Open Cholecystectomy

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Approximately 700,000 cholecystectomies are performed annually in the United States. Most are performed to address symptoms related to biliary colic from cholelithiasis, to treat complications of gallstones (eg, acute cholecystitis and biliary pancreatitis), or as incidental cholecystectomies performed during other open abdominal procedures. Currently, most cholecystectomies are done via the laparoscopic approach (see Laparoscopic Cholecystectomy); however, the open technique is sometimes required.

Indications for cholecystectomy, either open or laparoscopic, are usually related to symptomatic gallstones or complications related to gallstones. The most common of these indications are the following:

Other indications include the following:

Prophylactic cholecystectomy at the time of a splenorenal shunt has been proposed on the basis of the acute pain syndrome that these patients can develop postoperatively, which is often related to gallbladder symptoms, as well as the high likelihood of the formation of gallstones in this subset of patients with liver disease.

The procedure of choice for most of these indications has shifted from an open approach to a laparoscopic approach. However, some situations still require a traditional open cholecystectomy. Depending on the clinical situation, the procedure can either begin as an open operation or be converted to an open procedure from a laparoscopic one.

Some indications for forgoing laparoscopy and proceeding with an open operation are as follows:

When gallbladder cancer is suspected or confirmed preoperatively or intraoperatively, an open cholecystectomy should be performed with consultation from an experienced hepatobiliary surgeon if the primary surgeon is not comfortable with liver resections and hepatobiliary surgery. If the necessary expertise is not available, the patient can be referred to a hepatobiliary surgeon for reexploration, given that prior exploration, either laparoscopic or open, does not appear to adversely affect long-term survival. ^[1]

The recommendation for open cholecystectomy for gallbladder cancer, however, remains somewhat problematic, in that most gallbladder cancers are discovered incidentally during surgery or in the specimen. ^{[2, 3]}

Open cholecystectomy should also be considered in patients with cirrhosis and bleeding disorders, as well as pregnant patients. In patients with advanced cirrhosis and bleeding disorders, potential bleeding may be difficult to control laparoscopically, and an open approach (or a percutaneous cholecystostomy tube) may be more prudent. Also, patients with portal hypertension often have a recannulized umbilical vein, and placing ports in these patients may cause significant hemorrhage.

Although laparoscopic cholecystectomy has been proved to be safe in all trimesters of pregnancy, as well as possibly associated with fewer maternal and fetal complications, ^[4] an open operation should be considered, especially in the third trimester, because laparoscopic port placement and insufflation may be difficult.

Open cholecystectomy is also indicated, albeit infrequently, in patients who have trauma to the right upper quadrant and in the rare cases of penetrating trauma to the gallbladder.

Most open cholecystectomies result from conversion of a laparoscopic procedure, often because of bleeding complications or unclear anatomy. Conversion rates for laparoscopic cholecystectomy vary widely, with a reported range of 1-30%. ^[5] However, most series report the incidence of conversion to be lower than 10%, and some series report a figure closer to 1-2%. ^{[6, 7, 8]}

In a study by Ibrahim et al, predictors of conversion to open cholecystectomy included age greater than 60 years, male sex, weight exceeding 65 kg, the presence of acute cholecystitis, previous upper abdominal surgery, the presence of diabetes and high glycosylated hemoglobin levels, and a less experienced surgeon. ^[9]

In a study by Licciardello et al, ^[10] risk factors for conversion on univariate analysis included increased age; acute cholecystitis; comorbidities; elevated white blood cell count; and increased levels of aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, gamma glutamyl transpeptidase, C-reactive protein, and fibrinogen. On multivariate logistic regression analysis, acute cholecystitis and age greater than 65 years were found to be independent predictive factors for conversion.

Sutcliffe et al, using data from a prospective UK database of 8820 patients developed a validation risk score designed for preoperative identification of patients at high risk for conversion from laparoscopic to open cholecystectomy. ^[11]  This score was derived from the following six significant predictors: age, sex, indication for surgery, American Society of Anesthesiologists (ASA) score, thick-walled gallbladder, and CBD diameter. A score higher than 6 identified patients likely to require conversion.

Finally, in lower-income countries, open cholecystectomy may be more cost-effective than the laparoscopic equivalent and may therefore be preferred on that basis. ^[12]

Absolute contraindications for proceeding with an open cholecystectomy are few. Such absolute contraindications are limited to severe physiologic derangement or cardiopulmonary disease that prohibits general anesthesia.

In cases of terminal illness, temporizing procedures such as percutaneous transhepatic cholangiography or percutaneous cholecystostomy should be considered in lieu of cholecystectomy.

Fong Y, Jarnagin W, Blumgart LH. Gallbladder cancer: comparison of patients presenting initially for definitive operation with those presenting after prior noncurative intervention. Ann Surg. 2000 Oct. 232(4):557-69. [Medline].

Wullstein C, Woeste G, Barkhausen S, Gross E, Hopt UT. Do complications related to laparoscopic cholecystectomy influence the prognosis of gallbladder cancer?. Surg Endosc. 2002 May. 16(5):828-32. [Medline].

Varshney S, Butturini G, Buttirini G, Gupta R. Incidental carcinoma of the gallbladder. Eur J Surg Oncol. 2002 Feb. 28(1):4-10. [Medline].

Sedaghat N, Cao AM, Eslick GD, Cox MR. Laparoscopic versus open cholecystectomy in pregnancy: a systematic review and meta-analysis. Surg Endosc. 2017 Feb. 31 (2):673-679. [Medline].

