Surgical Management of the Difficult Gallbladder

Educational Objectives

The goal of this program is to improve the surgical management of difficult gallbladder. After hearing and assimilating this program, the clinician will be better able to:

1. Optimize management of difficult laparoscopic cholecystectomy.

Summary

Grade 3 acute cholecystitis: 2018 Tokyo Guidelines — if situated in an advanced center for laparoscopic surgery with improving organ dysfunction, consider early laparoscopic cholecystectomy (LC); otherwise, consider early gallbladder (GB) drainage; delayed LC can be decided later

Percutaneous cholecystostomy (PCO): currently performed only for those who are unsafe for general endotracheal anesthesia; after PCO, early LC has been associated with fewer adhesions and lower conversion rate compared with late LC, according to studies

Endoscopic cholecystostomy: placed via endoscopic retrograde cholangiopancreatography (ERCP); theoretically associated with fewer complications and reinterventions compared with PCO

Technical problems: sometimes it is hard to elevate a stiff liver and dissect structures at the hilum; high-tech laparoscopic equipment requires trained personnel; suction in case of pneumoperitoneum and bleeding can compromise the pneumoperitoneum; 2-dimensional imaging enables visualization of surfaces only; controlling major hemorrhage is difficult; haptic sensation is less in laparoscopy

Technical points for laparoscopic cholecystectomy: find the GB wall and stay on it; dissect from above down to the neck; dissect the GB neck and body away from its bed, widely open the hepatocystic triangle (HCT), and move the infundibulum back and forth; apply lateral traction to misalign the cystic duct (CD) and common bile duct (CBD) junction; apply critical view of safety (CVS) technique before clipping or dividing; in infundibular technique, tethered infundibulum is often encountered, and CBD may be inadvertently clipped and excised

Tips and tricks: have a colleague confirm the anatomy; use an angled scope; add a port or upsize the ports if needed; decompress the fundus in case of tense GB; laparoscopic ultrasonography may clarify the anatomy; divide the infundibulum if CVS cannot be achieved; leave the back wall of GB in situ; cholangiography through the GB rarely works because of cystic duct obstruction; irrigation dissection and Kittner dissector may be used; use endoloop for friable CD; decompress the GB and close the CD; dividing the CD with a stapler is occasionally necessary

Cholangiography: in case of very short cystic duct, can help define the location of the ducts; provides a road map for atypical right hepatic ducts from which CD can rise; indocyanine green fluorescence cholangiography may not be helpful when inflammation or a lot of fat is present

Intraoperative laparoscopic ultrasonography (ILU): in difficult cases, early ILU can help visualize CBD; in LC, it has been found helpful in preventing conversion or complications, according to studies

Difficult laparoscopic cholecystectomy: in cases where CVS cannot be achieved, conversion to open surgery, laparoscopic cholecystostomy, placing a tube in the GB, retrograde cholecystectomy, or subtotal cholecystectomy may be performed; elective conversion is not a complication, but prolonged LC without a complication is better regarding length of stay and complications compared with conversion

Limitations to laparotomy: very few open cholecystectomies are performed during training; visualization can be more challenging; retraction exposure techniques are vital but are not always fully understood by inexperienced surgeons; postoperative complications and recuperation are longer; CBD injuries do occur after conversion

Indications for conversion: indications for conversion include lack of progress during surgery, complications that cannot be managed laparoscopically, unclear anatomy, alternative strategies being unsafe, and patient not tolerating pneumoperitoneum; young patients may prefer laparotomy to an indwelling cholecystostomy tube

“Top-down” cholecystectomy: is difficult and CBD injuries do occur

Subtotal cholecystectomy (SCCE): indications include no possibility of achieving CVS, severe inflammation, intrahepatic GB, portal hypertension, coagulopathy, impacted stones in the neck and CD hindering CVS, and gangrenous or perforated GB; involves leaving the back wall of the GB and a portion of the infundibulum; reconstituted SCCE is not recommended; fenestrated SCCE may be performed; SCCE aims to avoid bile duct injury and bleeding from the GB bed, decrease conversion rate, and reduce the need for cholecystostomy; complications include bile leak, biliary fistula, need for postoperative ERCP, and retained stones in residual GB

Readings

Okamoto K, Suzuki K, Takada T, et al. Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis [published correction appears in J Hepatobiliary Pancreat Sci. 2019 Nov; 26(11):534]. J Hepatobiliary Pancreat Sci. 2018; 25(1):55-72. doi:10.1002/jhbp.516; Wakabayashi G, Iwashita Y, Hibi T, et al. Tokyo Guidelines 2018: surgical management of acute cholecystitis: safe steps in laparoscopic cholecystectomy for acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci. 2018; 25(1):73-86. doi:10.1002/jhbp.517; Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg. 1995; 180(1):101-125.; Gwinn EC, Daly S, Deziel DJ. The use of laparoscopic ultrasound in difficult cholecystectomy cases significantly decreases morbidity. Surgery. 2013; 154(4):909-917. doi:10.1016/j.surg.2013.04.041.

Disclosures

For this program, the following relevant financial relationships were disclosed and mitigated to ensure that no commercial bias has been inserted into this content. Dr. Soper is on the Advisory Panel for FlexDex, Inc.; and is a Stockholder/Shareholder with Mesh Suture Inc. Members of the planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Soper was recorded at the 50th Annual Phoenix Surgical Symposium, held January 27-29, 2022, and presented by Phoenix Surgical Society. For more information about upcoming CME activities from this presenter, please visit Phoenixsurgicalsociety.com. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

ABS Continuous Certification

Successful completion of this CME activity, which includes participation in the evaluation component, enables the learner to earn credit/s toward the CME [and Self-Assessment] requirements of the American Board of Surgery’s Continuous Certification pro

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

GS690702

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.