Managing the difficult gallbladder

INTRODUCTION — 

Laparoscopic cholecystectomy is one of the most commonly performed operations worldwide with over 750,000 cases done in the United States annually. While the most common indication for the operation is uncomplicated biliary colic, there are a number of conditions that can increase the difficulty and risk of this procedure.

The "difficult gallbladder" is a scenario in which a cholecystectomy incurs an increased surgical risk compared with standard cholecystectomy [1]. Cholecystectomy can be made difficult by processes that either obscure normal biliary anatomy (eg, acute or chronic inflammation) or operative exposure (eg, obesity or prior upper abdominal surgery).

In this topic, we discuss risk factors that could predispose to a difficult gallbladder. Recognition of a potentially difficult gallbladder by the surgeon is the first step toward mitigating the high risks of operating on such patients. Pre- and intraoperative strategies of managing a difficult gallbladder are also presented.

Techniques of performing a routine cholecystectomy, both laparoscopic and open; treatment of biliary colic and acute cholecystitis; and management of a biliary injury are reviewed in other topics. (See "Laparoscopic cholecystectomy" and "Open cholecystectomy" and "Treatment of acute calculous cholecystitis" and "Clinical manifestations and evaluation of gallstone disease in adults" and "Repair of common bile duct injuries" and "Complications of laparoscopic cholecystectomy".)

RECOGNITION — 

A difficult gallbladder may often, though not always, be predicted preoperatively based on certain patient characteristics (table 1). A difficult gallbladder is typically caused by difficult exposure or inflammation. Other rarer causes include cirrhosis of the liver and Mirizzi syndrome. An astute surgeon can often anticipate a difficult cholecystectomy based on these patient characteristics and take steps to ensure the safe performance of the procedure.

Difficult exposure

●Previous upper abdominal surgery – Adhesive disease related to prior upper abdominal surgery creates exposure issues in terms of accessing the operative field for cholecystectomy. If the patient has had prior periumbilical midline surgery, then a site other than the umbilicus should be chosen for the initial access. Options include open access in the epigastric region or closed Veress needle access either in the right upper quadrant or, most often, left upper quadrant (Palmer's point). An important principle is to perform the initial access in a quadrant of the abdomen expected to be free from prior operative procedures (eg, if the patient has had a prior right colectomy, then avoid the right upper quadrant initially). Also, the initial access site near a site of prior surgery should always be inspected laparoscopically to exclude a possible injury. Ancillary ports may need to be placed to carry out adhesiolysis before ports can be inserted in the preferred location for cholecystectomy. Adhesiolysis should be done without energy to the extent possible to minimize the risk of thermal injury to the bowel. (See "Abdominal access techniques used in laparoscopic surgery".)

●Obesity – Evidence suggests that individuals with obesity have a higher prevalence of gallstone diseases than normal-weight individuals [2] and that severe obesity can lead to increased complication and conversion rates of gallbladder surgery [3]. Obesity produces many technical challenges during cholecystectomy and has been associated with a higher rate of conversion to open cholecystectomy [4]. One study found that patients with body mass index (BMI) >50 kg/m² had an increased incidence of life-threatening postoperative complications and conversion to open procedures, especially with acute cholecystitis [5]. The incidence of common bile duct injury did not correlate with BMI.

Initial access may be more difficult in patients with obesity due to the increased thickness of the abdominal wall. Because the umbilicus is displaced inferiorly, the camera port should be placed more cephalad at approximately 15 cm below the xiphoid process to provide better laparoscopic visualization (picture 1).

Because patients with obesity have a thick abdominal wall, and the thickness of the wall inhibits the mobility of the trocars, trocars should be placed at the angle most likely to be used during the cholecystectomy. Longer trocars may be needed to traverse the abdominal wall in order to avoid trocar displacement and subsequent insufflation within the abdominal wall and subcutaneous emphysema. Longer instruments may be required to reach the gallbladder.

Both body habitus and BMI play a role leading to difficulties with operative exposure. Patients with a central obesity pattern have an abundance of visceral fat, which can obscure exposure of the lower part of the gallbladder. For such patients, extra measures to obtain proper retraction may be required; the surgeon should not hesitate to place additional trocars and instruments as needed to retract the omentum inferiorly.

Additionally, patients with obesity often have a bulky, fatty liver, which makes it heavier, less flexible, and harder to elevate to expose the gallbladder. The gallbladder is also often intrahepatic, which makes it more difficult to dissect from the liver bed. Implementation of a 1200 kcal diet for three weeks prior to surgery may reduce fatty liver bulk and reduce the technical difficulty of laparoscopic cholecystectomy [6,7].

Inflammation

●Severe chronic cholecystitis – Biliary colic, also referred to as symptomatic cholelithiasis, is the most common indication for gallbladder surgery. Classic biliary colic is described as discrete episodes of postprandial right upper quadrant abdominal pain that lasts for several minutes to hours. Other symptoms include bloating, epigastric discomfort, nausea, vomiting, and right-sided scapular area/back pain, and attacks often follow a meal high in fat. Typically, biliary colic is related to transient mechanical obstruction of the cystic duct caused by cholelithiasis, but it can also be related to functional issues with the gallbladder, as in biliary dyskinesia. The vast majority of patients with uncomplicated biliary colic can be managed with laparoscopic cholecystectomy, with the major risk factor for difficulty being a thickened gallbladder wall on ultrasound. Other factors that may be associated with increased difficulty in patients with biliary colic are multiple prior attacks, older age, male sex (likely due to the presence of more complicated gallstone disease in such patients), previous upper abdominal surgery, and obesity (table 1). (See "Approach to the management of gallstones", section on 'Biliary colic'.)

