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Open cholecystectomy Authors Daniel T Dempsey, MD, FACS Shefali Agrawal, MD, FACS Section Editor Stanley W Ashley,

MD Deputy Editor Kathryn A Collins, MD, PhD, FACS Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Mar 2013. | This topic last updated: 29, 2013. INTRODUCTION Cholecystectomy is one of the most commonly performed abdominal surgical procedures. The laparoscopic approach is preferred due to documented physiologic, economic, and cosmetic benefits compared with the open approach. However, when laparoscopic cholecystectomy is not possible or cannot be completed safely, open cholecystectomy is indicated. Open cholecystectomy may also be performed as an integral part of another operation (eg, pancreaticoduodenectomy) or incidentally, if indicated, during another gastrointestinal operation (eg, colon resection). (See "Laparoscopic cholecystectomy: Techniques" and "Complications of laparoscopic cholecystectomy".) This topic will review the technique of open cholecystectomy. Laparoscopic cholecystectomy is discussed in detail elsewhere. (See "Laparoscopic cholecystectomy: Techniques".) INDICATIONS The indications for a cholecystectomy include:

Symptomatic cholelithiasis with or without complications (see "Treatment of acute cholecystitis" and "Uncomplicated gallstone disease in adults"). Acalculous cholecystitis (see "Acalculous cholecystitis"). Asymptomatic cholelithiasis in patients at an increased risk for gallbladder carcinoma or gallstone complications (see "Approach to the patient with incidental gallstones") Gallbladder polyps >0.5 cm (see "Gallbladder polyps and cholesterolosis"). Porcelain gallbladder (see "Porcelain gallbladder").

Incidental cholecystectomy for asymptomatic cholelithiasis may be considered when the patient is undergoing surgery for another gastrointestinal indication provided that the index operation has proceeded uneventfully, the patient is stable, and the cholecystectomy looks like it would be straightforward. In patients with asymptomatic gallstones who undergo an abdominal operation, there is a risk of developing symptomatic gallbladder disease within several years [1,2]. (See "Approach to the patient with incidental gallstones".) Indications for open surgery The most common indication for open cholecystectomy is the inability to safely or effectively complete a laparoscopic cholecystectomy in the patient with symptomatic gallstones. Other reasons to perform open cholecystectomy preferentially over laparoscopic cholecystectomy are presented

below. (See 'Absolute indications for open surgery' below and 'Relative indications for open surgery' below.) Conversion from laparoscopic operation Conversion of the laparoscopic cholecystectomy to an open approach is usually performed to avoid injury to associated structures. This reflects sound surgical judgment and should not be viewed as a failure or complication of the laparoscopic approach. A conversion rate of 9.5 percent of cases was reported in The United States National Hospital Discharge Surveys, which identified one million patients who underwent cholecystectomy from 2000 to 2005 [3]. Similar conversion rates have been reported in other large population-based studies [4]. Predictors of conversion to open cholecystectomy include age (OR 1.01 per year, 95% CI 1.01-1.02), male gender (OR 2.40, CI 1.733.33), emergency status (OR 1.42, CI 1.09-1.84), serum albumin (-1g/dL) (OR 1.43, CI 1.26-1.62), and previous abdominal surgery (OR 1.64, CI 1.20-2.25) [4]. (See "Laparoscopic cholecystectomy: Techniques".) Absolute indications for open surgery Although a laparoscopic approach is generally preferred, cholecystectomy should not be undertaken laparoscopically in some patients. Absolute indications for open surgery as the initial approach include:

Patients who are unlikely to tolerate pneumoperitoneum due to hemodynamic instability or significant cardiorespiratory comorbidities. Pneumoperitoneum in a hemodynamically unstable patient or in a patient with marginal cardiopulmonary reserve may lead to cardiovascular collapse. Patients with refractory coagulopathy. Although coagulopathy should be corrected if possible before any operation, multiple bleeding points and generalized oozing is more easily handled in an open operation. (See "Preoperative assessment of hemostasis".) Patients who are strongly suspected to have gallbladder cancer. When there is a strong suspicion for gallbladder cancer on preoperative imaging, an open approach is recommended to avoid perforation of the gallbladder and intraperitoneal dissemination of malignant cells. (See "Surgical management of gallbladder cancer".) Patients who have other intraabdominal pathology requiring open surgery or who need cholecystectomy as part of another procedure (eg, Whipple procedure). (See "Pancreaticoduodenectomy (Whipple procedure): Techniques".)

