From
Dr. Jeffrey Ponsky
Gallstone Disease
With Dr. Jeffrey Ponsky · hosted by Dr. Alexander Gibbons & Dr. Todd Ponsky
Chapter 1 of 12 · Fundamentals
Introduction
Introduction and Guest Background
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
There is very little difference in the management of biliary disease, particularly gallstones and cholecystitis, between children and adults.
The first diagnostic test for suspected biliary disease is an ultrasound of the right upper quadrant.
When ultrasound shows stones or pericholecystic fluid and wall thickening, there is good evidence of biliary disease in the gallbladder.
For a gallbladder that looks normal without stones on ultrasound, add a HIDA scan with CCK ejection fraction to look for biliary dyskinesia.
Biliary dyskinesia is defined as an ejection fraction less than 35% on CCK-HIDA scan.
If ejection fraction is less than 35% and every other test is negative, you have presumptive evidence of biliary dyskinesia and may still take out the gallbladder.
Acute cholecystitis is characterized by pericholecystic fluid, wall thickening, and cystic duct obstruction where the stone has not fallen back.
Biliary colic (stones without inflammation where the stone has fallen back and obstruction is relieved) should be managed with elective cholecystectomy after discharge.
Acute cholecystitis is an indication for cholecystectomy.
The old practice of cooling patients down by making them NPO and waiting 6 weeks before cholecystectomy has been replaced by evidence showing that operating within the first week is better.
For stable cholecystitis patients without peritonitis presenting on Saturday, waiting until Monday for elective laparoscopic cholecystectomy is reasonable.
There is no evidence that putting cholecystitis patients on antibiotics while waiting for surgery helps.
Laparoscopic cholecystectomy is a very challenging operation where you are always looking for abnormal anatomy, and point of view and ability to retract are extremely important.
For four-port laparoscopic cholecystectomy, the first epigastric port should be placed just off the costal margin to the right of midline, angled toward the gallbladder rather than straight up and down.
The right lower quadrant port should be placed before the midclavicular port, because elevating the gallbladder with the RLQ port shows where to place the midclavicular port for good access to the cystic duct. If you put the midclavicular port in too early, it will be too low.
In A-frame patients (skinny patients with narrow rib cages), you are forced to put ports lower because the ribs prevent higher placement.
For a stuck gallbladder, take down adhesions slowly, stay toward the gallbladder side, lift omentum and cautery each piece, push down adhesions until you work down to the infundibulum.
When anatomy is unclear in a difficult gallbladder, start halfway up the gallbladder (not a total dome-down) and take the peritoneum downward on both sides, using the dome for retraction, working down to the cystic duct-gallbladder junction.
The sucker is a great tool for dissecting the gallbladder using blunt dissection and pushing away.
Hydrodissection (pumping water between the cystic duct and cystic artery) is useful in tough areas.
After isolating the cystic duct, turn the hook toward the gallbladder, put it in the space between cystic duct and artery, lift up and cauterize to get another 0.5 cm of cystic duct isolation.
Easy gallbladders are the ones where you can make bad mistakes because you get complacent. You have to make yourself slow down on easy cases.
Biliary surgery can be terribly punishing if you make a mistake.
In routine gallbladders, start at Calot's triangle, take peritoneum off the cystic duct by gentle pulling and tearing, incise peritoneum along lower lateral and medial sides of gallbladder to get in the subperitoneal plane, push down to accentuate the cystic duct-gallbladder junction.
Routine cholangiography in every case is debated. Zealots recommend it in every case, particularly in teaching institutions, to identify anatomy and improve skills for transcystic exploration.
Indications for cholangiography include history of pancreatitis (even if resolved), slightly large duct on ultrasound, or history of jaundice.
For cholangiography, clip the cystic duct on the gallbladder side, make a small incision a few millimeters proximal (toward common duct) from the clip, insert catheter with 10cc full-strength contrast.
If contrast only goes to the duodenum on cholangiogram (the 'cholangiogram from hell'), press on the papilla with the laparoscope through the umbilical port under fluoroscopy to make contrast go up and fill the proximal ducts.
Giving 30mg Toradol (age-adjusted) in the operating room before the patient wakes up allows same-day discharge after laparoscopic cholecystectomy.
For patients with a week of cholecystitis symptoms, the management is the same as for 24-hour symptoms—still operate within the first week.
If ultrasound or CT shows a lot of pericholecystic fluid or a collection, wait 4-6 weeks before operating.
If a patient calls with pain 3-5 days after laparoscopic cholecystectomy, something is wrong—lap choles don't have pain if everything went well. This is a bile leak or common duct injury until proven otherwise.
For suspected postoperative bile leak, get CT scan immediately. If it shows fluid collection, tap it. If there is bile in the fluid, the patient goes for ERCP.