Severe chronic cholecystitis results from longstanding inflammation due to repeated episodes of biliary colic. The resulting desmoplastic reaction leads to difficulty in retraction, exposure, and manipulation of tissue during cholecystectomy. The gallbladder may also become markedly contracted and shrunken with obliteration of tissue planes in the hepatocystic triangle, which can make the dissection hazardous. In a small trial, early laparoscopic cholecystectomy (defined as within 24 hours of diagnosis) prevented recurrent emergency room visits and complications (eg, pancreatitis, jaundice) and was associated with a shorter operative time, conversion rate, and length of hospital stay compared with delayed surgery (after a mean of 4.2 months) [8].

●Acute cholecystitis – Acute cholecystitis is the indication for approximately 10 percent of cholecystectomies (approximately 120,000 cases annually in the United States) and is the most common cause of a difficult gallbladder [9]. Patients with acute cholecystitis present with persistent right upper quadrant pain and inflammatory signs (fever, elevated white blood cell count, and a positive Murphy's sign on physical examination), although not all inflammatory signs are present in each patient. Classic diagnostic findings on ultrasound, besides cholelithiasis, include a distended gallbladder, a thickened gallbladder wall (>3 mm), and pericholecystic fluid. In some cases, a large stone may be impacted in the neck of the gallbladder. Although approximately 60 percent of patients with acute cholecystitis are women, pathology tends to be more severe in men.

Data from a large database review from 2000 to 2005 indicate that 85 percent of cholecystectomies for acute cholecystitis were started as laparoscopic procedures and 15 percent as open procedures; 9.5 percent of cases that started laparoscopically required conversion to open procedures [10]. In a more recent international prospective cohort study of over 21,000 patients undergoing cholecystectomy for benign gallbladder disease, the approach was laparoscopic in 91.3 percent (95.4 percent in elective cases and 82.9 percent in emergency cases). Conversion to open cholecystectomy occurred in 3 percent of patients overall and in 5.5 percent of those undergoing emergency surgery [11].

Challenges in laparoscopic cholecystectomy are related to the acute inflammatory process that can obscure the hepatocystic triangle and to difficulty in manipulating and retracting the gallbladder due to edema, large stones, or necrosis. Risk factors for increased difficulty of cholecystectomy for acute cholecystitis include greater than 72 hours of symptoms, white blood cell count greater than 18,000/mm³, a palpable gallbladder on exam, multiple comorbidities, and suspected gangrenous cholecystitis [12]. Imaging findings of a thickened gallbladder wall also are a risk factor for increased difficulty.

The results of several randomized trials and subsequent meta-analyses have shown that cholecystectomy performed within the first 72 hours of symptoms leads to earlier discharge, fewer wound complications, and reduced hospital costs [13-18]. An advantage of early cholecystectomy in this setting is that the inflammatory process is more edematous, which makes the dissection easier, whereas later in the process it becomes more vascular and fibrotic. If the patient presents in a delayed fashion (>72 hours from onset of symptoms), the surgery can be performed if there are no contraindications to an open procedure, as conversion is a significant risk. In the face of acute cholecystitis with multiple comorbidities, it may be preferable to treat with intravenous antibiotics and possibly percutaneous drainage, with subsequent laparoscopic cholecystectomy six to eight weeks later. (See "Treatment of acute calculous cholecystitis", section on 'Timing of cholecystectomy'.)

Mirizzi syndrome — Mirizzi syndrome is a rare condition in which there is obstruction of the common hepatic duct due to extrinsic compression from a large, impacted stone in the neck of the gallbladder or cystic duct [19]. Mirizzi syndrome was identified in between 0.06 and 2.7 percent of patients undergoing cholecystectomy [20,21]. There are two principal types: extrinsic compression of the common hepatic duct only, and extrinsic compression of the common hepatic duct with fistulization between the gallbladder and the common hepatic or common bile duct due to erosion by the stone. There are three subtypes of fistulization that require surgical reconstruction of the biliary system, which are beyond the scope of this review. The presence of a large stone in the neck of the gallbladder in association with a dilated common hepatic duct should raise suspicion for this diagnosis. Magnetic resonance cholangiopancreatography (MRCP) may be done to confirm the diagnosis in suspected cases. (See "Mirizzi syndrome".)

Laparoscopic surgery for Mirizzi syndrome presents a challenge because the dense adhesions and edematous inflammatory tissue cause distortion of the normal anatomy and increase the risk for biliary injury. In a 2010 systematic review of 124 patients from 10 studies, conversion, complication, and reoperation rates were 41, 20, and 6 percent, respectively. The risks for open conversion and procedure-related complications were similar for patients with type I and type II Mirizzi syndrome [22]. Laparoscopic cholecystectomy can be attempted in patients with Mirizzi syndrome but may require conversion to open surgery in cases of unclear anatomy or biliary duct involvement. For patients who have complex Mirizzi's with suspicion of a biliary fistula, treatment in a tertiary center with interventional endoscopic and advanced hepatobiliary surgical expertise is advisable.