Relative indications for open surgery Relative indications for open cholecystectomy as the initial approach include:

Patients who have had prior upper abdominal surgery because scar tissue may preclude safe laparoscopic dissection. Patients with a history of a cholecysto-enteric fistula. (See "Pathogenesis, clinical features, and diagnosis of acute cholecystitis", section on 'Cholecystoenteric fistula' and "Gallstone ileus".) Patients who are pregnant. Although studies report safety of laparoscopy in any trimester of pregnancy, an open approach may be needed in the third trimester due to difficulty in port placement and insufflation. (See "Gallstone disease in pregnant women" and "Laparoscopic surgery in pregnancy".)

Patients with cirrhosis and/or portal hypertension in whom cholecystectomy is associated with increased operative morbidity and mortality. (See "Overview of the complications, prognosis, and management of cirrhosis".)

PREOPERATIVE EVALUATION Compared with laparoscopic cholecystectomy, patients undergoing open cholecystectomy are generally older with more comorbidities [5]. To minimize perioperative morbidity and mortality, the patients medical history should be reviewed and measures should be instituted to optimize medical comorbidities prior to surgery. (See "Preoperative medical evaluation of the healthy patient" and "Estimation of cardiac risk prior to noncardiac surgery" and "Evaluation of preoperative pulmonary risk".) Specific complications of open cholecystectomy that should be discussed with the patient include possible injury to the bile duct or other portal structures (<0.2 to 0.5 percent) or surrounding viscera, bile leak, retained stones, and persistent symptoms (postcholecystectomy syndrome). (See "Repair of common bile duct injuries" and "Laparoscopic cholecystectomy: Techniques", section on 'Postcholecystectomy syndrome'.) The potential need for additional procedures depending upon the preoperative diagnosis should also be explained. Consent for common bile duct exploration should be obtained in patients with choledocholithiasis (suspected or proven) regardless of whether a preoperative ERCP has been performed. Patients with suspected gallbladder cancer may require more extensive surgery, which is discussed in detail elsewhere. (See "Surgical management of gallbladder cancer".) Laboratory testing Laboratory testing in patients with acute cholecystitis includes a complete blood count, liver enzymes, amylase, and lipase. Laboratory values may demonstrate leukocytosis. Elevated serum bilirubin, transaminases, or alkaline phosphatase are suggestive of choledocholithiasis, and elevated serum amylase and/or lipase are usually indicative of acute pancreatitis. These tests are typically obtained prior to elective cholecystectomy as well to serve as a baseline for comparison. (See "Pathogenesis, clinical features, and diagnosis of acute cholecystitis", section on 'Laboratory evaluation'.) Once the decision has been made to proceed with cholecystectomy (urgent or elective), additional laboratory studies include a coagulation profile and basic metabolic panel. An electrocardiogram or chest radiography are obtained as appropriate. (See "Preoperative medical evaluation of the healthy patient", section on 'Laboratory evaluation'.) Preoperative imaging The diagnosis of cholelithiasis or cholecystitis will have already been established using ultrasonography, nuclear cholescintigraphy (technetium-labeled hepatic iminodiacetic acid or HIDA scan) or other advanced imaging studies such as computed tomography. These studies need not be repeated. (See "Uncomplicated gallstone disease in adults", section on 'Diagnosis' and "Pathogenesis, clinical features, and diagnosis of acute cholecystitis", section on 'Diagnosis'.)

