Open Cholecystectomy

Updated: Feb 15, 2017
  • Author: William W Hope, MD; Chief Editor: Kurt E Roberts, MD  more...
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Overview

Background

Approximately 700,000 cholecystectomies are performed annually in the United States. Most are performed to address symptoms related to biliary colic from cholelithiasis, to treat complications of gallstones (eg, acute cholecystitis and biliary pancreatitis), or as incidental cholecystectomies performed during other open abdominal procedures. Currently, most cholecystectomies are done via the laparoscopic approach (see Laparoscopic Cholecystectomy); however, the open technique is sometimes required.

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Indications

Indications for cholecystectomy, either open or laparoscopic, are usually related to symptomatic gallstones or complications related to gallstones. The most common of these indications are the following:

Other indications include the following:

  • Biliary dyskinesia
  • Prophylactic cholecystectomy during various intra-abdominal procedures (controversial)

Prophylactic cholecystectomy at the time of a splenorenal shunt has been proposed on the basis of the acute pain syndrome that these patients can develop postoperatively, which is often related to gallbladder symptoms, as well as the high likelihood of the formation of gallstones in this subset of patients with liver disease.

The procedure of choice for most of these indications has shifted from an open approach to a laparoscopic approach. However, some situations still require a traditional open cholecystectomy. Depending on the clinical situation, the procedure can either begin as an open operation or be converted to an open procedure from a laparoscopic one.

Some indications for forgoing laparoscopy and proceeding with an open operation are as follows:

  • Suspected or confirmed gallbladder cancer
  • Type II Mirizzi syndrome (cholecystobiliary fistula)
  • Gallstone ileus
  • Severe cardiopulmonary disease

When gallbladder cancer is suspected or confirmed preoperatively or intraoperatively, an open cholecystectomy should be performed with consultation from an experienced hepatobiliary surgeon if the primary surgeon is not comfortable with liver resections and hepatobiliary surgery. If the necessary expertise is not available, the patient can be referred to a hepatobiliary surgeon for reexploration, given that prior exploration, either laparoscopic or open, does not appear to adversely affect long-term survival. [1]

The recommendation for open cholecystectomy for gallbladder cancer, however, remains somewhat problematic, in that most gallbladder cancers are discovered incidentally during surgery or in the specimen. [2, 3]

Open cholecystectomy should also be considered in patients with cirrhosis and bleeding disorders, as well as pregnant patients. In patients with advanced cirrhosis and bleeding disorders, potential bleeding may be difficult to control laparoscopically, and an open approach (or a percutaneous cholecystostomy tube) may be more prudent. Also, patients with portal hypertension often have a recannulized umbilical vein, and placing ports in these patients may cause significant hemorrhage.

Although laparoscopic cholecystectomy has been proved to be safe in all trimesters of pregnancy, as well as possibly associated with fewer maternal and fetal complications, [4] an open operation should be considered, especially in the third trimester, because laparoscopic port placement and insufflation may be difficult.

Open cholecystectomy is also indicated, albeit infrequently, in patients who have trauma to the right upper quadrant and in the rare cases of penetrating trauma to the gallbladder.

Most open cholecystectomies result from conversion of a laparoscopic procedure, often because of bleeding complications or unclear anatomy. Conversion rates for laparoscopic cholecystectomy vary widely, with a reported range of 1-30%. [5] However, most series report the incidence of conversion to be lower than 10%, and some series report a figure closer to 1-2%. [6, 7, 8]

In a study by Ibrahim et al, predictors of conversion to open cholecystectomy included age greater than 60 years, male sex, weight exceeding 65 kg, the presence of acute cholecystitis, previous upper abdominal surgery, the presence of diabetes and high glycosylated hemoglobin levels, and a less experienced surgeon. [9]

In a study by Licciardello et al, [10] risk factors for conversion on univariate analysis included increased age; acute cholecystitis; comorbidities; elevated white blood cell count; and increased levels of aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, gamma glutamyl transpeptidase, C-reactive protein, and fibrinogen. On multivariate logistic regression analysis, acute cholecystitis and age greater than 65 years were found to be independent predictive factors for conversion.

Sutcliffe et al, using data from a prospective UK database of 8820 patients developed a validation risk score designed for preoperative identification of patients at high risk for conversion from laparoscopic to open cholecystectomy. [11]  This score was derived from the following six significant predictors: age, sex, indication for surgery, American Society of Anesthesiologists (ASA) score, thick-walled gallbladder, and CBD diameter. A score higher than 6 identified patients likely to require conversion.

Finally, in lower-income countries, open cholecystectomy may be more cost-effective than the laparoscopic equivalent and may therefore be preferred on that basis. [12]

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Contraindications

Absolute contraindications for proceeding with an open cholecystectomy are few. Such absolute contraindications are limited to severe physiologic derangement or cardiopulmonary disease that prohibits general anesthesia.

In cases of terminal illness, temporizing procedures such as percutaneous transhepatic cholangiography or percutaneous cholecystostomy should be considered in lieu of cholecystectomy.

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