Cirrhosis — Patients with cirrhosis and symptomatic gallstones are at increased risk for cholecystectomy for a number of reasons:

●Increased collaterals and portal hypertension that increase the risk of bleeding

●Risk of deterioration in liver function with surgery and anesthesia

●Increased difficulty of exposure due to the fibrosis in the liver

Patients with cirrhosis should have determination of liver function by Child classification (calculator 1) or MELD (Model for End-Stage Liver Disease) score (calculator 2) preoperatively. Child A and B class patients can undergo laparoscopic cholecystectomy when clinically appropriate, whereas Child C class patients with gallbladder disease need to be managed individually in conjunction with a hepatologist due to high surgical risk and lack of data.

The MELD score predicted postoperative morbidity better than the Child classification; patients with preoperative MELD score >13 had a higher complication rate [23]. In a study of 349 cirrhotic patients undergoing cholecystectomy (59 percent laparoscopic), the morbidity and mortality rates were 18.7 and 3.8 percent, respectively. The MELD score was an independent factor of morbidity and mortality, while the laparoscopic approach had a protective effect on morbidity. A nomogram can be used to predict outcomes [24].

It should be noted that patients with cirrhosis and ascites are also at high risk for treatment by percutaneous cholecystostomy tube drainage. Failure of the cholecystostomy tube to seal around the gallbladder and abdominal wall can result in bile leak and infected ascites.

In a nonsystematic review of studies of laparoscopic cholecystectomy in cirrhotic patients published between 1994 and 2011, most of the 1310 patients were Child A or B (78 and 20 percent, respectively). The overall mortality was 0.45 percent, the overall morbidity was 17 percent, and the conversion rate was 5 percent [25]. The mortality rates for patients with Child C cirrhosis undergoing cholecystectomy, however, were as high as 50 to 83 percent in individual series [26,27].

In a 2003 meta-analysis of 25 comparative studies of cirrhotic patients, laparoscopic cholecystectomy was associated with less blood loss (113 versus 425 mL), shorter operative time (123 versus 150 minutes), and a shorter hospital stay (6 versus 12 days) compared with open cholecystectomy [26]. Two randomized trials published later also showed that compensated cirrhotic patients undergoing laparoscopic cholecystectomy had similar mortality, morbidity, and postoperative liver function but less pain, earlier mobilization and feeding, better cosmesis, and shorter hospital stay compared with patients undergoing open cholecystectomy [28,29].

In preparation for laparoscopic cholecystectomy, cirrhotic patients should undergo coagulation studies to exclude increased international normalized ratio (INR), a complete blood count to exclude anemia or thrombocytopenia, liver function tests, and a type and screen because of the potential of significant blood loss. Patients with low platelet count (<50,000/mm³) or abnormal prothrombin time require transfusion of platelets or fresh frozen plasma [30].

A computed tomography (CT) scan with contrast (portal phase) should also be obtained to identify any potential varices in the gallbladder bed or a recanalized umbilical vein that would increase the risk for injury and major hemorrhage. Modification of the surgical approach to cholecystectomy may be necessary for cirrhotic patients to avoid lacerating a recanalized umbilical vein or varices. Some authors prefer to use the open Hasson technique at the infraumbilical location where there are fewer varices [31]. If the umbilical vein or a varix is lacerated, it must be suture ligated.

An extra port may be necessary to facilitate retraction and exposure. Various topical hemostatic agents and energy sources (eg, the argon cautery device can be quite useful) need to be available in case bleeding develops. An advanced energy device (eg, ultrasonic coagulator or advanced bipolar device) may be preferable for dissection of the gallbladder for hemostasis reasons. In a small randomized trial, the use of an ultrasonic coagulator resulted in a shorter operative time, less blood loss, and a lower incidence of gallbladder perforation compared with conventional diathermy [32]. Particular care should be taken in making watertight closures for all incisions to minimize perioperative ascitic leaks [33].

It is extremely important to stay out of the liver bed during the dissection due to the increased bleeding risk. If increased collaterals are identified around the gallbladder at the time of operation, consideration should be given to subtotal cholecystectomy or aborting the procedure. In one study of Child A and B cirrhotic patients undergoing cholecystectomy, the subtotal approach was used in 78 percent of patients (206 out of 265) [34].

Finally, if unsuspected or undiagnosed cirrhosis is found at the time of cholecystectomy, a core needle biopsy may help confirm the diagnosis, and the patient should undergo hepatitis serology testing postoperatively and be referred to a hepatologist for further evaluation and management. (See "Cirrhosis in adults: Etiologies, clinical manifestations, and diagnosis" and "Cirrhosis in adults: Overview of complications, general management, and prognosis".)

Pregnancy — There is a strong association between pregnancy and gallstones. In the past, gallbladder surgery was deferred as much as possible until after pregnancy for fear of maternal or fetal complications. However, waiting until after pregnancy can lead to repeated hospitalizations and complications [35]. In contemporary practice, laparoscopic cholecystectomy can be performed safely for acute cholecystitis in any trimester of the pregnancy. (See "Gallstone disease in pregnancy", section on 'Cholecystectomy during pregnancy'.)

