Acute Cholecystitis
With Dr. John Rodriguez · hosted by Dr. Jeffrey Ponsky · StayCurrentMD
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What the experts said
Patients with acute cholecystitis who are cooled down with conservative management and discharged have a high recurrence rate and typically return on weekends, making management more difficult.
For a 45-year-old woman with straightforward acute cholecystitis (symptoms less than 2 days, normal LFTs, reasonable surgical candidate), early same-admission laparoscopic cholecystectomy is favored over conservative management.
For high-risk patients (e.g., 75-year-old with ejection fraction 15% and history of previous MIs), medical subspecialty consultation is needed to determine realistic operative risk factors before proceeding with cholecystectomy.
Many high-risk patients with acute cholecystitis will cool down with antibiotics alone and require no additional intervention.
Percutaneous cholecystostomy tubes can be placed by interventional radiology in patients who are not good operative candidates.
For high-risk cardiac patients with acute cholecystitis, admit to hospital, start broad-spectrum antibiotics, and if no improvement after one to two days, perform percutaneous cholecystostomy.
Percutaneous cholecystostomy tubes are placed through the liver into the gallbladder.
The combination of percutaneous cholecystostomy tubes with antibiotics is very effective in managing acute cholecystitis in high-risk patients, with most having uneventful recovery and hospital discharge.
Cholecystostomy tubes should be kept for 4 to 6 weeks before removal, with cholangiogram performed through the tube to confirm cystic duct patency before removal.
If the cystic duct is not patent when the cholecystostomy tube is removed, the patient will develop a recurrent episode of acute cholecystitis.
Patients with cholecystostomy tubes will have remaining stones in the gallbladder that cannot be managed with percutaneous intervention.
For patients on antiplatelet therapy due to cardiac stents who need to wait a year before stopping medication, cholecystostomy tube placement is reasonable as definitive management becomes easier once they can discontinue Plavix or aspirin.
Cholecystectomy cases in patients with prior cholecystostomy tubes are more challenging and should not be added at the end of the day when the surgeon is fatigued.
In patients with cholecystostomy tubes, obtain cholangiogram through the tube preoperatively and do not remove the tube before surgery, as it can help with orientation in adhesive cases and allow intraoperative cholangiography if anatomy is unclear.
For high-risk cardiac patients undergoing cholecystectomy, obtain cardiology consultation with stress testing if indicated, and coordinate timing of antiplatelet therapy cessation before surgery and resumption after surgery, particularly with newer generation blood thinners.
Some high-risk cardiac patients may require cardiac catheterization with stent placement before cholecystectomy to improve cardiac function.
Laparoscopic approach is used 99% of the time for cholecystectomy, even in very difficult acute cholecystitis cases.
For laparoscopic cholecystectomy, Rodriguez uses optical entry at Palmer's point (two finger breadths below left costal margin in midclavicular line) for the first 5mm trocar in patients with higher BMI, influenced by bariatric surgery practice.
Palmer's point (two finger breadths below rib cage on left side in midclavicular line) is one of the safest locations for initial laparoscopic entry.
By placing the first trocar at Palmer's point and dropping the hand about another inch lower, Rodriguez has never needed to place another trocar that did not help, as this location provides adequate length with longer instruments.
Rodriguez uses the left upper quadrant Palmer's point 5mm port as his right-hand operating port during laparoscopic cholecystectomy.
The second trocar is a 12mm periumbilical port placed under direct vision for the camera, with patient positioned in reverse Trendelenburg for exposure.
The third trocar (5mm, most lateral, right-sided) is placed under direct laparoscopic vision while visualizing the gallbladder, allowing the assistant to grab and elevate the gallbladder for better left-hand positioning, placed one to two finger breadths below the liver edge.
Placing trocars under direct laparoscopic vision (after the first port) provides better orientation toward the gallbladder based on liver and gallbladder position.
Rodriguez uses a four-port technique for laparoscopic cholecystectomy: left upper quadrant 5mm (right hand), periumbilical 12mm (camera), right lateral 5mm (assistant retraction), and a fourth port for left-hand dissection.
When omentum is adherent to the gallbladder in acute cholecystitis, lyse adhesions gently using hook electrocautery, especially when colon or duodenum are visualized, because edematous tissue bleeds easily and uncontrolled bleeding impedes visualization.
Hook electrocautery is a very fine dissecting tool that is hemostatic for lysing omental adhesions in acute cholecystitis.
Rodriguez has a low threshold to decompress tense, hard, thick gallbladders before attempting to grasp them.
Gallbladder decompression is performed using a long reusable needle connected via luer lock to a 60cc syringe, inserted under direct vision into the fundus of the gallbladder to aspirate contents and allow grasping without tearing.
