Open Cholecystectomy Technique

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

Approach Considerations

In general, open cholecystectomy can be performed via either of two different approaches: retrograde or anterograde.

The more traditional retrograde ("top down") approach starts with dissection at the gallbladder fundus and proceeds toward the portal triad and the triangle of Calot. This strategy facilitates sure identification of the cystic duct and artery, because they are the only two remaining attachments to the gallbladder. (See the video below.)

Retrograde technique for open cholecystectomy.

With increased experience and expertise in the laparoscopic technique, surgeons often feel more comfortable with the anterograde approach, in which dissection begins at the triangle of Calot with dissection and ligation of the cystic artery and duct. This is followed by dissection of the gallbladder from the liver bed, starting usually from the infundibulum up. Dissection from the fundus down can also be used. (See the video below.)

Anterograde technique for open cholecystectomy.
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Open Cholecystectomy

Preparation

Place the patient under general anesthesia, supine, with arms extended. Place a Foley catheter and sequential compression devices before the operation begins, and, if indicated, administer preoperative anticoagulation. If indicated, administer preoperative antibiotics within 60 minutes of skin incision.

The surgeon stands on the patient's left with the assistant opposite. The operating room and table should be oriented so that cholangiography can be performed if necessary.

Incision

A right subcostal (Kocher) incision is the most often used incision and allows excellent exposure of the gallbladder bed and cystic duct. Alternatively, an upper midline incision can be used when other concomitant operations are planned and a wider exposure is needed. Typically, the midline incision remains above the umbilicus, still allowing adequate exposure of the gallbladder with appropriate retraction. A right paramedian incision is another option but is not often used at present.

Start the subcostal incision approximately 1 cm to the left of the linea alba, about two fingerbreadths below the costal margin (~4 cm). Extend the incision laterally for 10-15 cm, depending on the patient's body habitus.

Incise the anterior rectus sheath along the length of the incision, and divide the rectus and lateral muscles (external oblique, internal oblique, and transversus abdominis) with the electrocautery. Then, incise the posterior rectus sheath and peritoneum and enter the abdomen.

Inspection

To the extent possible, perform a thorough manual and visual inspection to evaluate for concomitant pathology or anatomic abnormalities. Place a retracting device (eg, Balfour retractor, Bookwalter retractor, or wound protractor retractor) as needed for adequate exposure. (See the videos below.)

Exposure for open cholecystectomy.
Anatomy, exposure, and beginning of dissection for retrograde technique of open cholecystectomy.

Palpate and inspect the liver, and admit air into the subphrenic space to inferiorly displace the liver and better expose the inferior surface. If additional downward displacement is needed, laparotomy pads can be placed above and lateral to the liver to facilitate exposure (see the video below). Retract the duodenum inferiorly to expose the porta hepatis.

Anatomy and exposure for an open cholecystectomy. Placing packs above liver for improved visualization.

Palpate the gallbladder for stones or masses. The porta hepatis can be assessed by inserting the left index finger into the foramen of Winslow and using the thumb to palpate anteriorly on the porta hepatis/common bile duct (CBD) for stones or tumors.

Dissection

Grasp the dome of the gallbladder with a Kelly clamp, and elevate it superiorly. Adhesions to the undersurface of the gallbladder from the transverse colon or duodenum are typically encountered; these can be lysed with sharp dissection or judicious use of the electrocautery.

Dissection of the gallbladder can be performed in two ways. Traditionally, as previously noted, dissection in open cholecystectomy is performed with a "top down" or retrograde technique, in which the fundus is mobilized toward the porta hepatis. This technique differs from the anterograde technique, in which the dissection begins at the porta hepatis and extends up to the fundus (as is done in laparoscopic cholecystectomy).

Retrograde approach

In the retrograde approach, incise the visceral peritoneum overlying of the gallbladder fundus approximately 1 cm from its attachment to the liver. Grasp the fundus of the gallbladder with a Kelly clamp. Using a right-angle clamp or suction device, develop the plane on both the lateral and the medial side of the gallbladder, and carry the incision along the gallbladder parallel to the liver. This dissection ensures complete mobilization of the gallbladder from the liver bed before dissection within the triangle of Calot. (See the videos below.)

Beginning of dissection for retrograde technique of open cholecystectomy.
Dissecting gallbladder off liver bed in retrograde technique.
Completion of dissection of gallbladder off of liver bed in retrograde technique.

The dissection plane is typically avascular, with only small cholecystic veins that must be divided. Occasionally, more prominent veins may be encountered that must be ligated, especially in the presence of portal hypertension or gallbladder distention. If significant bleeding occurs, the dissection has likely been too deep entering the liver parenchyma.

Anterograde approach

In the anterograde approach, attention is initially directed to the porta hepatis. Grasp the fundus of the gallbladder, and elevate it superiorly while the neck of the gallbladder is mobilized away from the liver laterally to expose the triangle of Calot. Dissect the cystic artery and cystic duct, with careful attention to the potential for anatomic variations.