When laparoscopic surgery is performed in pregnant patients, the trocars need to be placed higher in the abdomen due to the enlarged uterus. The CO₂ insufflation should be kept at the lowest possible pressure while maintaining an adequate working space. If common bile duct imaging is necessary, laparoscopic ultrasound should be used in place of intraoperative cholangiogram to limit radiation exposure. Preoperative obstetric consultation and perioperative fetal monitoring are advisable [36]. Details of proper positioning for surgery and management of pregnant patients undergoing surgery are discussed elsewhere. (See "Anesthesia for nonobstetric surgery during pregnancy" and "Laparoscopic surgery in pregnancy".)

MANAGEMENT

Nonoperative management of acute cholecystitis in high-risk patients

Observation and antibiotics — Although the contemporary management of acute cholecystitis for low-risk patients is cholecystectomy within the index admission, nonoperative management with antibiotics is a viable option for high-risk patients. In a 2017 meta-analysis of 1841 patients, nonoperative management during the index admission was successful in 87 percent with acute calculus cholecystitis and 96 percent with mild disease. Mortality was 0.5 percent, and recurrent gallstone-related disease occurred in 22 percent of patients [37]. The choice and duration of antibiotics are discussed separately. (See "Treatment of acute calculous cholecystitis", section on 'Antibiotics'.)

Cholecystostomy tube drainage — Percutaneous cholecystostomy tube drainage of the gallbladder is an option for high-risk patients with acute cholecystitis who are at increased risk for urgent surgical treatment, including recent myocardial infarction, extreme age and deconditioning, or multiple high-risk medical comorbidities.

Percutaneous cholecystostomy tube drainage may also be elected due to gallbladder disease factors such as presentation beyond 72 to 96 hours, markedly thickened gallbladder wall on imaging, white blood cell (WBC) count >18,000 mm³, and other local conditions deemed hostile for urgent cholecystectomy (eg, localized abscess).

Cholecystostomy tube placement has proven to be effective in resolving the acute episode in approximately 90 percent of cases. Patients who fail to improve with percutaneous drainage should undergo urgent cholecystectomy. Following placement of a cholecystostomy tube, interval cholecystectomy can be performed two to three months later with a lower degree of technical difficulty and a lower risk of complications. In one trial, 150 patients with grade II acute cholecystitis who presented beyond 72 hours after the onset of symptoms were randomly assigned to early laparoscopic cholecystectomy or percutaneous gallbladder tube drainage followed by interval cholecystectomy six weeks later [38]. Although cholecystitis resolved quickly in both groups, the drainage group had a lower rate of conversion to open operation (2.7 versus 24 percent), shorter operative time (38 versus 89 minutes), less blood loss, a shorter hospital stay (11 versus 52 hours), fewer postoperative complications (2.7 versus 27 percent), and less bile leak (0 versus 10.7 percent) compared with the early cholecystectomy group. (See "Treatment of acute calculous cholecystitis", section on 'Gallbladder drainage'.)

In most patients, the cholecystostomy tube will need to remain in place until surgery. According to consensus conference guidelines on prevention of bile duct injury during cholecystectomy, patients who are good surgical candidates should undergo interval cholecystectomy once the inflammation has subsided. Poor or borderline candidates may pursue a nonsurgical approach such as percutaneous stone clearance through the tube tract, or tube removal and observation if the cystic duct is patent [39].

In a retrospective study of 288 patients with acute cholecystitis, resolution of symptoms was achieved in 91 percent after cholecystostomy tube placement, but reintervention for tube dysfunction was needed in 80 patients (28 percent) [40]. Elective interval cholecystectomy lowered the rate of recurrent biliary events from 21 to 7 percent and was more likely to be completed laparoscopically compared with patients who required urgent surgery due to tube complications or recurrent symptoms (44.7 versus 24.3 percent). In a separate study of 93 high-risk patients with acute cholecystitis managed by cholecystostomy tube placement, 31 patients did not undergo cholecystectomy due to medical reasons. The 30 day mortality was 6 percent in that group, and 19.3 percent developed recurrent cholecystitis after tube removal [41]. (See "Treatment of acute calculous cholecystitis", section on 'Subsequent care following drainage'.)

Endoscopic ultrasound-guided gallbladder drainage — Another technique for gallbladder drainage using endoscopic ultrasound has been described in high-risk patients. In this approach, a lumen-opposing metal stent is placed between the gallbladder and the duodenum using endoscopic ultrasound guidance. An advantage of this approach over percutaneous drainage is that it may allow for stones to pass and completely decompress the gallbladder without an external tube. However, it does create a fistula between the gallbladder and the duodenum. In one study of 34 patients, the technical and clinical success rates were 92 and 88 percent, respectively; adverse events occurred in 16 percent of cases [42]. The 30 day and one-year mortality rates were 12 and 32 percent due to the high-risk nature of the population undergoing this procedure. It should be emphasized that this approach to gallbladder drainage can make future cholecystectomy difficult because of the fistula between the gallbladder and duodenum that is created. (See "Treatment of acute calculous cholecystitis", section on 'Transmural drainage'.)

Safe dissection techniques — Regardless of operative approach (laparoscopic, robotic-assisted, or open) or nature of the underlying gallbladder pathology, a number of principles related to safe performance of cholecystectomy should be followed. In 2018, an international multi-society consensus conference was held on the prevention of bile duct injury during cholecystectomy, including the critical view of safety (CVS) and other safe strategies for this procedure, with subsequent publication of clinical practice guidelines for safe cholecystectomy throughout this review [39]. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Safe Cholecystectomy program has identified six steps that surgeons can undertake to enhance a universal culture of safety around cholecystectomy [43]:

●Understand and apply the critical view of safety. (See 'Critical view of safety' below.)