Prior to open cholecystectomy, we prefer preoperative endoscopic retrograde cholangiopancreatography (ERCP) in patients suspected of having biliary obstruction. ERCP with sphincterotomy and stone extraction is usually therapeutic in patients with choledocholithiasis, cholangitis, and gallstone pancreatitis with stone impaction, and can be used to rule out malignancy. If the ERCP is unsuccessful at clearing the stones, the surgeon should be prepared for an operative common bile duct exploration. (See "Overview of indications for and complications of ERCP and endoscopic biliary sphincterotomy" and "Common bile duct exploration".) For patients with a relatively low probability of common duct stones, magnetic resonance cholangiopancreatography (MRCP) may obviate the need for the more invasive ERCP. In patients with a high probability of common duct stones (eg, jaundice and choledocholithiasis on ultrasound), MRCP is unnecessary prior to ERCP [6]. (See "Magnetic resonance cholangiopancreatography", section on 'Bile duct obstruction'.) PREPARATION Equipment If available, a harmonic scalpel and/or an argon beam coagulator can help reduce blood loss occasionally associated during resection of the gallbladder from the liver bed in patients with coagulation abnormalities. Prophylactic antibiotics We recommend antibiotic prophylaxis prior to open cholecystectomy. A systematic review identified 42 trials that randomly assigned patients undergoing open biliary tract surgery to prophylactic antibiotics versus no antibiotics [7]. A pooled analysis found a significantly reduced risk of wound infection for those who received prophylactic antibiotics (odds ratio 0.3, 95% CI 0.230.38). Prophylactic intravenous antibiotics should be administered within 60 minutes of the incision. (See "Control measures to prevent surgical site infection following gastrointestinal procedures" and "Overview of control measures to prevent surgical site infection".) Some have questioned the need for prophylactic antibiotics prior to low risk elective cholecystectomy (cholelithiasis not associated with complications) [8-11]. However, most studies have evaluated patients undergoing laparoscopic cholecystectomy [11]. Thus, for patients undergoing low risk open cholecystectomy, we give a single dose of preoperative cefazolin 1 to 2 g (table 1), which provides adequate coverage against common gram-positive skin organisms as well as the most common gram-negative organisms isolated from the biliary tract [12-14]. To ensure adequate tissue levels, a dose of 2 g should be administered to patients weighing >80 kg. Additional antimicrobial coverage is needed for patients who are undergoing emergent surgery or those who are at risk for developing infected bile such as patients with acute cholecystitis, cholangitis, jaundice, choledocholithiasis, pancreatitis, diabetes or other immunosuppressive condition, or age greater than 60 years (table 1). For acute cholecystitis, second-generation cephalosporins including cefotetan or cefoxitin may be used. In penicillin-allergic patients, a combination of ciprofloxacin and metronidazole is an acceptable alternative. In the presence of acute cholangitis, piperacillin/tazobactam, imipenem, or ciprofloxacin with metronidazole may be used.

(See "Control measures to prevent surgical site infection following gastrointestinal procedures" and "Overview of control measures to prevent surgical site infection".) Thromboprophylaxis Most patients undergoing elective open cholecystectomy for symptomatic cholelithiasis will have a low to moderate risk for thromboembolism (table 2). Obese patients, elderly patients, and those undergoing open cholecystectomy for cancer will have a high risk for thromboembolism. We use intermittent pneumatic compression devices for all patients, and administer pharmacologic prophylaxis based upon the patients level of risk. (See "Prevention of venous thromboembolic disease in surgical patients", section on 'Group specific recommendations'.) GALLBLADDER ANATOMY The gallbladder is a small, pear-shaped organ that is located inferior to the margin of the right lobe of the liver (figure 1). The gallbladder is divided into distinct segments: the fundus, body, infundibulum and the neck [15].

The fundus is the expanded end of the gallbladder that projects away from the margin of the liver. It is anatomically associated with the anterior abdominal wall and hepatic flexure of the colon. The body of the gallbladder is attached to the liver by loose connective tissue superiorly. Inferiorly, the free margin abuts the duodenum and transverse colon. Superiorly, it is anatomically associated with segments IV and V of the liver (figure 2). The neck of the gallbladder extends from the body to the cystic duct.

The cystic duct joins the common bile duct along its course from the liver to the duodenum. The level of the juncture and course of the cystic duct can vary (figure 3). Anatomic variations of the ductal structures include accessory hepatic ducts, a short or nonexistent cystic duct, or a cystic duct that drains into the right hepatic duct. The various configurations of accessory hepatic ducts and variations in cystic and hepatic ducts are shown in the figures (figure 4 and figure 3). Less common anatomic variants of the ductal anatomy occur in Caroli's disease and Caroli's syndrome. Caroli's disease is a congenital disorder characterized by multifocal, segmental dilatation of large intrahepatic bile ducts. The condition is usually associated with renal cystic disease of varying severity. Caroli initially described two variants, which has led to some confusion in terminology. Caroli's disease is the less common form and is characterized by bile ductular ectasia without other apparent hepatic abnormalities. The more common variant is Caroli's syndrome in which bile duct dilatation is associated with congenital hepatic fibrosis. Caroli's disease and syndrome are discussed in detail elsewhere. (See "Caroli disease".) The gallbladder is supplied by the cystic artery, which is usually a branch of the right hepatic artery; however, the cystic artery or an accessory cystic artery can arise from the right hepatic, left hepatic, or common hepatic artery. The cystic artery courses along the cystic duct and divides at the neck of the gallbladder into superficial and deep branches, which supply in the anterior/inferior and posterior/superior aspects of the gallbladder, respectively. The venous drainage of the gallbladder generally parallels the course of the arteries draining into the cystic vein, which drains into the

