From the Guidelines
When encountering a hemorrhagic gallbladder with significant adhesions and lost normal anatomy during laparoscopic cholecystectomy, the best course of action is to consider subtotal cholecystectomy or conversion to an open procedure if visualization remains poor after initial management attempts, as recommended by the 2020 World Society of Emergency Surgery guidelines 1.
Key Considerations
- Establish hemostasis using electrocautery, clips, or hemostatic agents on bleeding vessels.
- Clear the field with careful suction and irrigation.
- Perform a "fundus-first" dissection technique to identify critical structures.
- Consider intraoperative cholangiography to clarify biliary anatomy and avoid bile duct injuries.
- If adhesions are dense, methodically take them down using blunt and sharp dissection, staying close to the gallbladder wall.
Subtotal Cholecystectomy
- May be appropriate when the critical view of safety cannot be established.
- Remove the anterior wall and ablate the mucosa of the posterior wall left in situ.
- This approach can help minimize the risk of major complications like bile duct injury.
Conversion to Open Procedure
- Should be considered if visualization remains poor after initial management attempts.
- Can help reduce the risk of complications and improve patient outcomes.
- The decision to convert to an open procedure should be made on a case-by-case basis, taking into account the individual patient's needs and the surgeon's expertise.
Evidence-Based Recommendations
- The 2020 World Society of Emergency Surgery guidelines recommend subtotal cholecystectomy or conversion to an open procedure in cases of difficult gallbladder surgery 1.
- A systematic review and meta-analysis found that subtotal cholecystectomy was a safe and effective option for difficult cholecystectomy cases 1.
- A nation-based database study found that the use of subtotal cholecystectomy increased over time, and the conversion rate from laparoscopic to open total cholecystectomy decreased 1.
From the Research
Approach to Difficult Gallbladder During Laparoscopic Cholecystectomy
During a laparoscopic cholecystectomy (lap chole) with a hemorrhagic gallbladder (GB), significant adhesions, and lost normal anatomy, the approach can be challenging. The options include:
- Partial cholecystectomy
- Open cholecystectomy
- Continuing with laparoscopic cholecystectomy
Considerations for Each Approach
Considerations for each approach include:
- Partial Cholecystectomy: This approach may be considered when there is significant difficulty in dissecting the gallbladder due to adhesions or inflammation. A study 2 found that laparoscopic partial cholecystectomy can be a safe and feasible alternative to conversion to open cholecystectomy.
- Open Cholecystectomy: This approach may be considered when the difficulty is too great to safely continue with laparoscopic cholecystectomy. A study 3 found that open conversion was necessary in 19.9% of cases with difficult gallbladders, with indications including severe inflammation/adhesion, difficult anatomy, and bleeding.
- Continuing with Laparoscopic Cholecystectomy: This approach may be considered when the difficulty is not too great and the surgeon is experienced in laparoscopic techniques. A study 4 found that up to 98% of all gallbladders can be removed laparoscopically with a conversion rate of less than 1% when following a standard technique.
Key Points to Consider
Key points to consider when deciding on an approach include:
- The experience and skill of the surgeon
- The severity of the difficulty, including the extent of adhesions and inflammation
- The potential risks and benefits of each approach, including the risk of bile duct injury, bleeding, and conversion to open cholecystectomy
- The need for a safe and effective procedure that minimizes complications and promotes optimal outcomes for the patient.