●Recognize and understand the potential for aberrant anatomy.

●Make liberal use of cholangiography or other means of imaging the biliary tree, which may be especially important in managing the difficult gallbladder.

●Consider an intraoperative timeout before clipping or cutting any ductal structures.

●Recognize when the dissection is approaching an area of significant risk (eg, severe inflammation in the hepatocystic triangle or porta hepatis) and halt the dissection before entering that zone. In such cases, one should consider altering to subtotal cholecystectomy or other approaches. (See 'Subtotal cholecystectomy' below.)

●Get help for difficult cases or if there is a suspicion of possible biliary or other injury.

Critical view of safety — The CVS is a method of ductal identification that has three elements (image 1) [44]:

●The hepatocystic triangle should be cleared of all fat and fibrous tissue.

●Two and only two structures (cystic artery and cystic duct) are seen going into the gallbladder in a 360° view.

●The gallbladder is dissected off the liver bed to expose the lower one-third of the cystic plate.

This approach is based on the principles of open cholecystectomy in which the cystic structures were isolated but not divided, and the entire gallbladder was then dissected from the liver bed, leaving it attached by the cystic artery and duct only [45]. Failure to establish the critical view of safety during laparoscopic cholecystectomy may necessitate conversion to open surgery or subtotal cholecystectomy.

However, it is important to note that there is some flexibility within establishing a critical view as originally outlined by Strasberg and Soper. A level of flexibility within the definition is important as there are many difficult cases where certain aspects of the critical view may not be achievable due to patient pathology [46]. Specifically, it may be necessary to separately identify, dissect, and divide the cystic artery, as it runs on the gallbladder first, in order to better mobilize the body of the gallbladder off the cystic plate. This dissection alternatively leaves one structure (the cystic duct) to be viewed in 360 degrees at the completion of the dissection.

Since its introduction in 1995, the CVS technique has been shown to be effective for ductal identification, with which several thousands of patients have undergone laparoscopic cholecystectomy without a biliary injury due to misidentification [47,48]. Although it is not the only acceptable method of ductal identification (the others being routine cholangiography and the infundibular technique) [49], CVS is endorsed by multiple surgical societies internationally [39,43,50,51].

Safe dissection of acutely inflamed gallbladder — In patients with an acutely inflamed gallbladder, a number of other techniques may need to be employed:

●If the gallbladder is distended, one should aspirate the bile with a laparoscopic needle before attempting to grasp and retract it to avoid spillage of bile and stones (picture 2). If the bile is too thick to aspirate, a 5 mm trocar can even be used to puncture the gallbladder wall and aspirate the content, with the puncture site subsequently secured with an endoscopic loop suture.

●The presence of an omental pack may signify an underlying gangrenous or perforated gallbladder, and the omental pack must be taken down as the initial step. In the process, one should also be aware of the potential for the duodenum or colon to be adherent to the omentum or gallbladder and be wary of the potential for thermal injury to those structures.

●When there is a large stone impacted in the neck of the gallbladder, which makes the gallbladder difficult to grasp, one can simply push the gallbladder from side to side with an open grasper.

●It may be necessary to use blunt dissection with a Kittner-type dissector to clear the hepatocystic triangle. Blunt dissection with a suction irrigator or laparoscopic peanut is particularly useful in defining anatomy around a grossly inflamed duct.

●An ultrasonic dissector or advanced bipolar device may facilitate separation of the gallbladder from the liver bed and enhance hemostasis and decrease smoke generation that occurs with monopolar electrosurgery. It is important to avoid getting into the liver parenchyma in dissecting the gallbladder from the liver bed because of the bleeding risk and also because of the potential for injuring a superficial bile duct that can result in a bile leak postoperatively. It should be noted that most bile leaks from the liver bed originate from a superficial bile duct that has been injured by dissection into the liver parenchyma. In a gallbladder densely adherent to the liver where the plane between the two is obliterated and/or in the presence of portal hypertension, it may be preferable to leave the back wall of the gallbladder intact and fully cauterize its mucosa [52].

Robotic-assisted laparoscopic cholecystectomy — Robotic-assisted approaches to cholecystectomy are being increasingly utilized for both elective and more difficult cases. Given the pervasiveness of robotic surgery across the spectrum of general surgery today, this trend will likely continue. It is critically important to recognize that regardless of whether a straight laparoscopic or robotic-assisted approach is utilized, the same principles of safe cholecystectomy apply.

In a 2023 study of over 1 million cholecystectomies from the Medicare claims data, a higher rate of bile duct injury requiring definitive repair was associated with the robotic approach compared with laparoscopic cholecystectomy (0.7 versus 0.2 percent) [53]. Robotic cholecystectomy was also associated with a higher rate of postoperative biliary interventions (7.4 versus 6 percent). In contrast, a large nationwide United States discharge database study of over 790,000 emergency or urgent cholecystectomies found that robotic surgery was associated with a significantly lower risk of conversion to open surgery (1.7 versus 3 percent) [54].

Another study analyzed 50 robotic-assisted cholecystectomy videos that were published online and were scored for achievement of the critical view of safety [55]. The mean CVS score was 2.4 out of 6 total points, and only 4 of 50 of the published videos (8 percent) reached a passing CVS score of five or higher, indicating room for improvement. A study of 600 robotic-assisted cholecystectomies from 11 centers in the United Kingdom involved in a structured robotic hepato-pancreato-biliary training program found conversion rates of zero and no bile duct injuries, which indicates robotic technology can be implemented safely into practice using a standardized training approach [56].

