Acute Cholecystitis

In straightforward acute cholecystitis with symptoms less than two days in a reasonable surgical candidate, early laparoscopic cholecystectomy during the same admission is favored because attempts to cool down have high recurrence rates and patients often return on weekends making management more difficult.

Preoperative preparation for acute cholecystitis includes admission, antibiotics, NPO status, routine labs, coagulation studies, type and screen, and pregnancy test to avoid delays in operative intervention.

Acute cholecystitis is an obstructive diverticulopathy where the cystic duct becomes obstructed (usually by a stone), causing backup of pressure in the gallbladder with decreased blood flow in the wall, and the wall can eventually rupture.

For patients with significant cardiac history, the last thing you want is to take them to the operating room and cause an acute cardiac event, so cardiology consultation and realistic risk assessment are essential.

In high-risk patients, antibiotics alone often cool down acute cholecystitis without additional intervention, but percutaneous cholecystostomy tubes can be very helpful for sicker patients who are not good operative candidates.

For patients who are poor operative candidates, admit to hospital, start broad spectrum antibiotics, and if no improvement after one to two days, recommend percutaneous cholecystostomy.

Percutaneous cholecystostomy tubes combined with antibiotics are very effective in managing acute cholecystitis in sicker patients, with most having uneventful recovery and hospital discharge.

Before removing a cholecystostomy tube, wait 4-6 weeks and perform cholangiogram through the tube to ensure the cystic duct is patent; if the duct is not patent, removing the tube will cause recurrent episode.

Cholecystostomy tubes are useful for timing intervention in patients on antiplatelet therapy for stents who need to wait (e.g., one year) before they can safely come off Plavix or aspirin for definitive surgery.

Cholecystectomy in patients with prior cholecystostomy tubes are more challenging cases that need to be planned well and should not be added on at the end of a long surgical day when the surgeon is tired.

Palmer's point is located two finger breadths below the rib cage on the left side in the midclavicular line and is one of the safest locations for initial trocar entry.

Placing the most lateral trocar while visualizing the gallbladder allows the assistant to grab and elevate it, providing better location for the left hand port.

When lysing omental adhesions in acute cholecystitis, use cautery (especially when colon and duodenum are visible) because edematous tissue bleeds easily, and uncontrolled bleeding impedes visualization later in the case.

There is a very low threshold to decompress tense gallbladders before trying to grab them, using a long reusable needle connected via luer lock to a 60cc syringe, inserted under direct vision into the fundus to aspirate.

Start dissection high up on the gallbladder where you are certain you are on the gallbladder, then gently and patiently tease tissues down toward the duodenum using hook electrocautery.

As Calot's node is taken down, the cystic artery becomes visible; dissect it up toward the body of the gallbladder to get length, because as long as you are on the gallbladder you are safe.

The critical view of safety requires visualization of the cystic duct-gallbladder junction, the cystic artery within Calot's triangle, and liver in the dissection window.

Taking some of the gallbladder just superior to the cystic duct junction and removing the back wall off the liver bed gives increased length for dissection.

Dr. Rodriguez uses routine cholangiography in almost all cases.

For cholangiography, place a clip very close to the gallbladder, make a dicotomy, then milk the cystic duct proximally with scissors or Maryland to express any stones before cannulation.

The Olsen clamp has a layout where the tip comes together but the middle does not, providing just enough occlusion of the cystic duct around the catheter without occluding the catheter itself.

Flush the cystic duct with 20cc of saline before cholangiography because when there is sludge and stones, clearing that beforehand is very helpful and also removes air bubbles from the system.

To get contrast to flow into the intrahepatic ducts when it only goes down initially, place the patient in Trendelenburg position or use the camera to put pressure on the distal common bile duct.

For a small stone in the distal duct, first try flushing again with good pressure, give glucagon to relax the ampulla, and repeat cholangiogram; if that does not work, use a commercial transcystic common bile duct exploration kit.

The transcystic CBD exploration kit includes a percutaneous introduction catheter with step dilator; introduce it through a separate stab incision (not through existing trocar) from the right side at a parallel angle to the cystic duct to avoid trauma and backwalling the duct.

The key for transcystic CBD exploration is to place a wire under fluoroscopic guidance distally into the duodenum; once the wire is down, the kit's basket (Dormia-type) can crush and retrieve stones, or the balloon dilator can push small stones through via antegrade sphincteroplasty.

When the infundibulum, cystic duct, Calot's triangle and node cannot be defined and dissection is very difficult, be aggressive about going top-down (fundus-down) fashion laparoscopically.

There is no fear of adding another trocar—they are free and there is nothing magical about one number or another; just put them where you need them.

In severe cases, the decision is between doing a partial cholecystectomy or leaving part of the back wall on the liver; sometimes opening the gallbladder, removing all stones, and placing a large cholecystostomy tube can bail you out.

When going open for a difficult case, top-down (dome-down) dissection is still the preferred approach.

Some patients have a very superficial right ductal system, and digging too deep into the liver during gallbladder dissection can injure it; many bile leaks labeled as duct of Luschka leaks are actually from the surgeon getting too deep into the liver and injuring the ductal system.

In subtotal cholecystectomy, open the gallbladder, remove stones, get down to a safe point, close it up (the cystic duct can eventually open again), and leave a drain to control bile leak if it occurs.

Back-wall preservation is indicated in horrible cases where the gallbladder is necrotic and falling apart and the cystic duct area looks equally bad; it is the safest approach to avoid major bile duct injury.

The big goal in difficult cholecystectomy cases is avoiding a major bile duct injury that will end up being a disaster.

When leaving the back wall, cauterize the mucosa with coagulation on a high setting and leave a drain.