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INTRODUCTION

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  • Gallbladder disease and thus surgery are extraordinarily common; whereas most cholecystectomies occur uneventfully, there are many serious complications that can occur. Thus, the surgeon should not be lulled into a sense of complacency

  • Regardless of patient or gallbladder disease severity, each surgeon should develop a list of steps to laparoscopic cholecystectomy, which should be followed in order every time. Inability to proceed through the steps should prompt either deviation to an established “bail out” maneuver (eg, sub-total cholecystectomy), or conversion to open

  • Anatomic variations in both biliary and arterial anatomy are common; the surgeon must familiarize themselves with these variants and anticipate their existence.

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STATE OF THE ART

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Cholecystectomy is one of the most commonly performed surgeries in North America. It is commonly performed on an outpatient basis, but also makes up a large portion of surgeries done in the hospital setting. It most often goes smoothly and is considered “just another gallbladder.” However, even a modestly experienced surgeon knows that gallbladder surgery can be fraught with technical difficulties and challenges. One of the biggest mistakes the surgeon can make regarding cholecystectomy is to become complacent and not appreciate the gravity of the rare but potentially devastating complications that are possible. In this chapter we will discuss potential bail-out strategies and surgical issues in regard to gallbladder surgery.

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Pitfalls and Pearls

  • ✓ Most cholecystectomies appear to proceed smoothly but this should not lull the surgeon into complacency in regard to potentially devastating complications.

  • ✓ The anatomy can be difficult to define, especially in the setting of severe or chronic inflammation.

  • ✓ Anatomic variation is common and should be well-known to the surgeon.

  • ✓ Cholecystectomy is the preferred treatment for cholecystitis except in the rare situation of prohibitive operative risk.

  • ✓ In rare situations, a percutaneous cholecystostomy tube may provide a temporizing measure to avoid likely complications.

  • ✓ Laparoscopic access to the hostile abdomen requires experience and patience.

  • ✓ Open surgery must always remain an option for the surgeon, even from the start.

  • ✓ Partial cholecystectomy is a well-described bail-out strategy and has acceptable outcomes, especially when compared with major complications.

  • ✓ The dome-down approach to cholecystectomy has proponents and detractors. Clarification of anatomy and meticulous dissection is likely more important than any particular technique.

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CASE SCENARIOS

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Case Study 11.1

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The hypothesis: If possible, at times it may be better to temporize cholecystitis and delay surgery until risk factors can be mitigated.

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The story: An 85-year-old male is in the intensive care unit (ICU) and being treated for a pneumonia and sepsis for the last week. He is now improving from a respiratory standpoint but he had a fever and right upper quadrant (RUQ) pain, and workup has revealed only cholecystitis as the likely source. The patient’s family members note that he has had RUQ pain after eating for ...

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