Cholecystectomy, Retrograde Method

Cholecystectomy is indicated in patients with proven disease of the gallbladder that produces symptoms. The incidental finding of gallstones by x-ray or a history of vague indigestion is insufficient evidence for operation in itself, especially in the elderly, and does not justify the risk involved. On the other hand, it is doubtful whether gallstones can ever be considered harmless, because, if the patient lives long enough, complications are likely to develop. 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 in combination with the laparoscopic approach.

A low-fat diet is advised. The patient should be free from respiratory infection. A roentgenogram of the chest is taken. Very obese patients should reduce their weight substantially by dieting, unless they are having recurrent attacks of colic. The entire gastrointestinal tract should be surveyed for additional disorders, i.e., hiatal hernia, ulcer of the stomach or duodenum, and carcinoma or diverticulitis of the colon.

General anesthesia with endotracheal intubation is recommended. Deep anesthesia is avoided by the use of a suitable muscle relaxant. Spinal, either single-injection or continuous technique, may be used in preference to general anesthesia. 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. An x-ray cassette or fluoroscopic C-arm needs 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.

Two incisions are commonly used: the vertical high midline and the oblique subcostal (Figure 2). A midline incision is used if other pathology, such as hiatus hernia or duodenal ulcer, requires surgical consideration. Those favoring the subcostal incision believe the exposure is good, early postoperative wound discomfort minimal, and the incidence of late postoperative hernias much lower than that following the vertical incisions. After the incision is made, the details of the procedure are identical, irrespective of the type of incision employed.

After the peritoneal cavity has been opened, the gloved hand, moistened with warm saline solution, is used to explore the abdominal cavity, unless there is an acute suppurative infection involving the gallbladder. The stomach and particularly the duodenum are inspected and palpated, and there is a general abdominal exploration that includes careful evaluation of the size of the esophageal hiatus. The surgeon next passes the right hand up over the dome of the liver, allowing air between the diaphragm and liver to aid in displacing the liver downward (Figure 3).

When assistance is limited, an external ring self-retaining retractor with adjustable retracting blades (such as a Bookwalter type) may be used advantageously, or an ordinary retractor of the Halsted type may be used on the right side to retract the costal margin. A half-length clamp is applied to the falciform ligament and another to the fundus of the gallbladder (Figure 4). Most surgeons prefer to divide the falciform ligament between half-length clamps, and both ends should be ligated; otherwise, active arterial bleeding will result. Downward traction is maintained by the clamps on the fundus of the gallbladder and on the round ligament. This traction is exaggerated with each inspiration as the liver is projected downward (Figure 4). After the liver has been pulled downward as far as easy traction allows, the half-length clamps are pulled toward the costal margin to present the undersurfaces of the liver and gallbladder (Figure 5). An assistant then holds these clamps while the surgeon prepares to wall off the field. If the gallbladder is acutely inflamed and distended, it is desirable to aspirate some of the contents through a trocar before the half-length clamp is applied to the fundus; otherwise, small stones may be forced into the cystic and common ducts. Adhesions between the undersurface of the gallbladder and adjacent structures are frequently found, drawing the duodenum or transverse colon up into the region of the ampulla. Adequate exposure is maintained by the assistant, who exerts downward traction with a warm, moist sponge. The adhesions are divided with curved scissors until an avascular cleavage plane can be developed adjacent to the wall of the gallbladder (Figure 6). After the initial incision is made, it is usually possible to brush these adhesions away with gauze sponges held in thumb forceps (Figure 7). Once the gallbladder is freed of its adhesions, it can be lifted upward to afford better exposure. In order that the adjacent structures may be packed away with moist gauze pads, the surgeon inserts the left hand into the wound, palm down, to direct the gauze pads downward. The pads are introduced with long, smooth forceps. The stomach and transverse colon are packed away, and a final gauze pack is inserted into the region of the foramen of Winslow (Figure 8). The gauze pads are held in position either by a large S retractor along the lower end of the field or by the left hand of the first assistant, who, with fingers slightly flexed and spread apart, maintains moderate downward and slightly outward pressure, better defining the region of the gastrohepatic ligament.

