Approach Considerations
Contraindications for surgical treatment of gallbladder mucocele would obviously include any associated medical conditions or illnesses that preclude surgery. No absolute contraindication for surgical treatment exists.
Laboratory research suggests that chemical ablation of the gallbladder mucosa may be an alternative in patients who are medically unfit, elderly, or critically ill. A combination of ethanol, sodium tetradecyl sulfate, and mucosal exfoliant has been successfully tried in rats. [2, 3, 4, 11]
A medical line of management with oral dissolution therapy should not be considered in patients with obstructed gallbladders. In acalculous hydrops observed in children as a part of a wider spectrum, expectant management may be considered.
Cholecystectomy and Cholecystostomy
Cholecystectomy is the definitive treatment for an obstructed gallbladder. Laparoscopic cholecystectomy (see the images below) is the criterion standard procedure. [12, 13, 14] A 2009 study derived from database information and a literature review found evidence that even when gallstones are absent in patients with right-upper-quadrant (RUQ) pain and a positive hepato-iminodiacetic acid (HIDA) scan, symptom relief is more likely to occur after cholecystectomy than it is after medical treatment. [15]
Laparoscopic view of distended gallbladder in woman aged 70 years with sudden onset of severe right upper abdominal pain.
Open cholecystectomy may be performed in patients who have a very large gallbladder, greatly thickened gallbladder walls, or an obliterated triangle of Calot. In such cases, laparoscopic dissection may be difficult and time-consuming.
In patients with systemic signs and symptoms, preoperative management should include correction of hydration, nasogastric drainage (if necessary), and appropriate broad-spectrum antibiotic therapy. Preferably, cholecystectomy is carried out during the same admission.
Intraoperative aspiration of the large gallbladder helps facilitate grasping the gallbladder for dissection. The aspirate is clear and watery or mucoid (white bile). Intraoperative cholangiography may be indicated, depending on clinical and investigative features that may suggest obstruction of the common bile duct.
Upon being opened, the gallbladder shows a white wall, clear and watery or mucoid content, a stone or stones impacted in the neck or cystic duct, a narrowed cystic duct, or a tumor or polyp causing obstruction of the neck of the gallbladder.
In some patients, percutaneous cholecystostomy (guided by ultrasonography [US]) or open cholecystostomy may be used as a temporary measure. Cholecystostomy is usually performed in cases where the patient is very sick or the dissection is technically very difficult; in such instances, if the surgeon is an expert, laparoscopic subtotal cholecystectomy also can be performed. A subsequent completion cholecystectomy may be carried out once the patient’s initial condition improves. [2]
Endoscopic US (EUS)-guided endoluminal approaches to gallbladder drainage have been described. [16]
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Image is from a 35-year-old woman who presented with recurrent episodes of right upper quadrant colic; most recent attack was 3 days before. Gross wall thickening is apparent; this is usually measured on anterior wall of gallbladder. Also apparent are clear content, stone in neck of gallbladder, and absence of pericholecystic fluid. All favor diagnosis of acute cholecystitis.
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Stone in neck of gallbladder, with postacoustic shadowing. Minimal wall thickening and dilated gallbladder suggest mucocele.
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Transverse scan shows stone in neck of gallbladder, with postacoustic shadowing. Minimal wall thickening and dilated gallbladder are also visible.
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Transverse scans show layering of gallbladder wall; this suggests edema and indicates acute cholecystitis.
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Longitudinal scan shows layering, with fluid in wall of gallbladder and impacted stone in neck of gallbladder. Intraluminal shadowing indicates sediments in fluid; image indicates acute cholecystitis with possible pyocele of gallbladder.
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Cluster of impacted calculi in neck of gallbladder, minimal wall thickening, and clear content; this indicates mucocele of gallbladder.
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Cluster of calculi with postacoustic shadowing in neck of gallbladder, normal wall, and clear content; this indicates mucocele of gallbladder.
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Distended gallbladder with evidence of adhesions on its wall. Irregular surface indicates recurrent attacks of cholecystitis.
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Yellowish aspirate from gallbladder of a 28-year-old woman who presented with features of right upper quadrant peritonitis. Slightly yellowish fluid was sterile and was rich in cholesterol.
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Subserosal perforation of acute, emphysematous, acalculous cholecystitis in a 58-year-old diabetic man. Patient presented with features suggestive of ileus. He had high intrathoracic liver (and gallbladder), and clinical signs were atypical. Green color is unusual.
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Laparoscopic view of distended gallbladder in woman aged 70 years with sudden onset of severe right upper abdominal pain.
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Stone being extracted from cystic duct through small ductotomy.
