Acute Cholecystitis
With Dr. John Rodriguez · hosted by Dr. Jeffrey Ponsky
Chapter 1 of 10 · Case-Based Learning
Case presentation
Case presentation and initial management decision
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What the experts said
Patients with acute cholecystitis who are cooled down and discharged have a high recurrence rate and typically return on weekends, making management more difficult.
For a 45-year-old patient with straightforward acute cholecystitis and normal liver function tests, early cholecystectomy during the same admission from the emergency room is favored.
Acute cholecystitis is an obstructive diverticulopathy where the cystic duct becomes obstructed by a stone, causing backup of pressure in the gallbladder with decreased blood flow in the wall that can eventually lead to rupture.
In patients with significant cardiac history, the last thing you want to do is take them to the operating room and cause an acute cardiac event.
Many patients with acute cholecystitis will cool down with antibiotics alone and no additional intervention is needed.
Percutaneous cholecystostomy tubes can be very helpful for patients who are not good candidates for operative intervention.
For high-risk patients with acute cholecystitis, give antibiotics for about one to two days, and if there's no improvement, then recommend percutaneous cholecystostomy.
The combination of percutaneous cholecystostomy tubes with antibiotics is very effective in managing acute cholecystitis in sicker patients, with most having an uneventful recovery.
Before removing a cholecystostomy tube, wait about 4 to 6 weeks and perform a cholangiogram through the tube to ensure the cystic duct is patent.
If the cystic duct is not patent when removing a cholecystostomy tube, the patient will get a recurrent episode as soon as the tube is removed.
For patients on antiplatelet therapy due to stents who need to wait a year, keeping a cholecystostomy tube is reasonable because once they can come off Plavix or aspirin it's easier to manage a recurrent episode definitively.
Cholecystectomy in patients with prior cholecystostomy tubes tends to be more challenging cases that need to be planned well and should not be added on at the end of the day when the surgeon is tired.
In patients with cholecystostomy tubes, the tube should not be removed before surgery if possible because it's useful for finding anatomy when there are adhesions and can be used to shoot a cholangiogram intraoperatively if the surgeon is lost.
Gallbladders in patients with prior cholecystostomy tubes tend to be pretty challenging and take quite some time to remove.
99% of the time the approach for cholecystectomy is laparoscopic, even in very difficult cases.
Palmer's point is about two finger breadths below the rib cage on the left side in the midclavicular line and is one of the safest locations for initial laparoscopic entry.
By placing the initial port at Palmer's point and dropping the hand about another inch lower, that port can serve as an operating port without needing an additional trochar.
Placing the most lateral trochar under direct vision while being able to see the gallbladder allows the assistant to grab and elevate the gallbladder, giving better location for the left hand port.
In acute cholecystitis cases, tissue can be very edematous and bleed easily, and when bleeding is not controlled early on it tends to impede visualization later.
Hook electrocautery is a very fine dissecting tool that tends to be hemostatic for taking down omental adhesions.
There is a very low threshold to decompress tense gallbladders before trying to grab them, using a long reusable needle connected to a 60cc syringe inserted at the fundus under direct vision.
Decompressing the gallbladder allows grasping without tearing the wall.
In acute cholecystitis, gallbladders tend to have a thicker rind, so once you get down on the gallbladder wall you can start gently teasing tissues down towards the duodenum.
The suction device is a great dissection tool during laparoscopic cholecystectomy.
As you take Calot's node down you can visualize the cystic artery, and dissecting up towards the body of the gallbladder gets length on the artery because as long as you're on the gallbladder you know you're safe.
Dissection should occur at the junction of the cystic duct and gallbladder and the cystic artery and gallbladder, not as close to the common duct as possible, because that's how you get in trouble.
The Maryland dissector is a great tool for gentle dissection at the junction between the cystic duct and gallbladder.
Moving the gallbladder back and forth with the left hand allows dissection on the lateral side, which is always a safe spot.
The critical view of safety requires visualizing the cystic duct, the gallbladder wall, liver in the window, and the cystic artery within Calot's triangle.
A useful trick is to take some gallbladder just superior to the junction of the cystic duct with the gallbladder and take the back wall off the liver bed to give increased length.
Routine cholangiography is used in almost all cholecystectomy cases.
Before attempting to cannulate the cystic duct for cholangiography, place a clip very close to the gallbladder, make a dichotomy, and milk the cystic duct proximally with scissors or a Maryland to see if there are any stones and try to get them out.
Giving the cholangiogram catheter a 45-degree angle before placing it into the body helps with cannulation.
The Olsen clamp has a layout where the tip comes together but the middle doesn't, allowing occlusion of the cystic duct around the catheter without occluding the catheter itself.
Flushing the cystic duct with a good 20cc of saline before cholangiography can be very helpful when there's sludge and stones, and also gets air bubbles out of the system.
To get contrast to flow proximally into the liver during cholangiography, tricks include laying the patient in slight Trendelenburg position or using the camera to put pressure on the distal common bile duct.
For a small stone in the distal common bile duct, first try flushing again with good pressure and give glucagon to relax the ampulla, which can sometimes help get distal stones out.
Commercial transcystic common bile duct exploration kits include a percutaneous introduction catheter with a step dilator that should be placed at a parallel angle to the cystic duct through a separate stab incision from the right side to avoid trauma to the duct.
The key for transcystic common bile duct exploration is to place a wire under fluoroscopic guidance distally into the duodenum, after which instruments including a Dormier basket and balloon dilator can be used for stone extraction.
For small common bile duct stones, it's easier to push them through with a balloon dilator (performing transcystic antegrade sphincteroplasty) than to try to extract them with a basket.
When the infundibulum, cystic duct, artery, and Calot's triangle cannot be defined due to severe inflammation and duodenal adherence, the approach is aggressive top-down dissection while remaining laparoscopic.
Placing the lateral left trochar under direct vision is helpful because it positions the port to be useful in difficult situations beyond just standard cholecystectomy technique.
There is no hesitation to add another trochar when needed during laparoscopic cholecystectomy.
You can tell laparoscopically how difficult it's going to be if you convert to open, and the reality is that in severe cases going open and trying to be heroic going for the cystic duct is not safe either.
In severe cases where anatomy cannot be defined, the decision is between opening the gallbladder and doing a partial cholecystectomy, or leaving part of the back wall on the liver.
In horrible cases, opening the gallbladder, taking out all the stones, and placing a large cholecystostomy tube creates an empty gallbladder with a tube and can bail you out.
When converting to open cholecystectomy for severe inflammation, the approach is still top-down dissection.
Some patients have a very superficial right hepatic ductal system, and as you start digging into the liver you can injure it, leading to bile leaks.
Many patients who come back with bile leaks labeled as duct of Luschka leaks are not really duct of Luschka leaks but rather the surgeon getting too deep into the liver and injuring the ductal system.
In cases where you cannot safely dissect to the cystic duct, open the gallbladder, get the stones out, get down to a point where you know you're safe and not injuring anything, then close it up rather than leaving it open.
In subtotal cholecystectomy cases, a drain is left most of the time to control a bile leak if it occurs.
The big goal any surgeon has in a difficult cholecystectomy case is avoiding a major bile duct injury that will end up being a disaster for the patient.
When leaving the back wall of the gallbladder, cauterize the mucosa with coagulation on a high setting.