Overview of Open Cholecystectomy
Gallbladder disease is a common health condition treated in the United States, leading to over 1.2 million surgeries each year to remove the gallbladder. This procedure is known as a cholecystectomy. Prior to 1991, cholecystectomies were typically performed using an open surgery technique. This would often involve creating a medical imaging of the bile duct during the operation (known as an intraoperative cholangiogram) and the patient staying in the hospital for 2 to 6 days after the operation.
However, the way we perform a cholecystectomy has changed dramatically since the late 1980s with the introduction of laparoscopic surgery. This less invasive technique, known as a laparoscopic cholecystectomy, has become the most popular option for cholecystectomy, with a 30% increase in its use. Nowadays, 92% of all cholecystectomies are performed using this method, although the traditional open surgery is still more common in less affluent places.
Despite the benefits of the laparoscopic technique, it’s important to note that the use of this method in the 1990s led to an increase in injuries to the common bile duct (CBD) by three to ten times. The injury rate has decreased to 0.3%, but this hasn’t improved much, even with better training, equipment, and safety measures in place. It’s worth mentioning that injuries to the CBD from laparoscopic surgery tend to be more complex.
Open cholecystectomies still have their role and are used in certain cases. Hence, learning this procedure remains a crucial part of the training for those learning general surgery.
Anatomy and Physiology of Open Cholecystectomy
The structure of the biliary tree, which includes the gallbladder and bile ducts, varies quite a bit from person to person. The gallbladder is a small, pear-shaped organ attached underneath sections of the liver and doesn’t have an outer layer. A tiny bulge, known as Hartman’s pouch, can be found on the lower part of the gallbladder, leading to a tube called the cystic duct, which connects to the bile duct. Valves inside the cystic duct help regulate bile flow. The bile duct empties into the first part of the small intestine, or duodenum, at a place called the Ampulla Vater.
Bile flow into the duodenum is controlled by a muscle known as the sphincter of Oddi. The common hepatic duct, located near the duodenum, splits into left and right branches in the liver and subsequently divides into smaller ducts. Occasionally, tiny ducts may run directly from the liver to the gallbladder. These are known as the ducts of Luschka and can cause bile leaks after surgery if they aren’t taken care of properly.
Blood is supplied to the gallbladder by the cystic artery, an offshoot of the right hepatic artery, which stems from the common hepatic artery. The gallbladder doesn’t have a dedicated venous structure. Often surgeons look out for an anatomical landmark known as the triangle of Calot to identify the cystic artery. This triangle is defined differently, but a common description includes the cystic duct, the common hepatic duct, and the liver’s underside. It’s important to remember that the structure of the biliary tree can significantly differ among individuals. Variations can include different types of cysts, swollen gallbladders, extra ducts, gallbladders located inside the liver, and duplicates.
It’s also worth noting that about 15% to 20% of patients might have a different biliary anatomy, which could increase surgical risks. For instance, a short cystic duct might be confused with the common bile duct, leading to potential damage. Similarly, a short cystic artery could lead to an injury to the right hepatic artery, a crucial blood vessel. 10% to 15% of individuals have a right hepatic artery that arises from the superior mesenteric artery, another crucial blood vessel.
Why do People Need Open Cholecystectomy
In recent times, we’ve seen a shift towards using laparoscopic surgeries to remove the gallbladder, reducing the need for traditional open surgeries. However, open surgeries are still required in certain cases, accounting for about 2% to 10% of all gallbladder removals.
An open surgery might be preferred over a laparoscopic one in situations where the surgeon faces difficulty due to unclear anatomy, heavy inflammation, adhesions (internal scar tissue), anatomical differences, damage to the bile duct, presence of unremoved bile duct stones, or if there’s uncontrollable bleeding.
At times, the surgeon might also have to explore the common bile duct, which can be difficult to do laparoscopically. In those cases, they might opt to go for an open surgery. Similarly, an open surgery would be planned out ahead of time if the patient has conditions like cirrhosis (a liver disease), gallbladder cancer, or a history of extensive surgeries in the upper abdomen leading to adhesions. Certain health complications like diabetes may also make an open procedure more suitable.
An open surgery might be preferred for critically ill patients too since it doesn’t involve certain physiological changes related to laparoscopic surgery, like decreased cardiac return and higher ventilation pressures.
Choosing to switch from a laparoscopic procedure to an open one mainly depends on the visibility and clarity of anatomy during surgery. Such a conversion isn’t a complication or a failure; instead, it shows sound judgment, as the surgeon prioritizes completing the operation in the safest way possible.