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After the field has been adequately walled off, the surgeon introduces the left index finger into the foramen of Winslow and, with finger and thumb, thoroughly palpates the region for evidence of calculi in the common duct as well as for thickening of the head of the pancreas. A half-length clamp, with the concavity turned upward, is used to grasp the undersurface of the gallbladder to attain traction toward the operator (Figure 9). The early application of clamps in the region of the ampulla of the gallbladder is one of the frequent causes of accidental injury to the common duct. This is especially true when the gallbladder is acutely distended, because the ampulla of the gallbladder may run parallel to the common duct for a considerable distance. If the clamp is applied blindly where the neck of the gallbladder passes into the cystic duct, part or all of the common duct may be accidentally included in it (Figure 10). For this reason it is always advisable to apply the half-length clamp well up on the undersurface of the gallbladder before any attempt is made to visualize the region of the ampulla of the gallbladder. The enucleation of the gallbladder is started by dividing the peritoneum on the inferior aspect of the gallbladder and extending it downward to the region of the ampulla. The peritoneum usually is divided with an electrocautery or long Metzenbaum dissecting scissors. The incision is carefully extended downward along with hepatoduodenal ligament (Figures 11 and 12). By means of blunt gauze dissection the region of the ampulla is freed down to the region of the cystic duct (Figure 13). After the ampulla of the gallbladder has been clearly defined, the clamp on the undersurface of the gallbladder is reapplied lower to the region of the ampulla.

With traction maintained on the ampulla, the cystic duct is defined by means of blunt dissection (Figure 13). A long right-angle clamp is then passed behind the cystic duct. The jaws of the clamp are separated cautiously as counter-pressure is placed on the upper side of the lower end of the gallbladder by the surgeon's index finger. Slowly and with great care, the cystic duct is isolated from the common duct (Figure 14). The cystic artery is likewise isolated with a long right-angle clamp. If the upward traction on the gallbladder is marked, and the common duct is quite flexible, it is not uncommon to have it angulate sharply upward, giving the appearance of a prolonged cystic duct. Under such circumstances, injury to the common duct or its division may result when the right-angle clamp is applied to the supposed cystic duct (Figure 15 and insert). Such a disaster may occur when the exposure appears too easy in a thin patient because of the extreme mobilization of the common duct.

After the cystic duct has been isolated, it is thoroughly palpated to ascertain that no calculi have been forced into it or the common duct by the application of clamps and that none will be overlooked in the stump of the cystic duct. The size of the cystic duct is carefully noted before the right-angle crushing clamp is applied. If the cystic duct is dilated and if it seems from palpation that the gallbladder contains calculi so small that they could pass through it easily, it is advisable to perform a choledochostomy. Regardless, an operative cholangiogram is performed routinely through the cystic duct after it has been divided (Plate 97, Figure 24). Because it is more difficult to divide the cystic duct between two closely applied right-angle clamps, a curved half-length clamp is placed adjacent to the initial right-angle clamp. The curvature of the half-length clamp makes it ideally suited for directing the scissors downward during the division of the cystic duct (Figure 16). Whenever possible, unless occluded by severe inflammation, the cystic duct and cystic artery are isolated separately to permit individual ligation. Under no circumstances is a right-angle clamp applied to the supposed region of the cystic duct in the hope that both the cystic artery and cystic duct can be included in one mass ligature. It is surprising how much additional cystic duct can often be developed by maintaining traction on the duct as blunt gauze dissection is carried out. After the cholangiogram, the cystic duct is ligated with a transfixing suture (Figure 17) or ligature, being sure not to encroach on the common duct. In general, the free length beyond the tie should approximate the diameter of the duct or vessel.