gallbladder fossa directly into the right hepatic vein (ie, it does not accompany the cystic artery). Anatomic variations of the origin and course of the cystic artery are shown in the figure (figure 5). OPEN CHOLECYSTECTOMY PROCEDURE Open cholecystectomy is typically performed under general anesthesia through a right upper quadrant incision. Cholecystectomy under regional anesthesia has been reported [16]. (See "Overview of anesthesia and anesthetic choices".) Once the patient is anesthetized, he or she is positioned supine on the operating table with arms extended laterally to facilitate placement of self-retaining retractors. The general principles for performing open cholecystectomy are discussed below and are illustrated in the figure (figure 6). Exposing the gallbladder The most common approach for open cholecystectomy is through a right subcostal incision, extending obliquely from the midline, parallel to and 2 to 3 cm inferior to the right costal margin. Gallbladder exposure is optimized by completely dividing the right rectus abdominis muscle and incising the linea alba. (See "Principles of abdominal wall incisions", section on 'Subcostal'.) In patients undergoing conversion from a laparoscopic approach to an open approach, the subcostal incision can be made by connecting the subxiphoid and medial subcostal port-site incisions (figure 7). (See "Laparoscopic cholecystectomy: Techniques", section on 'Conventional port placement'.) A midline incision can also provide adequate exposure for open cholecystectomy and is preferred in patients undergoing a concomitant abdominal or pelvic procedure. (See "Principles of abdominal wall incisions", section on 'Midline incision'.) Once the incision is made, moist sponges and retractors are placed (handheld or selfretaining) to retract the hepatic flexure of the colon inferiorly, the duodenum medially, and the liver superiorly. Care is taken to avoid injury to surrounding organs, particularly in the setting of acute or chronic inflammation. Exposure may sometimes be improved by decompressing the gallbladder, which can be performed by making a small incision in the gallbladder fundus, suctioning out the bile and suturing the defect closed to prevent subsequent spillage. Gallbladder dissection and removal Although laparoscopic cholecystectomy is most often performed bottom-up starting from the infundibulum of the gallbladder, many surgeons perform open cholecystectomy top-down starting from the fundus of the gallbladder. The top-down approach frees the gallbladder from the liver first, leaving the cystic duct as the only remaining attachment, which can be divided without requiring dissection more medially, potentially minimizing the likelihood of injury to the portal structures. Top-down approach A top-down approach can be a good alternative if there is any uncertainty about the location of the cystic duct and cystic artery in relation to other structures in the hilum of the liver. However, chronic inflammation can tether the gallbladder to the right-sided hilar structures and lead to complications with this approach [17]. A small contracted intrahepatic gallbladder may be indicative of this

possibility. Prior to dissecting the gallbladder, it may be useful to identify the cystic duct and artery and doubly loop them with suture or small vessel loops. The fundus of the gallbladder is grasped and retracted away from the liver. The plane between the gallbladder and liver is divided using electrocautery. Dissection is continued until the gallbladder is freed from the liver bed. Any bleeding from the liver bed can usually be controlled with direct pressure or electrocautery. Argon beam coagulation and/or suture ligation of visible vessels may be useful in some cases, but deep suturing into the liver should be avoided. (See "Devices for dissection and hemostasis in laparoscopic surgery", section on 'Electrosurgery'.) The structures entering the gallbladder are dissected from the surrounding connective tissue and fat, identifying the cystic duct entering the base of the gallbladder and the cystic arteries. The cystic artery or arteries can be ligated close to the gallbladder wall. The cystic duct should be milked toward the gallbladder to remove debris, and then it is ligated. It is not necessary to dissect the cystic duct/common duct junction and, in the setting of severe inflammation or obliteration of tissue planes, it is acceptable to leave some gallbladder attached to the cystic duct. If this option is necessary, the residual gallbladder remnant should be cleared of debris and closed securely. Once the cystic duct has been divided and ligated, the gallbladder is removed from the field. Bottom-up approach Unequivocal identification of the cystic duct and cystic artery is important for avoiding injury to the portal structures. The cystic duct should not be clipped or divided until the surgeon is certain that the putative cystic duct goes directly into the gallbladder, and that there are no other ductal structures coursing between the base of the gallbladder and the liver bed. An anomalous cystic duct or cystic artery should not be divided until the surgeon is absolutely certain that the structure is not a major duct or artery. If there is any question regarding ductal anatomy, intrahepatic cholangiography should be performed. (See 'Intraoperative cholangiography' below.). For a bottom-up approach, retraction and dissection of the gallbladder is similar to laparoscopic cholecystectomy. The fundus of the gallbladder is grasped with a clamp and retracted cranially. This helps expose the infundibulum of the gallbladder. The infundibulum is grasped and retracted laterally and inferiorly. With the gallbladder retracted in this manner, the cystic duct and artery will straighten, which facilitates dissection in the triangle of Calot, (bounded by the cystic duct inferiorly, the cystic artery superiorly and the common hepatic duct medially), to obtain the critical view of safety (figure 8), which must be achieved prior to clipping or ligating the cystic duct and cystic artery and when accomplished, the structures seen entering the gallbladder can only be the cystic duct and artery, and thus, injury to major structures is avoided [18,19]. To achieve the critical view of safety, a term originally adopted to describe the proper camera view during laparoscopic cholecystectomy, the triangle of Calot is dissected free of all connective tissue and fat exposing the cystic duct and cystic artery, and the medial margin of the gallbladder is freed from the liver. It is not necessary to routinely open the peritoneum over the common duct, but the surgeon should be confident about the location of the common duct where the putative cystic duct drains into it. The dissection begins at the level of the infundibulum. The peritoneum over the infundibulum of the gallbladder is bluntly dissected and the peritoneum stripped along the cystic duct. An unusually large cystic duct should prompt the surgeon to re-evaluate the anatomy. Once the cystic duct has been