Once the cystic duct and cystic artery are completely dissected and identified entering directly into the gallbladder (the so-called critical view popularized by Strasberg [13] ), the structures can be divided if cholangiography is not being performed. Before division of the cystic duct, "milk" the duct from proximal to distal to deliver stones that reside in the cystic duct into the gallbladder lumen. After dividing the cystic artery and duct, dissect the gallbladder away from the liver bed as described in the retrograde technique.

Division of cystic duct and artery

When the cystic duct and artery are correctly identified and completely dissected, they are ligated. Various techniques for ligation have been described, including using suture, staplers, and clips. (See the videos below.)

Ligation of cystic duct and artery in retrograde technique of open cholecystectomy.
Completion of retrograde technique of open cholecystectomy showing ligated cystic artery and cystic duct.

Nonabsorbable sutures are acceptable for use on the cystic duct stump; however, they are not recommended for biliary-enteric anastomosis or choledochotomy suture lines, because they can be lithogenic and incite a chronic inflammatory reaction. Absorbable sutures, such as polyglactin 910 or polydioxanone, are traditionally used for ligation of the cystic duct. Metallic (titanium) clips or locking (Weck) clips can also be used.

If the cystic duct is large and inflamed, mechanical staplers may be used, as well. The cystic artery can be ligated with ties (absorbable or nonabsorbable), suture ligature, or clips. Mechanical staplers are rarely necessary for ligation of the cystic artery.

Pearls

A blunt Kitner (peanut) dissector aids in dissection of the cystic duct and artery, but it is best to proceed toward the portal structures so as to avoid avulsion of the blood supply of the CBD or avulsion of the cystic duct. The blood supply to the CBD courses on the medial and lateral side of the duct at the 3 o'clock and 9 o'clock positions. Knowledge of the anatomy and careful dissection on the lateral edge (9 o'clock) position avoids inadvertent injury and ischemia to the CBD.

Thermal energy devices must be used with caution in dissecting in the triangle of Calot and are not recommended for working immediately adjacent to biliary structures.

Sudden bleeding from the porta hepatis can be alarming and should initially be managed with direct pressure to allow for adequate exposure and sufficient time to call for assistance, if needed. Surgeons should avoid blind placement of sutures or clips in this area, as well as thermal energy devices. If bleeding cannot be controlled, a Pringle maneuver may be needed. Suture ligation of bleeding porta hepatis structures should be carefully and precisely carried out with 5-0 polydioxanone horizontal mattress sutures.

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Complications

Although generally a safe procedure with limited morbidity and mortality, [14]  open cholecystectomy does carry a risk of potential complications. Traditionally, the complication rate for this procedure has been reported to be in the range of 6-21%, [15]  though this has likely decreased in the current era. [5]  For patients with Child-Pugh class A or B cirrhosis who are undergoing cholecystectomy for symptomatic cholelithiasis, laparoscopic cholecystectomy has decreased complication rates and increased recovery as compared with open cholecyestectomy. [16]

Bleeding and infection

Inherent to any surgical procedure are the risks of bleeding and infection. Potential sources of hemorrhage include the liver bed, the hepatic artery and its branches, and the porta hepatis. Most bleeding sources are recognized and addressed intraoperatively. However, occasional postoperative hemorrhage can result in substantial hemoperitoneum.

Infectious complications range from skin and soft-tissue infection to intra-abdominal abscess. The risk of infection is minimized by maintaining meticulous sterile technique, as well as avoiding leakage of bile into the abdominal cavity. Should significant bile or stone spillage occur, thorough irrigation can help decrease the risk of intra-abdominal infection. All spilled stones should be removed to prevent further abscess formation. [17]

Biliary complications

Complications related to the biliary system include bile leaks and CBD injuries, which can result in biliary strictures. Bile leaks can be caused by clips or ligatures slipping off the cystic duct stump, injuries to the bile ducts, or, most commonly, transected Luschka ducts. Patients may present with persistent abdominal pain, nausea, vomiting, and elevated liver function test results. Once diagnosed, an endoscopic retrograde cholangiopancreatography (ERCP) can help further characterize the leak as well as provide therapeutic options.

Perhaps the most morbid complication related to open cholecystectomy is injury to the CBD. Bile duct injury, though already a known complication during open cholecystectomy, has increased twofold with the advent of laparoscopic cholecystectomy (1 injury per 200-5,000 cases). [5, 18, 19]

When a bile duct injury is recognized intraoperatively, consult an experienced hepatobiliary surgeon. If one is not available, strongly consider transferring the patient to a tertiary care center for definitive care. Delayed diagnosis of a bile duct injury can occur weeks to months after the initial operation with elevation of liver function test results or, in some cases, cholangitis. As noted previously, these patients should be referred to experienced hepatobiliary centers for evaluation and definitive treatment.

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