Conversion to open surgery — When a laparoscopic cholecystectomy is made difficult because of local gallbladder or intraabdominal conditions, conversion to open surgery may be necessary. The most compelling immediate reason for conversion to open cholecystectomy is bleeding that could not be controlled laparoscopically.

There have been concerns that the increase in laparoscopic and robotic cholecystectomy over time has created a lack of experience with an open approach for surgical trainees with difficult gallbladder cases. As a result, a tolerance to bail out procedures such as laparoscopic subtotal cholecystectomy may be a better option (see 'Subtotal cholecystectomy' below). For the rare case in which the hepatocystic triangle could not even be reached because of the degree of inflammation and adhesions, placing a cholecystostomy tube and referring the patient to a tertiary center may be considered (see 'Cholecystostomy tube drainage' above). Ultimately, the surgeon's experience and expertise with open cholecystectomy is one of the most important determinants of whether conversion is the best management option or not.

Presently, most open cholecystectomies are conversions from the laparoscopic approach. In a multicenter prospective cohort study of 8820 patients undergoing laparoscopic cholecystectomy, the overall conversion rate was 3.4 percent and bile duct injury rate 0.33 percent [57]. On multivariate analysis, independent factors associated with an increased risk of conversion were older age, higher American Society of Anesthesiologists (ASA) class, being male, presence of acute cholecystitis or bile duct stone, increased gallbladder wall thickness, and a dilated bile duct.

In a study of 1 million laparoscopic cholecystectomies for acute cholecystitis derived from the National Hospital Discharge Sample for 2000 to 2005, the conversion rate from laparoscopic to open surgery was 9.5 percent [10]. In another study from a tertiary care center of 809 patients with acute cholecystitis treated from 2002 to 2007, open cholecystectomy was the initial approach in 1 percent of cases, and conversion rate from laparoscopic to open surgery was 6.3 percent [58]. In a more recent international prospective cohort study of over 21,000 patients undergoing cholecystectomy for benign gallbladder disease, conversion to open cholecystectomy occurred in 3 percent of patients overall and in 5.5 percent of those undergoing emergency surgery [11].

It should be noted that conversion to open cholecystectomy in the setting of acute cholecystitis is not necessarily protective of a bile duct injury. In a prospective study of laparoscopic cholecystectomy for acute cholecystitis across multiple centers and from 53 surgeons, the initial operative approach was laparoscopic in 93.2 percent and open in 6.8 percent [59]. Conversion to open cholecystectomy occurred in 11.4 percent of cases and was twice as common in males as in females (14.9 versus 7.5 percent). The incidence of biliary injury, including bile leaks, in this study was 1.4 percent. For the 116 patients converted from laparoscopic to open cholecystectomy, the bile duct injury rate was 6.0 percent and the biliary fistula rate 7.7 percent for an overall biliary complication rate of 13.7 percent. Of the seven major bile duct injuries in converted patients, three occurred after conversion to an open operation. These findings highlight the risks in this population of patients and support the concept of altering the approach to a less-than-total cholecystectomy (eg, laparoscopic subtotal cholecystectomy) when conditions are considered dangerous. (See 'Subtotal cholecystectomy' below.)

Top-down cholecystectomy — An alternative approach in patients undergoing laparoscopic cholecystectomy in whom the dissection is difficult is the top-down approach, which has been advocated by some groups [60]. When the dissection of the hepatocystic triangle is difficult, the gallbladder can instead be taken off the liver bed from the fundus down until the area of the hepatocystic triangle is reached. It can be challenging to initially develop the proper dissection plane because of a lack of traction with the neck of the gallbladder still attached to the liver bed. Initiating a top-down approach can also be a first step to performing a safe subtotal cholecystectomy either laparoscopically or open. However, because the common bile duct and/or right hepatic artery are still tethered to the hepatocystic triangle and are vulnerable to injury, one should exercise extreme caution when approaching the hepatocystic triangle and potential zone of danger during dissection, especially when considerable inflammation is present. It should be noted that severe vasculo-biliary injuries that result in major liver injury or death have been associated with the top-down technique [61].

Subtotal cholecystectomy — In scenarios when surgeons encounter marked acute local inflammation or chronic cholecystitis with biliary inflammatory fusion of tissues/tissue contraction during laparoscopic cholecystectomy that prevent the safe identification of the cystic duct and artery, consensus conference guidelines suggested that surgeons perform subtotal cholecystectomy either laparoscopically or open [39]. Strategies for working through various difficult cholecystectomy scenarios in which subtotal cholecystectomy may be indicated have been detailed [62].

In subtotal cholecystectomy, the gallbladder is opened above the neck, all stones are removed, and the neck of the gallbladder is left in situ to protect the area of the critical structures (eg, common bile duct). Cholangiography may be done if deemed necessary directly from within the lumen of gallbladder neck or cystic duct. The gallbladder above the neck is removed, although the back wall of the gallbladder may be left attached to the liver bed. Other bailout options if conditions are too dangerous include surgically placing a drainage tube in the gallbladder or aborting the procedure.

