From the Research
The management of a poorly distended gallbladder typically involves surgical intervention, with laparoscopic cholecystectomy being the preferred approach. When encountering a poorly distended gallbladder during surgery, the surgeon should first attempt careful dissection to identify anatomical structures, particularly Calot's triangle. Intraoperative cholangiography may be necessary to clarify biliary anatomy and prevent bile duct injuries. If laparoscopic dissection proves too difficult due to inflammation, adhesions, or anatomical distortion, conversion to open cholecystectomy is recommended rather than risking biliary injury. In cases where inflammation makes dissection hazardous, a subtotal cholecystectomy leaving part of the posterior wall attached to the liver may be performed. Alternatively, cholecystostomy tube placement under radiological guidance can serve as a temporizing measure in high-risk patients, allowing for interval cholecystectomy after inflammation subsides. Adequate exposure is critical, often requiring additional ports or retraction techniques. These approaches are justified by the increased risk of bile duct injuries and other complications when operating on poorly distended gallbladders, which often indicate chronic inflammation or fibrosis that distorts normal anatomical relationships.
Key Considerations
- The use of peri-operative antibiotic agents is recommended for patients undergoing laparoscopic cholecystectomy for acute cholecystitis, as stated in the guidelines by the Surgical Infection Society 1.
- The management approach should prioritize minimizing morbidity, mortality, and improving quality of life, which in most cases, involves surgical intervention.
- Medical dissolution therapy with ursodeoxycholic acid (UDCA) or in combination with chenodeoxycholic acid (CDCA) may be considered for patients with radiolucent gallstones in a functioning gallbladder, but this approach has limited efficacy and is generally reserved for patients who are not candidates for surgery 2, 3, 4, 5.
- The choice between UDCA alone or in combination with CDCA should be based on stone density as assessed by CT scan, with isodense stones showing better response rates to dissolution therapy 5.
Surgical Approach
- Laparoscopic cholecystectomy is the preferred surgical approach due to its minimally invasive nature and faster recovery times.
- Intraoperative cholangiography and careful dissection are crucial to prevent bile duct injuries and ensure safe removal of the gallbladder.
- Conversion to open cholecystectomy or subtotal cholecystectomy may be necessary in cases of severe inflammation or anatomical distortion.