology
Kurt E Roberts, MD Associate Professor, Division of Bariatric and Minimally Invasive Surgery, Department of Surgery, Yale University School of Medicine; Chair, Department of Surgery, Saint Francis Hospital, Trinity Health of New England Medical Group
Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoscopic and Robotic Surgeons
The authors thank Cissy Swartz for her assistance with manuscript preparation and editing.
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