Acute Cholecystitis

In acute cholecystitis cases presenting within 48 hours with straightforward presentation, early cholecystectomy during the same admission is favored over conservative management because cases managed conservatively have high recurrence rates and often return on weekends making management more difficult.

Preoperative antibiotics should be started in acute cholecystitis cases presenting to the emergency room.

In high-risk patients with significant cardiac history, medical subspecialty consultation is needed to determine realistic operative risk factors before proceeding with cholecystectomy.

Percutaneous cholecystostomy tubes combined with antibiotics are very effective in managing acute cholecystitis in high-risk surgical patients, with most patients having uneventful recovery.

Before removing a percutaneous cholecystostomy tube, wait 4-6 weeks and perform a cholangiogram through the tube to confirm cystic duct patency, because if the cystic duct is not patent, recurrent cholecystitis will occur immediately after tube removal.

Percutaneous cholecystostomy is a reasonable temporizing measure for patients on antiplatelet therapy who need to wait (e.g., one year after cardiac stent) before it is safe to discontinue medications for definitive surgery.

Cholecystectomy cases in patients with prior percutaneous cholecystostomy tubes tend to be more challenging and should be planned as dedicated cases, not added on at the end of a long operative day.

The laparoscopic approach is used in 99% of cholecystectomy cases, even in very difficult acute cholecystitis.

Palmer's point (two finger breadths below the left costal margin in the midclavicular line) is one of the safest locations for initial laparoscopic entry, particularly in higher BMI patients.

Placing the lateral right-sided trocar under direct laparoscopic vision while visualizing the gallbladder allows optimal positioning for retraction based on individual patient anatomy.

In acute cholecystitis, edematous tissue bleeds easily, and controlling bleeding from omentum early with cautery prevents impaired visualization later in the case.

There is a low threshold to decompress tense, inflamed gallbladders before attempting to grasp them, to prevent tearing the gallbladder wall.

Gallbladder decompression is performed at the fundus using a long reusable needle connected via luer-lock to a 60cc syringe, aspirating under direct vision.

In acute cholecystitis, dissection should start high on the gallbladder where anatomy is certain, then work down toward Calot's node and triangle, staying on the thickened gallbladder wall.

The suction device is an effective dissection tool in laparoscopic cholecystectomy.

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

Taking the posterior gallbladder wall off the liver bed just superior to the cystic duct-gallbladder junction provides increased length for safer dissection.

Routine intraoperative cholangiography is performed in nearly all cholecystectomy cases.

Before cannulating the cystic duct for cholangiography, place a clip close to the gallbladder, make a dichotomy, and milk the cystic duct proximally to express any stones.

Flushing the cystic duct with 20cc of saline before cholangiography clears sludge and stones and removes air bubbles from the system.

If contrast flows only distally on cholangiogram, placing the patient in slight reverse Trendelenburg or using the laparoscope to compress the distal common bile duct can redirect flow proximally to visualize the hepatic ducts.

For small common bile duct stones identified on cholangiogram, initial management includes flushing the duct and administering glucagon to relax the ampulla, which may allow spontaneous stone passage.

Transcystic common bile duct exploration uses a commercial kit with a percutaneous introducer catheter and step dilator, inserted through a separate stab incision (not through an existing trocar) at a parallel angle to the cystic duct to avoid ductal trauma.

The key to transcystic CBD exploration is placing a wire under fluoroscopic guidance distally into the duodenum, which then allows passage of basket or balloon instruments.

For small CBD stones, balloon dilation (antegrade sphincteroplasty) to push stones through is often easier than basket extraction.

When the infundibulum, cystic duct, cystic artery, and Calot's triangle cannot be defined due to severe inflammation, a top-down approach (starting at the fundus) should be used.

Placing the lateral trocar under direct vision is particularly important because it positions the port to be helpful in difficult cases requiring top-down dissection, not just standard cholecystectomy.

In severe acute cholecystitis cases, the difficulty of open dissection can be assessed laparoscopically, and attempting heroic open dissection to reach the cystic duct is often not safe.

In cases where complete cholecystectomy is unsafe, options include opening the gallbladder to perform partial cholecystectomy or leaving part of the posterior wall on the liver.

A bailout technique for severe cases is to open the gallbladder, remove all stones, place a large cholecystostomy tube, creating an empty gallbladder with drainage.

When dissecting the gallbladder off the liver bed in severe inflammation, caution is needed to avoid injury to superficial right hepatic ducts, as overly deep dissection can cause bile leaks often mislabeled as ducts of Luschka but actually representing injury to the ductal system.

A drain should be left after subtotal cholecystectomy to control potential bile leak.

The primary goal in difficult cholecystitis cases is avoiding major bile duct injury, which would be a disaster for the patient—this takes priority over achieving complete cholecystectomy.

In subtotal cholecystectomy where posterior wall is left, the residual mucosa should be cauterized with coagulation on high setting.