Cholecystectomy is indicated in patients with proven diseases of the gallbladder that produce symptoms. The incidental finding of gallstones by imaging studies, or a history of vague indigestion, is insufficient evidence for operation in itself and does not justify the risk involved, particularly in the elderly. Today, most patients have laparoscopic removal of their gallbladder. The procedure described here is called “open” and is most commonly performed at a conversion to open when the initial laparoscopic approach encounters complex technical events (swollen, gangrenous gallbladder, confusing anatomy, or abnormal cholangiograms, etc.) or major complications (ductal, blood vessel, or bowel injury) that are best treated with open exposure. Although open cholecystectomy is no longer the primary operation of choice, its mastery is essential for surgeons who perform laparoscopic cholecystectomy. A safe surgeon knows when it is appropriate to convert to an open operation, and does risk endangering the safety of the patient in order to complete the procedure laparoscopically at all costs.
Following a history and physical examination, the diagnosis of biliary disease is typically documented with ultrasound examination of the right upper quadrant. The remainder of the gastrointestinal tract may require additional studies. A chest x-ray and electrocardiogram may be performed as indicated. Routine laboratory blood tests are obtained and should include a liver function panel. Coagulation studies should be ordered if there is a concern for hepatic insufficiency or other causes of coagulopathy. The risks of cholecystectomy include bleeding, infection, visceral injuries, and bile duct injury.
General anesthesia with endotracheal intubation is recommended. Deep anesthesia is avoided by the use of a suitable muscle relaxant. In those patients suffering from extensive liver damage, barbiturates as well as other anesthetic agents suspected of hepatotoxicity should be avoided. In elderly or debilitated patients, local infiltration anesthesia is satisfactory, although some type of analgesia is usually necessary as a supplement at certain stages of the procedure.
The proper position of the patient on the operating table is essential to secure sufficient exposure (figure 1). Arrangements should be made for an operative cholangiogram in the event that one is necessary. A fluoroscopic C-arm requires sufficient space to be centered under the patient to ensure coverage of the liver, duodenum, and head of the pancreas. The exposure can be enhanced by tilting the table until the body as a whole is in a semi-erect position. The weight of the liver then tends to lower the gallbladder below the costal margin. Retraction is also aided in this position, because the intestines have a tendency to fall away from the site of operation.
The skin is prepared in the routine manner. Patients are administered appropriate prophylactic antibiotics prior to the time of incision. The use of prophylactic antibiotics appears to be more efficacious ...