identified with certainty, its contents should be gently "milked" toward the gallbladder and if substantial debris is suspected, a doubly looped silk suture (Potts tie) can be placed around the cystic duct and held under gentle tension to prevent the debris from passing distally during subsequent gallbladder manipulation, which can lead to postcholecystectomy complications or choledocholithiasis. After the cystic duct has been dissected, the cystic artery, which usually has anterior and posterior branches, is located. The cystic artery branches can often be unequivocally identified entering the gallbladder where they can be ligated prior to freeing the gallbladder from the liver bed. Otherwise, it should be secured with a double loop of silk suture and temporarily occluded while the gallbladder is freed from the liver bed. If there is concern that the structure could be a diminutive right hepatic artery, a vessel loop can be used for temporary occlusion. Once the dissection is completed and the cystic duct and artery have been identified with certainty, they are ligated and the gallbladder removed. Dissection of the gallbladder from the liver is accomplished by retracting the gallbladder from the liver and dividing the tissue in the plane between the gallbladder and liver using electrocautery. Any bleeding from the liver bed can usually be controlled with direct pressure or electrocautery. Argon beam coagulation and/or suture ligation of visible vessels may be useful in some cases, but deep suturing into the liver should be avoided. (See "Devices for dissection and hemostasis in laparoscopic surgery", section on 'Electrosurgery'.) Unusual situations Unusual situations are sometimes encountered during cholecystectomy. These include the following:

Intrahepatic gallbladder Intrahepatic gallbladder can be removed in the usual fashion. Rarely, it is necessary to leave the back wall of the gallbladder on the liver bed to avoid a difficult dissection and excessive bleeding from the liver. In this setting, the mucosa should be obliterated with electrocautery or argon beam coagulation. Inability to safely perform cholecystectomy If an open cholecystectomy is started and difficulties are encountered, conversion to a cholecystostomy may be useful, provided the gallbladder has not been devascularized. (See 'Open cholecystostomy tube placement' below.) Gallbladder fistula Gallbladder fistulae are rare, and typically involve the duodenum, stomach, colon, or common bile duct. Once the gallbladder is separated, intestinal defects are usually closed primarily. Fistulous connections to the extrahepatic biliary tree, such as with Mirizzi syndrome, may be adequately managed with T-tube insertion into the biliary defect, but may require ductal reconstruction. (See "Gallstone ileus", section on 'Treatment' and "Mirizzi syndrome", section on 'Treatment'.) Gallbladder cancer Gallbladder cancer is rare, but a suspicion may be raised during the course of cholecystectomy. An appropriately trained hepatobiliary surgeon may proceed with extended cholecystectomy or more radical procedure. Those surgeons with less experience can complete the cholecystectomy and await the results of final pathology to determine the next course of treatment, which may be referral to a tertiary center for re-resection. (See "Surgical management of gallbladder cancer".)

Intraoperative cholangiography Absolute indications for intraoperative cholangiography during open cholecystectomy include unclear ductal anatomy, jaundice, and stones in the biliary tree suspected by palpation or preoperative imaging. Intraoperative ultrasound may be equivalent to cholangiography in diagnostic accuracy for common duct stones in experienced hands. (See "Approach to the patient with suspected choledocholithiasis", section on 'Intraoperative ultrasonography'.)

