Managing the difficult gallbladder
- L. Michael Brunt, MD
L. Michael Brunt, MD
- Professor of Surgery
- Washington University Institute For Minimally Invasive Surgery
- Nathaniel Stoikes, MD
Nathaniel Stoikes, MD
- Assistant Professor
- University of Tennessee Health Science Center
Laparoscopic cholecystectomy is one of the most commonly performed operations worldwide with over 750,000 cases done in the United States annually. While the most common indication for the operation is uncomplicated biliary colic, there are a number of conditions that can increase the difficulty and risk of this procedure.
The "difficult gallbladder" is a scenario in which a cholecystectomy incurs an increased surgical risk compared with standard cholecystectomy . Cholecystectomy can be made difficult by processes that either obscure normal biliary anatomy (eg, acute or chronic inflammation) or operative exposure (eg, obesity or prior upper abdominal surgery).
In this topic, we discuss risk factors that could predispose to a difficult gallbladder. Recognition of a potentially difficult gallbladder by the surgeon is the first step toward mitigating the high risks of operating on such patients. Pre- and intraoperative strategies of managing a difficult gallbladder are also presented.
Techniques of performing a routine cholecystectomy, both laparoscopic and open; treatment of biliary colic and acute cholecystitis; and management of a biliary injury are reviewed in other topics. (See "Laparoscopic cholecystectomy" and "Open cholecystectomy" and "Treatment of acute calculous cholecystitis" and "Uncomplicated gallstone disease in adults" and "Repair of common bile duct injuries" and "Complications of laparoscopic cholecystectomy".)
A difficult gallbladder may be predicted preoperatively based on certain patient characteristics (table 1). A difficult gallbladder is typically caused by difficult exposure or inflammation. Other rarer causes include cirrhosis of the liver and Mirizzi syndrome. An astute surgeon can often anticipate a difficult cholecystectomy based on these patient characteristics and take steps to ensure the safe performance of the procedure.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
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- Difficult exposure
- Mirizzi syndrome
- Nonoperative management of acute cholecystitis in high-risk patients
- - Observation and antibiotics
- - Cholecystostomy tube drainage
- Safe dissection techniques
- - Critical view of safety
- Conversion to open surgery
- Top-down cholecystectomy
- Subtotal cholecystectomy
- Imaging adjuncts
- - Intraoperative cholangiography
- - Intraoperative ultrasound
- - Fluorescent imaging
- Managing a bile duct injury
- SUMMARY AND RECOMMENDATIONS