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If the cystic artery was not divided before the cystic duct, it is now carefully isolated by a right-angle clamp similar to those used in isolating the cystic duct (Figure 18). The cystic artery should be isolated as far away from the region of the hepatic duct as possible. A clamp is never applied blindly to this region, lest the hepatic artery lie in an anomalous location and be clamped and divided, resulting in a fatality (Figure 19). Anomalies of the blood supply in this region are so common that this possibility must be considered in every case. The cystic artery is divided between clamps similar to those utilized in the division of the cystic duct (Figure 20). The cystic artery should be tied as soon as it has been divided to avoid possible difficulties while the gallbladder is being removed (Figure 21). If desired, the ligation of the cystic duct can be delayed until after the cystic artery has been ligated. Some prefer to ligate the cystic artery routinely and leave the cystic duct intact until the gallbladder is completely freed from the liver bed. This approach minimizes possible injury to the ductal system as complete exposure is obtained before the cystic duct is divided. If the clamp or tie on the cystic artery slips off, resulting in vigorous bleeding, the hepatic artery may be compressed in the gastrohepatic ligament (Pringle maneuver) by the thumb and index finger of the left hand, temporarily controlling the bleeding (Figure 22). The field can be dried with suction by the assistant, and, as the surgeon releases compression of the hepatic artery, a hemostat may be applied safely and exactly to the bleeding point. The stumps of the cystic artery and cystic duct each are inspected thoroughly and, before the operation proceeds, the common duct is again visualized to make certain that it is not angulated or otherwise disturbed. Blind clamping in a bloody field is all too frequently responsible for injury to the ducts, producing the complication of stricture. Classic anatomic relationships in this area should never be taken for granted, since normal variations are more common in this critical zone than anywhere else in the body.

After the cystic duct and artery have been tied, removal of the gallbladder is begun. The incision, initially made on the inferior surface of the gallbladder about 1 cm from the liver edge, is extended upward around the fundus (Figure 23). An edematous cleavage plane can be developed easily by injecting a few milliliters of saline between the serosa and the seromuscular layer, utilizing this cleavage plane for dissection. It is important that the serosa be divided with a scalpel or scissors along both the lateral and medial margins of the gallbladder so that the gallbladder is not torn from the liver bed by traction. If this occurs, raw liver surface results, and it may be impossible to peritonealize the liver bed. With the left hand, the surgeon holds the clamps that have been applied to the gallbladder and, by careful scissors dissection, divides the loose areolar tissue between the gallbladder and the liver. This allows the gallbladder to be dissected from its bed without dividing any sizable vessels. The final peritoneal attachment between gallbladder and liver is severed.

When facilities permit, an operative cholangiogram (Figure 24) should be made routinely to ensure complete clearance of the ductal system. A syringe of saline as well as diluted contrast media should be connected by a two-way adapter in a closed system to avoid the introduction of air into the ducts. The cholangiogram catheter is filled with saline and it is introduced a short distance into the cystic duct. The tube is secured in the cystic duct by one tied suture utilizing a surgeon's knot. All gauze packs, clamps, and retractors are removed as the table is returned to a level position by the anesthesiologist. Five milliliters of contrast media, 20% to 25% concentration, are injected and the x-ray immediately taken. Limited amounts of a dilute solution prevent the obliteration of any small calculi within the ducts. A second injection of 15 to 20 mL is made to outline the ductal system completely and ensure patency of the ampula of Vater. The tube should be displaced laterally and the duodenum gently pushed to the right to ensure a clear roentgenogram without interference from the skeletal system or the tube filled with contrast media. Two roentgenograms are taken to provide a comparison in case doubtful shadows are noted, and another complete series of cholangiograms may be obtained if interpretation of the first two films is difficult. Alternatively, a fluoroscopic examination with continuous dye injection and periodic films may be performed. If no further studies are warranted, the tube is removed and the cystic duct ligated near the common duct. If the cystic duct cannot be used for the cholangiogram, a fine gauge needle, such as a butterfly, can be inserted into the common duct (Figure 25). The metal needle may be bent anteriorly as shown in the lateral view inset to facilitate its placement. Two or three dye injections are made and the needle is removed. The puncture site in the common duct is oversewn with a 0000 absorbable suture and some surgeons place a closed suction Silastic suction drain (Jackson-Pratt) in Morrison's pouch.

The portal vessel area and the gallbladder bed are inspected for hemostasis and the omentum is tacked against the gallbladder bed. Culture of the gallbladder bile is performed routinely.

The routine closure is performed. Most surgeons do not use a drain when the field is dry and there is no evidence of leakage from accessory ducts.

The orogastric tube is removed in the operating room by the anesthesiologist, while a nasogastric tube may be beneficial for a day or two if significant infection, ileus, or debility is present. Perioperative antibiotics are administered unless significant infection, gangrenous gallbladder, or cholangitis require several days of coverage for resolution of sepsis. Coughing and ambulation are encouraged immediately. Oral intake of fluids is begun within a day, whereupon intravenous hydration and electrolyte replacement are discontinued. The diet is advanced to solid food as tolerated; however, foods that historically trigger the biliary attacks are resumed gradually.