Rodriguez dissects high on the gallbladder where he is certain of being on gallbladder wall, then gently teases peritoneum down toward duodenum; acute cholecystitis cases have a thicker rind.
Dissect toward Calot's node to visualize the cystic artery, and dissect up toward the gallbladder body to gain length on the cystic artery, because as long as you are on the gallbladder, you are safe.
The suction device is a great dissecting tool during laparoscopic cholecystectomy.
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, which is how surgeons get into trouble.
The critical view of safety requires visualizing the cystic duct, the gallbladder wall, liver in the dissection window, and the cystic artery within Calot's triangle.
Maryland forceps are a great tool for gentle dissection at the cystic duct-gallbladder junction.
Residents should be reminded to use their left hand to move the gallbladder back and forth during dissection, allowing dissection on the lateral side which is always a safe spot.
Taking some of the gallbladder just superior to the cystic duct junction and removing the back wall from the liver bed provides increased length on the cystic duct.
Rodriguez uses routine intraoperative cholangiography, performing it almost always including in acute cholecystitis cases.
For cholangiography, Rodriguez uses the Ponsky catheter (small ERCP-type catheter with wire that makes cystic duct cannulation easy) placed through an Olsen clamp.
Before cannulating the cystic duct for cholangiography, place a clip very close to the gallbladder, make a dicotomy, then milk the cystic duct proximally with the back of scissors or Maryland forceps to express any stones.
Rodriguez introduces the Olsen clamp with Ponsky catheter through the left upper quadrant trocar and gives the catheter a 45-degree angle before inserting into the body, which helps with cannulation.
The Olsen clamp tip comes together to occlude the cystic duct around the catheter, but the middle does not close, so it does not occlude the catheter lumen.
Before injecting contrast for cholangiography, flush the catheter with saline to ensure no backflow, then flush the duct with 20cc saline to clear sludge, stones, and air bubbles.
When cholangiogram contrast flows only distally and not proximally into the liver, place the patient in reverse Trendelenburg position or use the laparoscopic camera to compress the distal common bile duct, which redirects contrast flow proximally.
For small retained common bile duct stones on cholangiogram, first attempt flushing the duct again with saline.
Administer glucagon to relax the ampulla of Vater, which can help pass distal common bile duct stones, then repeat cholangiogram.
If flushing and glucagon do not clear retained CBD stones, use a commercial transcystic common bile duct exploration kit with percutaneous introducer catheter and step dilator.
For transcystic CBD exploration, introduce the catheter from the right side through a separate stab incision (not through an existing trocar) at a parallel angle to the cystic duct to avoid trauma and backwalling the duct.
The key to transcystic CBD exploration is placing a guidewire under fluoroscopic guidance into the duodenum; once the wire is down, various instruments from the kit can extract stones.
Transcystic CBD exploration kits include a Dormia-type basket that can be placed through the cystic duct to crush and retrieve stones.
Transcystic CBD exploration kits include a balloon dilator; passing the balloon can push small stones through (transcystic antegrade sphincteroplasty), which is often easier than attempting basket retrieval.
In severely inflamed gallbladders where infundibulum, cystic duct, artery, and Calot's triangle/node cannot be defined, Rodriguez is aggressive about using fundus-first (dome-down) dissection while remaining laparoscopic.
For fundus-first dissection, the assistant uses the lateral left trocar for retraction; Rodriguez places this trocar under direct vision because he encounters difficult anatomy requiring dome-down approach more commonly than standard anatomy.
There is nothing magical about a specific number of trocars; surgeons should place them where needed and not be afraid to add additional trocars.
When fundus-first dissection fails to safely reach the cystic duct, the decision is between opening the gallbladder for partial cholecystectomy or leaving part of the back wall on the liver.
In severe cases, the surgeon can assess laparoscopically how difficult it will be to proceed with open surgery, and going open to heroically pursue the cystic duct is often not safe either.
Ponsky's bailout technique for horrible cases: open the gallbladder, remove all stones, place a large cholecystostomy tube, leaving an empty gallbladder with drainage.
When performing open cholecystectomy in severely inflamed cases, Rodriguez would proceed with fundus-first (dome-down) dissection to carefully find the anatomy.
When the gallbladder is severely inflamed and difficult to separate from liver, the concern is not primarily bleeding from liver but injury to a superficial right hepatic ductal system, which can cause bile leaks.
Many postoperative bile leaks labeled as duct of Luschka leaks are not true ducts of Luschka but rather result from the surgeon dissecting too deep into the liver and injuring the ductal system.