Cholecystostomy, while not recognized as routine treatment for cholelithiasis, may be a lifesaving procedure. Cholecystostomy is indicated for management of acute calculous or acalculous cholecystitis in patients with medical comorbidities that preclude safe cholecystectomy or, given the timing of patient presentation, when severe inflammation is anticipated to make immediate cholecystectomy unsafe. Today, cholecystostomy is usually performed under image guidance via a percutaneous technique. Nevertheless, surgical cholecystostomy may be needed in some situations. The two primary indications for surgical cholecystostomy are lack of equipment or expertise to perform percutaneous cholecystostomy and intraoperative findings at the time of planned cholecystectomy that make further attempts at gallbladder removal hazardous.
The skin is prepped and draped. Then a time-out is performed.
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 is encountered, the procedure is carried out through the standard right subcostal incision. The adhesions are not dissected from the undersurface of the gallbladder unless it is thought that cholecystectomy might be feasible (FIGURE 1).
The fundus is walled off with gauze before 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 Suction is maintained adjacent to the incision in the fundus as the trocar is withdrawn.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. Because 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, mushroom catheter, or Foley catheter is inserted into the lumen of the gallbladder and anchored with an interrupted silk suture (FIGURES 6 and 7). 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 ...