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 ...