Cholecystectomy from the fundus downward is the desirable method in many cases of acute or gangrenous cholecystitis, where exposure of the cystic duct is difficult and hazardous. Extensive adhesions, a large, thick-walled, acutely inflamed gallbladder, or a large calculus impacted in the ampulla of the gallbladder makes this the safe and wiser procedure. Better definition of the cystic duct and cystic artery is ensured with far less chance of injury to the common duct. Some prefer this method of cholecystectomy as a routine procedure.
In the presence of acute cholecystitis, the preoperative treatment depends on the severity and duration of the attack. Early operation is indicated in patients seen within 48 hours after the onset, as soon as fluid balance and antibiotic coverage have been established. Frequent clinical and laboratory evaluation over a 24-hour period is necessary. Constant gastric suction may be advisable. Antibiotic therapy is given. Regardless of the duration of the acute manifestations, surgical intervention is indicated if there is recurrence of pain, a mounting white cell count, or an increase in the signs and symptoms suggesting a perforation. The gallbladder may show advanced acute inflammation despite a normal temperature and white count and negative physical findings. About 75 percent of the patients will respond to conservative treatment, and surgery in this group can be delayed a few days until fluid and electrolyte intake returns to normal. Approximately one patient in five with acute cholecystitis will not progressively improve and may worsen. Such patients require operation as an “off-schedule” urgent procedure, especially if they have diabetes mellitus.
The patient is placed in the usual position for gallbladder surgery. If local anesthesia is used, the position may be modified slightly to make the patient more comfortable.
The skin is prepared in the usual manner.
Incision and exposure are carried out as shown in Plate 95. The omentum must be separated carefully by either sharp or blunt dissection from the fundus of the gallbladder, care being taken to tie all bleeding points. An oblique incision below the costal margin is preferred, especially if the mass presents rather far laterally.
The appearance of the fundus and the patient's general condition determine whether it is safer to drain the gallbladder or to remove it from the fundus downward, or to proceed with the retrograde cholecystectomy. Blunt dissection only is utilized to free the omentum and other structures from the gallbladder wall. It is safer to empty the contents immediately to decrease the bulk and to give more exposure. A short incision is made through the serosa of the fundus, a trocar introduced, and the liquid contents are removed by suction. Cultures are taken. A fenestrated forceps is introduced deep into the gallbladder to remove any calculi in the ampulla. The opening is closed with a pursestring suture, which prevents further soiling and serves as traction.
An incision is made into the serosa of the gallbladder with a scalpel along both sides about 1 cm from the liver substance (Figure 1); otherwise, excessive traction will result in avulsion of the gallbladder from the liver bed. Separation is accomplished by blunt or scissors dissection, especially since the loose tissue beneath the serosa is edematous in the presence of acute cholecystitis (Figure 2). The cuff of gallbladder serosa in the region of the fundus is held with forceps, while the gallbladder is further freed by scissors dissection (Figure 3).
As an alternative method, since the contents have been aspirated and are frequently sterile, the opening in the fundus is enlarged, permitting the index finger or a gauze sponge to be inserted to give counter-resistance and to aid in dissecting within the developed cleavage plane.
The serosa is incised on each side down to the ampulla of the gallbladder. Since there may be difficulty from oozing because the cystic artery is intact, all bleeding points should be meticulously clamped. As the cuff at the margin of the liver is held by a curved, half-length clamp, a relatively dry field is obtained if the cuff is closed with interrupted sutures as the dissection progresses down to the ampulla (Figure 4). Most surgeons, however, leave the cuff edges free. Great care must be taken in isolating the ampulla from the common duct. It may be possible by finger compression to dislodge a calculus impinged in the ampulla and to separate the distorted ampulla from the adjacent structures. Alternate sharp and gauze dissection is advisable until the majority of adhesions have been separated. The gallbladder is retracted medially and outward to assist in identifying the cystic duct and cystic artery. After the ampulla is defined, the cystic duct is isolated with a right-angle clamp cautiously introduced from the lateral side to avoid injury to the common duct and to the right hepatic artery (Figure 4). The cystic artery is isolated with any accompanying indurated tissue. The artery may be much larger than normal, and the right hepatic artery may be in an anomalous position. It is safer to isolate the cystic artery as near the gallbladder wall as possible. The cystic artery and adjacent tissues are divided between a half-length and a right-angle clamp (Figure 5) and ligated.
The cystic duct is palpated carefully, especially if acute cholecystitis is present, to ensure that a stone has not been overlooked. The common duct is palpated carefully, and exploration is avoided unless the cholangiogram showed clear-cut evidence of a calculus there. If choledochostomy is not indicated, the cystic duct is divided between right-angle and half-length clamps (Figure 6) and tied unless a cholangiogram is planned through the cystic duct. After thorough inspection of the area for oozing, the clamp is removed from the liver margin. Since inflammation and technical difficulties have made this procedure necessary, a closed-system suction catheter made of Silastic is inserted down beyond the region of the cystic duct into Morison's pouch. Because of bile leakage, if raw liver surface has been exposed, drainage is always indicated. The bile is cultured for bacterial growth and antimicrobial sensitivities.