When a Person Should Avoid Open Cholecystectomy
There are no specific reasons to prevent a person from choosing either open or laparoscopic cholecystectomy (gallbladder removal surgery). But, among those two, the laparoscopic method, which is done using special tools through small incisions, is generally favored. This is because it allows the patient to leave the hospital on the same day as the surgery, and the recovery is faster – usually about a week, compared to several weeks with open surgery.
However, there are some general health conditions that may make the open cholecystectomy not suitable for some patients, such as a severe underlying illness like shock, severe heart and lung disease, recent usage of blood-thinning medications, a recent brain-related event, and other serious health problems. These conditions can make surgery more risky.
Furthermore, if there is a chance that the gallbladder may be cancerous, it’s crucial to perform a thorough examination before the removal procedure. This includes understanding how deep the suspected cancer has invaded and if it has spread (metastasized) to other parts of the body. The results of this examination will guide surgeons on whether to proceed with the gallbladder removal or not.
Equipment used for Open Cholecystectomy
Surgeons carry out their operations in a suitable operating room under general anesthesia. “General anesthesia” means that you will be totally unconscious for the surgery. The surgeons make use of typical surgical equipment designed for carrying out operations in the abdomen.
Fluoroscopy, which uses X-rays to get real-time moving images of the inside of your body, and cholangiogram catheters, which are tubes used to inject dye into your bile ducts for clear imaging, need to be on standby in case there’s a need for an intraoperative cholangiogram. This is a procedure that uses these tools to examine your bile ducts in the middle of the operation.
They also need to have a colonoscope, a tool used for viewing the inside of your colon, and other instruments needed for a possible exploration of your common bile duct, the pipe that transfers bile from your liver to your small intestine.
Extraction tools for removing stones from the common bile duct, like bile duct baskets, graspers, and Fogarty catheters, are also necessary. A Fogarty catheter is a medical device used to unblock vessels.
If they are performing a bile duct exploration, they also need an assortment of T-tubes, which are shaped like a “T” and used to drain bile. In situations where you have acute cholecystitis, an inflammation of the gallbladder, or clear infections, they may also take samples for cultures. Cultures are tests to find germs (like bacteria or a fungus) that could be causing an infection.
Self-retaining retractors, which are devices that hold back your organs or tissue, such as a Bookwalter, may also be beneficial depending on the situation of the operation. If a cholangiogram is needed, either a flat plate x-ray or C arm fluoroscopy, a special type of x-ray equipment, can be useful.
Who is needed to perform Open Cholecystectomy?
The most critical role in an open cholecystectomy is played by a seasoned surgeon who is proficient in conducting the procedure. Nowadays, new trainees (residents) tend to have less practice with this surgery compared to surgeons who received training before the 1990s. This operation also requires a skilled anesthesiologist who can safely provide general anesthesia, which puts you to sleep for the surgery.
In addition to these, an experienced first assistant, usually a senior resident who is training to specialize in surgery, is equally necessary for a successful surgery. The team also includes a scrub technician and a circulating nurse who work together to make sure everything runs smoothly during the operation.
If a patient requires an intraoperative cholangiogram – a special X-ray of the bile ducts during surgery, a radiology technician with skills in fluoroscopy (a type of medical imaging that shows a continuous X-ray image on a monitor, almost like an X-ray movie) would also be needed. This team of professionals ensures that your surgery is conducted safely and effectively.
Preparing for Open Cholecystectomy
If you’re suspected to have gallbladder disease, your doctor will need to conduct several tests to confirm it. These tests may include a gallbladder ultrasound, which uses sound waves to create images of your gallbladder, an abdominal CT scan, providing a detailed picture of the inside of your abdomen, a Hida scan, which checks the functioning of your gallbladder, and some blood tests.
Once the diagnosis is confirmed, your surgeon will decide if you should have gallbladder surgery (also known as a cholecystectomy). The surgeon may first try a less invasive technique, laparoscopic surgery, which uses small incisions and a tiny camera. If necessary, they can switch to open surgery, which involves a larger incision, during the procedure.
Your surgeon always weighs the risks and benefits before deciding to choose laparoscopic surgery to make sure it’s the safest for you. First, they’ll ensure that your vital signs like blood pressure and pulse (also known as being hemodynamically stable) are good. If necessary, they’ll take steps to stabilize your condition.
