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 ...