Cholecystectomy: definition and Surgical Anatomy

Cholecystectomy, a surgical procedure aimed at removing the gallbladder, stands as one of the most frequent abdominal surgeries conducted in the Western world. Indications for cholecystectomy include symptomatic cholelithiasis, cholecystitis, gallbladder polyps > 0.5 cm, porcelain gallbladder, choledocholithiasis, gallstone pancreatitis, and on rare occasions, gallbladder cancer. With advancements in surgical techniques, over 90% of cholecystectomies are now performed laparoscopically, offering improved recovery time and reduced postoperative pain. While cholecystectomy generally carries a low-risk profile, potential complications such as vascular and biliary ductal injuries are among the most concerning.

Definition and Surgical Anatomy:

Definition:

Cholecystectomy refers to the surgical extraction of the gallbladder and can be conducted using either an open or a laparoscopic approach.

Anatomy:

Gallbladder:

- A bile-filled sac situated in a fossa on the inferior aspect of the liver beneath the junction of hepatic segments Ⅳb and Ⅴ.

- Measures 7–10 cm in length with an average capacity of 30–50 mL.

- Anatomic divisions include the fundus (uppermost aspect), corpus (body), infundibulum (round, blind end extending below the liver margin), and neck (connecting with the cystic duct).

- The cystic duct connects the gallbladder to the biliary tree and contains the spiral valves of Heister.

- Blood supply typically originates from the cystic artery, which is often a branch of the right hepatic artery (in 90% of cases).

- Gallbladder wall layers comprise the mucosa (columnar cells with microvilli), lamina propria, muscular layer (not distinctly layered), and serosa, lacking a muscularis mucosae. Rokitansky–Aschoff sinuses, invaginations of mucosae, extend through the muscular layer.

Biliary Tree:

- The right and left hepatic ducts unite to form the common hepatic duct.

- The cystic duct joins the common hepatic duct to create the common bile duct.

- The length of the cystic duct varies considerably.

Calot’s (Hepatobiliary) Triangle:

- Borders include the medial aspect (common hepatic duct), lateral aspect (cystic duct), and superior aspect (inferior edge of the liver or, in the original definition, the cystic artery).

- Contents consist of the right hepatic artery, cystic artery, lymph node of Lund, and lymphatics.

Anatomic Variants:

- Variations in the cystic duct's junction with the common hepatic duct.

- Different paths of the cystic duct relative to the common hepatic duct.

- Various origins and configurations of the cystic artery, including single or multiple branches from hepatic arteries.

Indications and Contraindications:

Indications:

- Symptomatic cholelithiasis without cholecystitis, characterized by gallstones predominantly composed of cholesterol and, sometimes, bilirubin.

- Cholecystitis, both acute and chronic, resulting from inflammation of the gallbladder typically due to cystic duct obstruction, often by stones.

- Biliary dyskinesia, presenting as abnormal emptying of bile due to physiologic dysfunction of the gallbladder.

- Choledocholithiasis and gallstone pancreatitis.

- Gallbladder polyps larger than 0.5 cm.

- Porcelain gallbladder, evidenced by calcification of the gallbladder.

- Gallbladder cancer necessitating radical cholecystectomy, involving lymphadenectomy and resection of adjacent liver parenchyma.

- Emergent indications such as gangrenous or emphysematous gallbladder, and gallbladder perforation.

Contraindications:

- Absolute contraindication includes uncontrolled coagulopathy.

- Relative contraindications encompass conditions like chronic obstructive pulmonary disease (COPD), severe cardiac ailments such as heart failure or recent myocardial infarction (within 6 months), severe aortic stenosis, cirrhosis, portal hypertension, and sepsis/hemodynamic instability. In cases without strict indications for emergent cholecystectomy, alternative approaches may be better tolerated.

Alternative Approaches:

- In cases where surgery is contraindicated, acute cholecystitis can initially be managed with antibiotics while stabilizing the patient and correcting coagulopathy.

- For patients still deemed poor surgical candidates, a percutaneous drain can be placed into the gallbladder to provide source control. After 6–8 weeks, the patient can be reevaluated for cholecystectomy.

Procedure:

The surgical objective is to remove the gallbladder and its contained stones while ensuring complete clearance of the ductal system. This goal remains consistent for both laparoscopic and open approaches.

Preoperative Preparation:

- Supportive management including nothing by mouth, pain control, nausea treatment, and fluid resuscitation with electrolyte correction.

- Administration of preoperative antibiotics tailored to the specific clinical scenario.

- Anesthesia induction under general anesthesia with consideration for orogastric/nasogastric tube placement and optional Foley catheter insertion.

Laparoscopic Cholecystectomy:

- Considered the gold standard due to reduced postoperative pain, shorter hospital stay, and earlier return to work.

- Procedure involves port incisions, creation of pneumoperitoneum, trocar insertion, visualization of Calot’s triangle, dissection, and extraction of the gallbladder.

- Conversion to an open approach is necessary if anatomical clarity is compromised.