What to do during laparoscopic (lap) cholecystectomy (Chole) when a hemorrhagic gallbladder (GB) with significant adhesions and loss of normal anatomy is encountered?

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 alternative techniques such as subtotal cholecystectomy to prioritize patient safety and prevent bile duct injuries. 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. The guidelines also suggest that subtotal cholecystectomy can be a viable option in difficult cases where anatomic identification is challenging and the risk of iatrogenic injuries is high 1. Additionally, the 2021 WSES guidelines for the detection and management of bile duct injury during cholecystectomy emphasize the importance of achieving the critical view of safety and considering bailout procedures such as subtotal cholecystectomy if this cannot be achieved 1. Some key considerations in managing such cases include:

• Attempting methodical dissection to separate adhesions and maintain hemostasis
• Establishing the critical view of safety before clipping or dividing any structures
• Considering alternative techniques such as subtotal cholecystectomy or cholecystostomy tube placement if standard approaches are not feasible
• Utilizing intraoperative cholangiography or ultrasound to identify biliary anatomy when standard landmarks are obscured. By prioritizing patient safety and taking a thoughtful and methodical approach to managing challenging cases, surgeons can minimize the risk of complications and ensure the best possible outcomes for their patients.

From the Research

Approach to a Hemorrhagic Gallbladder with Adhesions and Lost Normal Anatomy During Laparoscopic Cholecystectomy

• The situation described involves a hemorrhagic gallbladder (GB) with significant adhesions and loss of normal anatomy during a laparoscopic cholecystectomy (lap Chole), which poses a challenge for the surgeon.
• 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 conversions from laparoscopic to open cholecystectomy are primarily due to bleeding, adhesions, and obscured anatomy, with bile leakage being the most common short-term complication, indicating the need for careful consideration of when to convert.
• Laparoscopic partial cholecystectomy (LPC) is proposed as a safe and feasible alternative to conversion in cases of difficult gallbladders, as indicated by 4, with the advantage of potentially reducing the risk of bile duct injury and other complications.
• Predictors of a difficult laparoscopic cholecystectomy, as identified by 5, include factors such as age, history of hospitalization for acute cholecystitis, body mass index, abdominal scar, palpable GB, GB wall thickness, pericholecystic collection, and impacted stone, which can guide the decision-making process.
• The standard of laparoscopic cholecystectomy, as discussed in 6, emphasizes the importance of following optimal steps and considering the use of intraoperative cholangiography, especially in cases where normal anatomy is obscured or there is a high risk of complications.

Options for Proceeding

• A. Partial cholecystectomy: This approach, as supported by 4, can be considered when the gallbladder is difficult to remove due to adhesions or inflammation, aiming to leave a portion of the gallbladder in place to avoid further complications.
• B. Open cholecystectomy: Converting to an open procedure, as discussed in 2 and 3, may be necessary in cases of severe bleeding, extensive adhesions, or when the anatomy is too distorted to safely proceed laparoscopically.
• C. Continue laparoscopic cholecystectomy: If the situation allows, with careful dissection and control of bleeding, continuing the laparoscopic approach might be feasible, as suggested by 2, emphasizing the importance of surgical experience and judgment in making this decision.