If there is doubt about the ductal anatomy, injection of contrast into the gallbladder using a needle may be preferable to ductotomy and clip occlusion of (what may turn out to be) an important ductal structure. Ideally, the anatomy should be clarified before any ductotomy is made, but if this is not possible, the ductal opening for the cholangiogram catheter should be small in case what is thought to be the cystic duct turns out to be the common duct or a lobar duct. Real-time imaging with fluoroscopy is preferred to static radiography. Glucagon (1 mg intravenously) may be needed to relax the ampulla of Vater to facilitate contrast flow into the duodenum.

Common bile duct exploration If cholangiography confirms the presence of common bile duct stones and postoperative ERCP with stone extraction is not a likely option (eg, Roux-en-Y gastric bypass, prior failed ERCP, lack of local expertise), common bile duct exploration and removal of stones will be necessary. The procedure of common bile duct exploration is discussed in detail elsewhere. (See "Common bile duct exploration".) Closure When the cholecystectomy is completed, the region of the dissection should be irrigated and drained, and examined for evidence of bleeding or biliary leak (eg, liver bed, cystic duct stump). Routine drainage of the peritoneal cavity after cholecystectomy is not indicated because it increases wound infection rates and delays hospital discharge [20-23]. However, it is acceptable to selectively drain the peritoneal cavity after a difficult cholecystectomy, or if there is evidence of residual bile leakage from the liver bed. Drains are not a substitute for adequate hemostasis and cannot be relied upon to indicate the extent of, or the absence of, postoperative hemorrhage [23]. When drains are employed, closed suction drains should be used and the drain(s) should be brought through a separate stab wound, rather than through the surgical incision, which may compromise incisional healing. Although the subcostal incision is resistant to dehiscence and/or herniation, healing may be compromised by poor technique. When closing the right subcostal incision, most surgeons approximate the fascia in two layers. Care should be taken to ensure incorporation of the appropriate tissue layers lateral to the border of the rectus muscle. Single-layer mass closure is acceptable, particularly when the posterior fascia will not hold suture well. The principles of surgical wound closure are discussed elsewhere. (See "Principles of abdominal wall closure".) OPEN CHOLECYSTOSTOMY TUBE PLACEMENT To place a cholecystotomy tube, a pursestring suture is placed into the fundus of the gallbladder through which

an 18 F balloon catheter (inflated once inside the gallbladder) or mushroom catheter is introduced after making a stab incision within the confines of the pursestring suture. The pursestring suture is drawn up and tied to secure the catheter. The catheter should be brought out of the abdomen through a site separate from the abdominal incision. The gallbladder wall is sutured to the peritoneum where the catheter exits the abdomen. If the gallbladder cannot be brought up to the abdominal wall, the space between the gallbladder and abdominal wall should be buttressed with omentum and closed-suction drains placed. The cholecystostomy tube is placed to gravity drainage and should be irrigated with small quantities of sterile saline, as needed. After one week, cholangiography can be performed through the cholecystostomy tube. The cholecystostomy tube can be clamped in two to three weeks, and if tolerated, the tube can be removed one month after placement, provided there is no ongoing need for the tube. POSTOPERATIVE CARE AND FOLLOW-UP After an uncomplicated open cholecystectomy, patients can drink clear liquids once awake from anesthesia and their diet can be advanced as tolerated. Incentive inspirometry and early ambulation should be encouraged. (See "Strategies to reduce postoperative pulmonary complications".) Most patients undergoing open cholecystectomy will require a minimum of one to two days in the hospital to assure adequate pain control. (See "Management of postoperative pain".) If pharmacologic deep vein thrombosis (DVT) prophylaxis is used, we avoid the use of non-steroidal antiinflammatory agents (NSAIDs) such as ibuprofen or ketorolac because of the potential increased risk for postoperative bleeding. Routine postoperative laboratory studies are not necessary unless complications such as bleeding, infection, bile leak, choledocholithiasis, or pancreatitis are suspected. Antibiotics should be discontinued within 24 hours unless there is evidence or suspicion of ongoing infection. (See "Overview of control measures to prevent surgical site infection".) The nasogastric tube that is placed in the operating room can be discontinued in the postanesthesia care unit. If the patient is refractory to anti-emetic medications, the nasogastric tube can be replaced. Following discharge from the hospital, the patient should see the operating surgeon around two and six weeks postoperatively. At these intervals, patients are evaluated for signs and symptoms of infection, biliary complications, and wound problems. Following open cholecystectomy, most patients are feeling quite well at two weeks (minimal narcotic use and improving appetite) and are usually fully recovered at six weeks. Failure to progress accordingly may be indicative of postoperative complications. (See 'Perioperative morbidity and mortality' below.) The patient may develop problems with dyspepsia and possibly persistent abdominal discomfort following gallbladder removal, a constellation of symptoms known as the postcholecystectomy syndrome (PCS). This is discussed in detail elsewhere. (See