Two primary options exist for subtotal cholecystectomy, fenestrating versus reconstituting subtypes (figure 1) [63]:

●Subtotal fenestrating cholecystectomy leaves the neck of the gallbladder open, although the cystic duct may be closed from within the lumen by direct suturing; in many cases, the cystic duct is occluded, so this may not be necessary (picture 3) [64].

●Subtotal reconstituting cholecystectomy closes the neck of the gallbladder by sutures, a loop ligating suture (Endoloop type), or a surgical stapler.

The details of how subtotal cholecystectomy is performed are important. In general, closure of the gallbladder remnant with the reconstituting technique can lead to stone reformation and recurrent symptoms, whereas the fenestrating technique has a higher likelihood of bile leak or biliary fistula. Regardless of the method, the gallbladder remnant should be relatively small with enough margin to protect the critical biliary structures and all stones should be removed. In a retrospective study of 191 patients, bile leakage was more common after fenestrating than after reconstituting subtotal cholecystectomy (18 versus 7 percent) [65]. After a median follow-up of 6 years, recurrent biliary events were more common after reconstituting than after fenestrating subtotal cholecystectomy (19 versus 9 percent). A similar proportion of patients required reintervention after fenestrating versus reconstituting subtotal cholecystectomy (32 versus 26 percent), although more completion cholecystectomy was required after fenestrating subtotal cholecystectomy (9 versus 4 percent). In another series of 85 subtotal cholecystectomies, reconstituting subtotal cholecystectomies had lower odds of postoperative endoscopic retrograde cholangiography than reconstituting subtotal cholecystectomies (odds ratio 0.12, 95% CI 0.023 to 0.58) [66]. In a single-center series of 46 completion cholecystectomy, remnant cholecystitis was the most common reason for reoperation (80 percent), followed by choledocholithiasis, bile leak, gallstone pancreatitis, and abdominal abscess [67].

One group described plugging the remnant gallbladder with a piece of omentum after subtotal cholecystectomy and showed it reduced bile leak rate in a small retrospective study [68].

Regardless of the technique used, a closed suction drain should be placed in the gallbladder fossa after a subtotal cholecystectomy to evacuate any bile leak, which usually will close spontaneously. It should be noted that the subtotal technique can be performed either laparoscopically or open and is applicable to patients with cirrhosis and increased collaterals in the liver bed as well.

In a meta-analysis of 30 studies on subtotal cholecystectomy for difficult gallbladders, the procedure was carried out laparoscopically in 72.9 percent of cases [1]. The most common indications were severe cholecystitis (72 percent) followed by portal hypertension (18 percent). The bile duct injury rate was 0.08 percent, although the rate of bile leak was 18 percent. The laparoscopic approach was associated with a lower rate of subhepatic fluid collections, retained stones, wound infection, reoperation, and mortality but a higher rate of bile leaks.

A study compared outcomes of laparoscopic subtotal cholecystectomy versus conversion to open cholecystectomy as a bail-out procedure [69]. Conversion to open was performed in 67 percent of 675 patients and was associated with a significantly higher risk of bile duct injury (3.9 versus 0.44 percent), bleeding, intestinal injury (4.4 versus 0 percent), and wound infection (4 versus 0.89 percent). Laparoscopic subtotal cholecystectomy had a higher risk of bile leak (13 versus 8.2 percent).

A multi-center institutional study also compared outcomes of open and laparoscopic cholecystectomy [70]. Bailout procedures were performed in 727 patients: laparoscopic subtotal (n = 317), open subtotal (n = 172), and open total cholecystectomy (n = 238). Open procedures were associated with higher rates of intraoperative bleeding, surgical site infection, intensive care unit admission, and length of stay. Also, reoperations occurred more commonly with open reconstituting subtotal cholecystectomy than with other subtypes. The rate of bile duct injury overall was 1.1 percent but was not significantly lower in the laparoscopic subtotal cholecystectomy group (bile duct injury rate 0.63 percent). Together, these studies suggest that defaulting to open cholecystectomy in these difficult cases does not necessarily lead to better outcomes.

Imaging adjuncts — Various imaging modalities can be used liberally during a difficult cholecystectomy to define anatomy, guide dissection, and avoid injury to the bile duct.

Intraoperative cholangiography — The consensus conference guidelines recommend that cholangiography be performed liberally in patients with acute cholecystitis or a history of acute cholecystitis to mitigate the risk of bile duct injury [39]. The consensus made a strong recommendation for using cholangiography in patients with uncertain biliary anatomy or suspicion of biliary injury to mitigate the risk of injury, although no recommendation was made for routine cholangiography during elective cholecystectomy due to inconclusive evidence.

We recommend performing intraoperative cholangiography in difficult gallbladder scenarios to help identify vital structures, guide dissection, and confirm anatomy. The role of routine cholangiography in prevention of bile duct injury, however, is controversial. Some population-based studies [71-74], but not others [75], show a lower overall rate of biliary injuries or a higher rate of intraoperative common duct stone management with routine cholangiography.

Intraoperative cholangiography involves cannulating the cystic duct and injecting contrast dye under fluoroscopy to evaluate the biliary ductal system and confirm the anatomy as well as identification of common bile duct stones. Hallmarks of a complete and adequate cholangiogram include identification of the cystic duct, visualization of both the right and left hepatic ducts, smooth tapering of the common bile duct, and emptying of contrast into the duodenum (image 2). Cholangiography is also a prerequisite for performing common bile duct exploration. (See "Surgical common bile duct exploration", section on 'Intraoperative cholangiography'.)

