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Acute Cholecystitis
With Dr. John Rodriguez · hosted by Dr. Jeffrey Ponsky
Part of
Acute Cholecystitis 4 items
Chapter 1 of 9 · Case-Based Learning
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What the experts said
Early cholecystectomy is favored for straightforward acute cholecystitis because patients managed conservatively have a high recurrence rate and often return on weekends
Patients with acute cholecystitis should be admitted, started on antibiotics, kept NPO, and have coagulation studies, type and screen, and pregnancy test completed before surgery
For patients with prohibitive cardiac risk and acute cholecystitis, broad-spectrum antibiotics are given for 1-2 days, and if no improvement occurs, percutaneous cholecystostomy is recommended
Percutaneous cholecystostomy tubes combined with antibiotics are very effective in managing acute cholecystitis in high-risk patients
Cholecystostomy tubes should remain in place 4-6 weeks, and a cholangiogram through the tube should confirm cystic duct patency before removal to prevent recurrent episodes
Patients on antiplatelet therapy for cardiac stents who need cholecystectomy require cardiology consultation to determine safe timing for stopping medications before surgery and restarting them after
Laparoscopic approach is used in 99% of cholecystectomy cases even in very difficult acute cases
Palmer's point is located two finger breadths below the rib cage in the left midclavicular line and is one of the safest sites for initial trocar entry
In acute cholecystitis, edematous omental tissue bleeds easily, and controlling bleeding early with cautery prevents impaired visualization later in the operation
There is a low threshold to decompress tense, hard gallbladders before attempting to grasp them to prevent tearing
Gallbladder decompression is performed at the fundus using a long reusable needle connected to a 60cc syringe under direct vision
Dissection should start high on the gallbladder where the surgeon is certain to be on the gallbladder wall, taking peritoneum off using hook electrocautery to visualize Calot's node
In acute cholecystitis, the gallbladder tends to have a thicker rind, and once on the gallbladder wall, tissues can be gently teased down toward the duodenum
The critical view of safety requires visualization of the cystic duct-gallbladder junction, the cystic artery within Calot's triangle, and liver in the dissection window
Taking the back wall of the gallbladder off the liver bed just superior to the cystic duct junction provides increased length for safer dissection
Routine cholangiography is used in nearly all cholecystectomy cases
Before cannulating the cystic duct for cholangiogram, a clip is placed close to the gallbladder, a dichotomy is made, and the duct is milked proximally to express any stones
Flushing the cystic duct with 20cc of saline before cholangiography clears sludge and stones and removes air bubbles from the system
When contrast flows only down and not up into the liver on cholangiogram, placing the patient in reverse Trendelenburg or using the camera to compress the distal common bile duct can redirect flow proximally
For small distal common bile duct stones, flushing the duct again and giving glucagon to relax the ampulla should be attempted first
Transcystic common bile duct exploration uses a commercial kit with a percutaneous introducer, step dilator, and wire placed under fluoroscopic guidance into the duodenum
The introducer for transcystic exploration is placed from the right side in a parallel angle to the cystic duct through a separate stab incision to avoid trauma and backwalling the duct
Transcystic exploration kits include a Dormier-type basket for stone extraction and a balloon dilator for antegrade sphincteroplasty to push small stones through
When the infundibulum, cystic duct, artery, and Calot's triangle cannot be defined due to severe inflammation, a dome-down approach is used aggressively
In severe acute cholecystitis cases, going open and attempting to reach the cystic duct is often not safe either
Bailout options for severe inflammation include opening the gallbladder for partial cholecystectomy or leaving part of the back wall on the liver
When the gallbladder is very inflamed and difficult to separate from the liver, there is risk of injuring a superficial right ductal system, which can cause bile leaks
Many postoperative bile leaks attributed to ducts of Luschka are actually from surgeons dissecting too deep into the liver and injuring the ductal system
In partial cholecystectomy, the gallbladder is opened, stones removed, and the gallbladder closed rather than left open, with a drain placed to control potential bile leak
The primary goal in severe acute cholecystitis is avoiding major bile duct injury, which would be a disaster for the patient
When leaving the back wall of a necrotic gallbladder, the mucosa is cauterized on a high coagulation setting and a drain is left
Acute cholecystitis is an obstructive diverticulopathy where cystic duct obstruction by a stone causes pressure backup, decreased wall blood flow, and potential rupture with wall thickening
Dissection should occur at the junction of the cystic duct and gallbladder, not as close to the common duct as possible, to avoid injury
There is nothing magical about a specific number of trocars; additional ports should be placed where needed for adequate exposure
Operating early in uncomplicated acute cholecystitis is recommended, while patients with cardiac or pulmonary disease may benefit from percutaneous cholecystostomy with delayed elective surgery