McAneny D. Open cholecystectomy. Surg Clin North Am. 2008 Dec. 88(6):1273-94, ix. [Medline].

Visser BC, Parks RW, Garden OJ. Open cholecystectomy in the laparoendoscopic era. Am J Surg. 2008 Jan. 195(1):108-14. [Medline].

Livingston EH, Rege RV. A nationwide study of conversion from laparoscopic to open cholecystectomy. Am J Surg. 2004 Sep. 188(3):205-11. [Medline].

Tang B, Cuschieri A. Conversions during laparoscopic cholecystectomy: risk factors and effects on patient outcome. J Gastrointest Surg. 2006 Jul-Aug. 10(7):1081-91. [Medline].

Ibrahim S, Hean TK, Ho LS, Ravintharan T, Chye TN, Chee CH. Risk factors for conversion to open surgery in patients undergoing laparoscopic cholecystectomy. World J Surg. 2006 Sep. 30(9):1698-704. [Medline].

Licciardello A, Arena M, Nicosia A, Di Stefano B, Calì G, Arena G, et al. Preoperative risk factors for conversion from laparoscopic to open cholecystectomy. Eur Rev Med Pharmacol Sci. 2014 Dec. 18(2 Suppl):60-8. [Medline].

Sutcliffe RP, Hollyman M, Hodson J, Bonney G, Vohra RS, Griffiths EA, et al. Preoperative risk factors for conversion from laparoscopic to open cholecystectomy: a validated risk score derived from a prospective U.K. database of 8820 patients. HPB (Oxford). 2016 Nov. 18 (11):922-928. [Medline].

Silverstein A, Costas-Chavarri A, Gakwaya MR, Lule J, Mukhopadhyay S, Meara JG, et al. Laparoscopic Versus Open Cholecystectomy: A Cost-Effectiveness Analysis at Rwanda Military Hospital. World J Surg. 2016 Nov 30. [Medline].

Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg. 1995 Jan. 180(1):101-25. [Medline].

Sandblom G, Videhult P, Crona Guterstam Y, Svenner A, Sadr-Azodi O. Mortality after a cholecystectomy: a population-based study. HPB (Oxford). 2015 Mar. 17(3):239-43. [Medline].

A prospective analysis of 1518 laparoscopic cholecystectomies. The Southern Surgeons Club. N Engl J Med. 1991 Apr 18. 324(16):1073-8. [Medline].

de Goede B, Klitsie PJ, Hagen SM, van Kempen BJ, Spronk S, Metselaar HJ, et al. Meta-analysis of laparoscopic versus open cholecystectomy for patients with liver cirrhosis and symptomatic cholecystolithiasis. Br J Surg. 2013 Jan. 100(2):209-16. [Medline].

Iannitti DA, Varker KA, Zaydfudim V, McKee J. Subphrenic and pleural abscess due to spilled gallstone. JSLS. 2006. 10(1):101-104.

Metcalfe MS, Ong T, Bruening MH, Iswariah H, Wemyss-Holden SA, Maddern GJ. Is laparoscopic intraoperative cholangiogram a matter of routine?. Am J Surg. 2004 Apr. 187(4):475-81. [Medline].

McLean TR. Risk management observations from litigation involving laparoscopic cholecystectomy. Arch Surg. 2006 Jul. 141(7):643-8; discussion 648. [Medline].

William W Hope, MD Assistant Professor of Surgery, University of North Carolina at Chapel Hill School of Medicine; Director of Surgical Education, Department of Surgery, New Hanover Regional Medical Center/South East Area Health Education Center

William W Hope, MD is a member of the following medical societies: American College of Surgeons, North Carolina Medical Society, Society of American Gastrointestinal and Endoscopic Surgeons

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Cr bard, WL Gore, Intuitive Surgical<br/>Received research grant from: CR bard, WL Gore<br/>Received income in an amount equal to or greater than $250 from: CR Bard, WL Gore, Intuitive surgical<br/>Received grant/research funds from CR Bard and WL Gore for consulting.

Daniel C Barzana, DO Resident, Department of Surgery, New Hanover Regional Medical Center

Daniel C Barzana, DO is a member of the following medical societies: American College of Surgeons, American Osteopathic Association

Disclosure: Nothing to disclose.

David A Iannitti, MD Clinical Associate Professor of Surgery, University of North Carolina at Chapel Hill School of Medicine; Chief, HepatoPancreaticoBiliary Surgery, Department of General Surgery, Division of Gastrointestinal and Minimally Invasive Surgery, Program Director, HepatoPancreaticoBiliary Surgical Fellowship, Carolinas Medical Center

David A Iannitti, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, International Hepato-Pancreato-Biliary Association, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Surgical Oncology, Americas Hepato-Pancreato-Biliary Association, American Society of Clinical Oncology

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Kurt E Roberts, MD Assistant Professor, Section of Surgical Gastroenterology, Department of Surgery, Director, Surgical Endoscopy, Associate Director, Surgical Skills and Simulation Center and Surgical Clerkship, Yale University School of Medicine

Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

Kurt E Roberts, MD Assistant Professor, Section of Surgical Gastroenterology, Department of Surgery, Director, Surgical Endoscopy, Associate Director, Surgical Skills and Simulation Center and Surgical Clerkship, Yale University School of Medicine

Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

The authors thank Cissy Swartz for her assistance with manuscript preparation and editing.

Open Cholecystectomy

Research & References of Open Cholecystectomy|A&C Accounting And Tax Services
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