Intraoperative ultrasound — Laparoscopic intraoperative ultrasound is another option that can be used in difficult cases with high reliability for defining biliary anatomy [76]. In one study of patients with acute cholecystitis, intraoperative ultrasound allowed for successful and safe completion of laparoscopic cholecystectomy in patients who would otherwise have required conversion to an open procedure [77]. For surgeons with appropriate expertise and training, intraoperative ultrasound can be used as an alternative to intraoperative cholangiography [39].

Fluorescent imaging — The newest imaging adjunct for cholecystectomy is near-infrared fluorescent cholangiography [78]. After the intravenous injection, indocyanine green (ICG) is taken up by the liver and excreted into the bile, which allows visualization of the biliary tree and cystic duct (picture 4). Fluorescent imaging requires a special camera system and laparoscope but no additional technical steps intraoperatively, such as those required for conventional cholangiography. It allows continuous biliary mapping throughout the procedure rather than a one-time assessment.

Early studies have found it to be cost effective and faster than intraoperative cholangiography in elective cases, but its role in the setting of the inflamed or difficult gallbladder has yet to be defined. In a systematic review of 16 studies, the frequency of detection was 71 to 100 percent for the cystic duct, 33 to 100 percent for the common hepatic duct, 50 to 100 percent for the common bile duct, and 25 to 100 percent for the cystic-common hepatic duct junction [79]. However, the frequency of visualization of the cystic and common bile duct was reduced in patients whose body mass index was >35 kg/m² [79,80].

In a randomized trial of over 600 laparoscopic cholecystectomies, near-infrared fluorescent cholangiography was superior to white light alone in detecting seven critical extrahepatic biliary structures [81]. However, no statistically significant difference in the rate of bile duct injury or conversion could be demonstrated due to the low number of cases in the series. The consensus guideline, therefore, suggested that near-infrared imaging may be used as an adjunct to white light alone for identification of biliary anatomy during cholecystectomy. However, it should not be a substitute for careful dissection and structure identification technique [39].

Managing a bile duct injury — Despite best efforts, bile duct injury still occurs in 0.2 to 0.4 percent of laparoscopic cholecystectomies [82]. Management of a bile duct injury during or after laparoscopic cholecystectomy is discussed separately. (See "Repair of common bile duct injuries".)

SOCIETY GUIDELINE LINKS — 

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Gallbladder surgery" and "Society guideline links: Laparoscopic and robotic surgery".)

SUMMARY AND RECOMMENDATIONS

●Preoperative indicators of a difficult gallbladder – A difficult gallbladder may often be predicted preoperatively based on certain patient characteristics (table 1). Recognition of a potentially difficult gallbladder by the surgeon is the first step toward mitigating the high risks of operating on such patients. (See 'Recognition' above.)

●Patients with cirrhosis – Patients with cirrhosis should have determination of liver function by Child classification or MELD (Model for End-Stage Liver Disease) score preoperatively. Child A and B class patients who require gallbladder surgery can undergo laparoscopic cholecystectomy if clinically appropriate. Child C class patients should be managed individually with input from a hepatologist due to high operative risk and lack of data. (See 'Cirrhosis' above.)

●Nonoperative management of acute cholecystitis – Although the contemporary management of acute cholecystitis for low-risk patients is cholecystectomy within the index admission, nonoperative management with antibiotics and/or percutaneous cholecystostomy tube drainage during the index admission is a viable option for high-risk patients. (See 'Nonoperative management of acute cholecystitis in high-risk patients' above and "Treatment of acute calculous cholecystitis", section on 'Poor surgical candidates'.)

●Critical view of safety during laparoscopic cholecystectomy – The critical view of safety is a method of ductal identification that has three elements:

•The hepatocystic triangle should be cleared of all fat and fibrous tissue.

•Two and only two structures (cystic artery and cystic duct) are seen going into the gallbladder in a 360° view.

•The gallbladder is dissected off the liver bed to expose the lower one-third of the cystic plate.

During cholecystectomy (laparoscopic, robotic-assisted, or open), the critical view of safety should be established before any ductal clipping or division. Failure to establish the critical view of safety may necessitate a bailout procedure such as conversion to open surgery or subtotal cholecystectomy. (See 'Safe dissection techniques' above.)

●Alternatives to standard cholecystectomy – When the hepatocystic triangle is difficult to expose, either a subtotal cholecystectomy or conversion to open cholecystectomy can be performed depending on surgeon preference and expertise. Top-down cholecystectomy should be used with caution when there is severe inflammation in the hepatocystic triangle. (See 'Conversion to open surgery' above and 'Top-down cholecystectomy' above and 'Subtotal cholecystectomy' above.)

●Subtotal cholecystectomy – Subtotal cholecystectomy is a procedure in which the gallbladder is opened above the neck, all stones are removed, and the neck of the gallbladder is left in situ to protect the area of the critical structures. The fenestrating subtype leaves the gallbladder neck open and is preferred, whereas the reconstituting subtype closes the gallbladder neck. (See 'Subtotal cholecystectomy' above.)

●Intraoperative imaging adjuncts – Intraoperative imaging adjuncts, such as cholangiography, laparoscopic ultrasound, and fluorescent imaging, should be used liberally in difficult cholecystectomies to help identify vital structures, guide dissection, and confirm anatomy. (See 'Imaging adjuncts' above.)