The surgeon must also explain to you what the surgery involves, its potential risks and benefits, and any other options you might have. As with all surgeries, there are specific preparations before an operation. These may include not eating or drinking anything for a certain period (nothing by mouth), possibly taking antibiotics, and implementing measures to prevent a blood clot in your veins (known as deep vein thrombosis).
It is also crucial to note that your medical history will be thoroughly reviewed and a physical evaluation will be done. In some instances, specialists like a gastroenterologist (a doctor who specializes in digestive issues) or an interventional radiologist (a doctor who uses imaging techniques) may be involved. They can help with tests like an endoscopic retrograde cholangiopancreatography, a procedure that combines endoscopy and X-rays to treat problems of the bile or pancreatic ducts, or prepare a cholecystostomy tube if needed. This helps to ensure the treatment planned for you is the best possible one.
How is Open Cholecystectomy performed
Once the patient has been properly anesthetized (put to sleep) and prepared for the surgery, the surgeon makes a cut in the upper right side of the abdomen, either in the middle or slightly to the side. Then, using sponges and special tools to hold back the other organs, they get a clear view of the gallbladder, the area known as the triangle of Calot, and the tubes that transport bile – a digestive fluid.
While doing this, the surgeon has to be careful not to injure the liver. Once everything is clearly seen, the surgeon uses clamps to hold the gallbladder and move it for the best view. At this point, they decide from which end to start removing the gallbladder, top or bottom is decided based on the patient’s anatomy.
To do this, the surgeon first needs to identify and cut the cystic duct (pipe draining the gallbladder) and cystic artery (blood supply to the gallbladder). Both are sealed with small surgical clips before cutting. Checking that these are the correct structures is very important to prevent complications. Then, the gallbladder can be taken out from its liver “bed” or attachment point, using a special kind of electrical scalpel.
The liver bed from where the gallbladder was removed needs to be checked for bleeding or leaks from a small bile duct (duct of Luschka). Based on further conditions related to gallstone in the bile duct, such as elevated bilirubin (a body waste product) and over stretched bile duct, the surgeon makes the decision for further inspection or exploration. Finally, the abdomen is closed in layers in the usual manner.
Sometimes, the gallbladder might be extremely swollen due to inflammation and it might be necessary to reduce this swelling with a decompression needle before starting the surgery. The technique that would be chosen for the surgery depends entirely on what the surgeon is comfortable and experienced with.
Should the procedure encounter considerable inflammation or fibrosis (thickening or scarring), it might be necessary to switch tactics. These could include inserting a tube to drain the gallbladder, doing a partial gallbladder removal, or even leaving the back wall if it’s too damaged. The surgeon could also decide to place a closed suction drain in the wound.
Possible Complications of Open Cholecystectomy
When a certain surgical procedure called an open cholecystectomy is performed, it implies that it’s not the standard way of removing the gallbladder. As such, the chance of complications happening is higher compared to when it’s done through a method called laparoscopic cholecystectomy (according to a recent study, 16% versus 9%). Laparoscopic cholecystectomy is a smaller, less invasive procedure with lower risks.
Because an open surgery requires a larger cut than a laparoscopic one, patients undergoing an open method face higher risks of developing hernias, having their wounds infected, and getting a condition known as hematoma, which is a swelling filled with blood. Besides, open surgeries tend to hurt more compared to laparoscopic ones.
The surgery also carries risks of bile leaks, injuries to the bile duct (which is the tube that carries bile), and the possibility of leaving behind some gallstones in the bile duct.
Another aspect worth considering is the cost. Typically, open cholecystectomy has higher direct and indirect costs. These might be due to the longer stay in the hospital, higher chance of complications that require additional treatments or medicines (especially if the bile duct gets injured), and the more extended recovery time that could keep patients from returning to their work for a longer period.
What Else Should I Know About Open Cholecystectomy?
Gallbladder surgery typically involves a less invasive procedure called a laparoscopic cholecystectomy. However, it’s important that surgeons are also ready to perform an open cholecystectomy if required. Some situations might need the open method from the start, while other times, a surgeon could have to shift to this technique during surgery.
Experience and good judgement are essential in tricky cases. Likewise, being prepared and seeking help when necessary are key. Safety should always come first. For surgical trainees, the opportunity to participate in an open cholecystectomy procedure should not be missed. This type of procedure isn’t very common anymore. It usually occurs when some challenging issue forces the use of this technique.