"Laparoscopic cholecystectomy: Techniques", section on 'Postcholecystectomy syndrome'.) PERIOPERATIVE MORBIDITY AND MORTALITY Open cholecystectomy is associated with significant morbidity and mortality, which is not surprising given that open cholecystectomy is more often performed for complicated biliary tract disease [3,5]. Compared with laparoscopic cholecystectomy, a study from the National Surgical Quality Improvement Program (ACS NSQIP) database found that patients who underwent open surgery were older with a higher comorbidity burden and had higher rates of mortality (2.8 versus 0.3 percent), infection (8.4 versus 1.3 percent), and other serious complications (11 versus 1.4 percent) [5]. Complications related to cholecystectomy can be systemic, related to patient comorbidities or anesthetic technique, or related directly to the cholecystectomy. The most common systemic complications are pulmonary in nature. An observational study of 2139 patients who underwent either open cholecystectomy or were converted to open cholecystectomy reported failure to wean off the ventilator after more than 48 hours in 4.7 percent, unplanned intubation in 3.4 percent, pneumonia in 3.6 percent, and pulmonary embolism in 0.3 percent of patients [4]. Atelectasis and more serious postoperative pulmonary complications can be prevented in some cases by early ambulation, incentive spirometry, and analgesia. (See "Strategies to reduce postoperative pulmonary complications" and "Overview of the management of postoperative pulmonary complications".) Complications specifically related to the surgical procedure include bleeding, bile leak (which may be related to ductal injury), and infection (surgical site or intraabdominal). These are discussed below. Bleeding Significant bleeding during cholecystectomy is unusual in patients who do not have coagulation abnormalities (eg, cirrhosis). Hemodynamically stable patients may be observed initially; however, postoperative bleeding associated with hemodynamic instability should prompt abdominal exploration. Major bile duct injury may be associated with injury to associated vessels, most commonly, the right hepatic artery. In the setting of severe acute or chronic inflammation, inadvertently dissecting the common bile duct can also lead to injury of the portal vein. If a major vascular injury is recognized during an open cholecystectomy, primary repair should be performed by an experienced vascular, hepatobiliary, or liver transplant surgeon. Following repair, duplex imaging should be used to confirm patency. Bile leak Bile leak due to major bile duct injury following open cholecystectomy is rare; bile leaks are more commonly related to the liver bed or cystic duct stump. If a major ductal injury is found, in the absence of a surgeon appropriately trained in advanced hepatobiliary surgery, transfer to a tertiary center is appropriate. If a drain has been placed during the cholecystectomy procedure, bilious drainage in the postoperative period is obvious. In those patients who have not had a drain placed,

a bile leak should be suspected if postoperative progress is delayed. Common symptoms include persistent abdominal pain, ileus, fever, and hyperbilirubinemia. The bile leak may be from the liver bed (duct of Luschka), cystic duct stump (displaced clip or suture), or, rarely, due to an extrahepatic biliary ductal injury. Ultrasound or computed tomography (CT) of the abdomen may show a substantial subhepatic, perihepatic, or, sometimes, free intraperitoneal fluid. The choice of initial postoperative study depends upon the clinical scenario and urgency. Although CT scan of the abdomen shows more detail, abdominal ultrasound is generally quicker to obtain and does not require contrast administration. Biliary scintigraphy (technetium labeled hepatic iminodiacetic acid [HIDA] scan) or ERCP can be used to confirm bile extravasation. Major ductal injury (eg, transection of the common bile duct, hepatic ducts) should be suspected on the basis of HIDA scan or ERCP. Worrisome findings include extravasation of isotope and nonvisualization of bowel on HIDA scan, and failure to visualize the proximal common duct or lobar branches on ERCP. If the bowel lights up on HIDA scan, this confirms that there is at least partial ductal continuity between the liver and duodenum. (See "Repair of common bile duct injuries".) In general, the source of bile leak and amount of drainage determine the next course of therapy.

