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INDICATIONS

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Cholecystostomy, while not recognized as routine treatment for cholelithiasis, may be a lifesaving procedure. Today cholecystostomy is usually placed under image guidance by a percutaneous technique. Surgical cholecystostomy may be needed in some situations. It is the operation of choice in some elderly patients with acute cholecystitis, in poor surgical risks who present a well-defined mass, in seriously ill patients in whom minimum surgery is desirable, and when technical difficulties make cholecystectomy hazardous. If there is obstruction of the common duct with long-standing jaundice and a tendency toward hemorrhage that cannot be controlled by vitamin K and transfusions or percutaneous transhepatic biliary tube drainage, preliminary cholecystostomy for decompression may be the procedure of choice.

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INCISION AND EXPOSURE

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A small incision is made with its midportion directly over the maximum point of tenderness in the right upper quadrant. Occasionally, when unsuspected technical difficulties or inflammation more severe than anticipated are encountered, the procedure is carried out through the usual upper right rectus or infracostal incision. The adhesions are not dissected from the undersurface of the gallbladder unless it is thought that cholecystectomy might be feasible (figure 1).

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DETAILS OF PROCEDURE

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The fundus is walled off with gauze before the evacuation of its contents. An incision is made just through the serosa of the bulging fundus (figure 2). A trocar is inserted to remove the liquid contents (figure 3). Suction is maintained adjacent to the incision in the fundus as the trocar is withdrawn. A culture is taken routinely. The edematous wall is then grasped with Babcock forceps, and the opening is extended (figure 4). A purse-string suture of fine absorbable material is placed about the opening in the fundus to control oozing and to close the fundus about the drainage tube. Any liquid or debris remaining in the lumen of the gallbladder is removed by suction. Since there is usually an impacted stone in the neck of the gallbladder, a determined effort is made to remove it to permit drainage of the gallbladder. A small, flexible scoop, such as a Cushing pituitary curette, is directed down to the neck (figure 5). If the scoop cannot dislodge the stones, a fenestrated forceps is used. The lumen of the gallbladder is repeatedly flooded with saline. A small rubber catheter or mushroom catheter is inserted into the lumen of the gallbladder and anchored with an interrupted silk suture (figures 6 and 7) or a Foley catheter may be used. The previously placed purse-string suture is tied snugly about the drainage tube (figure 7). If the inflammation is severe, if an abscess was encountered, or if there has been soiling about the wall, a closed suction drain is inserted along the wall of the gallbladder. The common duct must be decompressed if suppurative cholangitis is suspected.

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