Plate 95

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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