A low output bile leak (ducts of Luschka) can generally be treated with drainage alone (percutaneous drainage if intraoperative drainage was not provided). Substantial leakage from the liver bed or cystic duct stump can initially be treated with drainage and temporary endoscopic stenting of the ampulla of Vater to reduce biliary pressure. Reoperation may be needed to provide better drainage or repair the cystic duct. Rarely, an aberrant right segmental or sectoral duct has a very low insertion into the biliary tree and is prone to injury during cholecystectomy (figure 4). If the severed aberrant duct is left open (Strasberg type C injury), a postoperative bile leak is evident and typically it is refractory to ERCP stenting since there is discontinuity between the leaking duct and the common bile duct. Ligation of aberrant right sectoral ducts (Strasberg type B injury) is typically well tolerated if the duct is small and drains only one hepatic segment or less, and the biliary tree is sterile. Otherwise, biliary reconstruction is necessary. Management of transection of more major biliary ducts (eg, common bile duct) is discussed elsewhere. (See "Repair of common bile duct injuries" and "Complications of laparoscopic cholecystectomy", section on 'Biliary and cystic duct leaks'.)

Infection Infectious complications associated with open cholecystectomy include surgical site infection, and intraabdominal abscess typically, which may be related to bile leak and/or hematoma. In a study of 2139 patients who underwent either open cholecystectomy or were converted to open cholecystectomy, superficial wound infections occurred in 5.4 percent of patients, deep wound infections in 1 percent, and wound dehiscence in 1 percent of patients [4]. Wound infections are treated with antibiotics and open

drainage, as needed. The prevention and treatment of wound infections and urinary tract infections is discussed elsewhere in detail. (See "Abdominal surgical incisions: Prevention and treatment of complications" and "Urinary tract infection associated with urethral catheters".) INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The Basics and Beyond the Basics. The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on patient info and the keyword(s) of interest.)

Basics topic (see "Patient information: Gallbladder removal (cholecystectomy) (The Basics)")

SUMMARY AND RECOMMENDATIONS

The most common indication for open cholecystectomy is the inability to safely and/or effectively complete a laparoscopic cholecystectomy in the patient with symptomatic gallstones. Conversion to an open operation from laparoscopic cholecystectomy is performed when laparoscopic dissection is difficult, gallbladder cancer or a cholecystenteric fistula is identified, the anatomy is not well defined, or intraoperative complications arise. (See 'Conversion from laparoscopic operation' above.) Open cholecystectomy should be planned in patients who are unable to tolerate pneumoperitoneum, patients with coagulopathy, patients who are suspected to have gallbladder cancer, and critically ill patients who require open surgery for other intraabdominal pathology. (See 'Indications for open surgery' above.) Open cholecystectomy is typically performed under general anesthesia through a right upper quadrant incision. Open cholecystectomy can be performed using a top-down approach, starting from the fundus of the gallbladder, or a bottom-up approach, starting from the infundibulum of the gallbladder. Using a bottom-up approach, the unequivocal identification of the cystic duct and cystic artery is essential to avoid ductal injuries. The advantage of the top-down approach is that it frees the gallbladder from the liver first, leaving the cystic duct and artery as the only remaining attachments; however, chronic inflammation can tether the gallbladder to the right-sided hilar structures making a top-down approach difficult. (See 'Gallbladder dissection and removal' above.) Indications for intraoperative cholangiography during open cholecystectomy include unclear ductal anatomy, jaundice, and stones in the biliary tree

suspected by palpation or preoperative imaging. If cholangiography confirms the presence of common bile duct stones and postoperative ERCP is not a likely option, common bile duct exploration and removal of stones will be necessary. (See 'Intraoperative cholangiography' above and 'Common bile duct exploration' above.) Following uneventful open cholecystectomy, most patients are feeling quite well at two weeks (minimal narcotic use and improving appetite) and are usually fully recovered at six weeks. Failure to progress accordingly may be indicative of postoperative complications. (See 'Postoperative care and followup' above.) Complications related to cholecystectomy can be systemic, related to patient comorbidities or anesthetic technique, or related directly to the cholecystectomy. The most common systemic complications are pulmonary in nature. Complications specifically related to the surgical procedure include bleeding, bile leak (which may be related to ductal injury), and infection (surgical site or intraabdominal). (See 'Perioperative morbidity and mortality' above.) Bile leak should be suspected in patients who do not progress normally after cholecystectomy. Common symptoms include persistent abdominal pain, ileus, fever, and hyperbilirubinemia. Ultrasound or computed tomography of the abdomen may be used in the initial evaluation of bile leak, and suspected leak confirmed using biliary scintigraphy (HIDA scan) or ERCP. The management of bile leak following open cholecystectomy depends upon the amount and source of the leak. (See 'Bile leak' above.)

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REFERENCES
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