From the Guidelines
When encountering a hemorrhagic gallbladder with significant adhesions and loss of normal anatomy during laparoscopic cholecystectomy, the surgeon should consider converting to an open procedure or performing a subtotal cholecystectomy to ensure patient safety and minimize the risk of major complications. This approach is supported by the 2020 World Society of Emergency Surgery guidelines, which recommend conversion from laparoscopic to open cholecystectomy in cases of severe local inflammation, adhesions, bleeding from the Calot’s triangle, or suspected bile duct injury 1. Additionally, the guidelines suggest that subtotal cholecystectomy is a valid option in situations where anatomic identification is difficult and the risk of iatrogenic injuries is high 1.
Some key considerations during the procedure include:
- Attempting methodical dissection by starting at a recognizable anatomical landmark, such as the infundibulum-cystic duct junction
- Employing the "critical view of safety" technique to clearly identify the cystic duct and artery before clipping or dividing any structures
- Using careful blunt dissection with judicious electrocautery to manage adhesions, and considering hydrodissection to create tissue planes
- Applying direct pressure with a gauze swab, using electrocautery judiciously, and having hemostatic agents like Surgicel or fibrin sealants ready for bleeding control
- Maintaining a low threshold for intraoperative cholangiography to clarify biliary anatomy and prevent bile duct injuries
It is also important to note that the use of the critical view of safety (CVS) during laparoscopic cholecystectomy is recommended to minimize the risk of bile duct injuries, and if the CVS is not achievable, a bailout procedure such as subtotal cholecystectomy should be considered 1.
Overall, the goal is to prioritize patient safety and minimize the risk of major complications, and the approach should be tailored to the individual patient's needs and the surgeon's expertise.
From the Research
Approach to a Hemorrhagic Gallbladder with Adhesions and Lost Normal Anatomy During Laparoscopic Cholecystectomy
- The situation described involves a hemorrhagic gallbladder with significant adhesions and loss of normal anatomy, which complicates the laparoscopic cholecystectomy procedure.
- According to 2, total laparoscopic cholecystectomy can be safely performed in difficult gallbladder situations with a lower conversion rate than previously reported, but predictors of conversion include urgency, necrotic gallbladder, and history of prior abdominal surgeries.
- A study by 3 suggests that while laparoscopic cholecystectomy is generally preferred, timely conversion to open surgery is essential for patient safety, especially in cases with bleeding, adhesions, or obscured anatomy.
- Laparoscopic partial cholecystectomy is proposed as an alternative approach to prevent bile duct injury in difficult dissections, as discussed in 4, with the advantage of avoiding conversion to open surgery in some cases.
Options for Proceeding
- A. Partial Cholecystectomy: This approach may be considered to avoid bile duct injury and prevent the need for conversion to open surgery, as supported by 4.
- B. Open Cholecystectomy: Conversion to open cholecystectomy may be necessary in cases with severe inflammation, adhesions, or bleeding, as indicated by 2 and 3.
- C. Continue Laparoscopic Cholecystectomy: Attempting to continue with the laparoscopic approach may be feasible if the surgeon is experienced and the situation allows for safe completion of the procedure, as suggested by 2 and 5.
Considerations
- The decision to proceed with one of the above options should be based on the surgeon's judgment, taking into account the patient's condition, the complexity of the case, and the potential risks and benefits of each approach.
- Studies such as 6 emphasize the importance of understanding the variations in outcomes of different approaches to cholecystectomy and selecting the best technique for each individual patient.