Every surgeon gets cystic duct leaks—sometimes there is clip-duct size mismatch or necrosis. This can be fixed, but you want to prove there is no bile duct injury.
For cystic duct leak on ERCP, place a stent (with or without small sphincterotomy). The stent should be short (5cm) and large diameter (10 French) to totally reduce sphincter pressure. Remove at 3-6 weeks.
Charcot's triad (jaundice, right upper quadrant pain, shaking chills with fever) indicates cholangitis.
Gallstone pancreatitis is diagnosed by abdominal pain with elevated amylase and lipase (lipase is preferred because amylase goes up and down).
In the old days, everyone with gallstone pancreatitis got ERCP on the day they came in, but two-thirds of those ERCPs were normal because the small stones causing pancreatitis had already passed.
For gallstone pancreatitis, wait overnight and see which way the amylase and lipase trend. If they go down, don't do ERCP—wait a few days and operate (cholecystectomy with cholangiogram).
If the patient with gallstone pancreatitis does not improve (jaundice remains high, worsening pancreatitis signs), then do sphincterotomy and clear the duct with ERCP.
Management of common duct stones depends on local resources. It is not uncommon for surgeons to request preoperative ERCP when they lack facilities or comfort with laparoscopic common duct exploration, and this is not unreasonable.
Patients with persistently elevated bilirubins should probably have preoperative ERCP.
For intraoperative transcystic common duct clearance, make an opening in the cystic duct and milk it back with a Maryland. If stones come back, do a cholangiogram.
A meniscus sign on cholangiogram suggests a stone at the papilla. Give 1mg glucagon (one amp in an adult-sized child), wait 1-2 minutes, flush with saline, and repeat cholangiogram.
If the stone persists after glucagon, pass a soft-tip wire through the cystic duct under fluoroscopy to try to knock it through. Never push against resistance and always watch under fluoroscopy to avoid injury.
A Dormia basket can be passed down the cystic duct under fluoroscopy, opened slightly, and pulled back with jiggling to try to catch the stone.
A #5 Fogarty balloon (vascular Fogarty is fine, just longer) can be used: put it in the duodenum, inflate, pull back until you feel resistance, deflate 1mm, pull back and inflate again, then pull back to extract the stone.
New choledochoscopes are less than 3mm and can be passed down the cystic duct (sometimes requiring balloon dilation). Saline fills the duct for visualization. Stones can be grabbed with Dormia or trapped between a balloon and the scope and pulled out.
After transcystic exploration, use endoloops on the cystic duct stump (not just clips) because an obstructed duct can blow a tie off.
Laparoscopic choledochotomy should be done in dilated ducts (over 1cm, preferably 1.5cm or larger, ideally 2cm). Don't do it in normal-sized ducts with small stones—you risk stricture or injury.
For laparoscopic choledochotomy, don't divide the cystic duct—use the gallbladder for lateral retraction. Wipe the cystic duct down toward the common duct to expose loose peritoneum and fat over the anterior common duct surface.
For choledochotomy, make a small incision (0.5cm initially) 1-2mm above the cystic-common duct junction, going downward toward the duodenum. Flush with red rubber catheter (#10), use Fogarty up and down, inspect with choledochoscope or nephroscope.
For choledochotomy closure, use a T-tube (14 or 12 French) cut to 1 inch on each side of the T, with beveled edges and back wall removed. Insert bottom end first, then bend and pop in top end. Close with interrupted 4-0 Vicryl sutures, pushing T-tube toward duodenum. Get cholangiogram at 10 days, remove T-tube at 2 weeks.
For severe pancreatitis after gallstone passage, get a CT to look for phlegmon in the pancreatic head. If present, waiting 6 weeks is probably better, though the old rule was to operate before discharge once pancreatitis settled.
For patients with many stones going up both branches of a very dilated common duct, especially stone-formers like sickle cell patients, consider choledochoduodenostomy (can be done laparoscopically or open). Make the anastomosis large (2cm) to allow future stones to pass.
For acutely ill patients with large phlegmon and high fevers, percutaneous cholecystostomy can temporize the situation, then wait 6 weeks before cholecystectomy.
Percutaneous cholecystostomy is contraindicated in patients with clotting disorders because it goes through the liver.
In an operation where you can't recognize anything, consider fenestrated or partial cholecystectomy: open the fundus, clean out stones, remove half the gallbladder, staple across it. Leave the distal gallbladder and back wall in place.
If you can't find anatomy and everything is tearing, take off the anterior wall (or it falls off), bovie the back wall to kill the mucosa, clip the cystic duct if you can see it, put drains in, and settle for a controlled leak.
Common duct injuries happen in easy cases when surgeons are not vigilant. The common duct can come right up to the gallbladder and take a bend like a knee, looking just like a cystic duct. If you keep dissecting, you'll find it goes up toward the liver, then a 2-3mm cystic duct comes off that knee.