What are the absolute contraindications to cholecystectomy (surgical removal of the gallbladder)?

From the Guidelines

Absolute contraindications to cholecystectomy include conditions where the risks of surgery significantly outweigh the benefits, such as inability to tolerate general anesthesia, end-stage liver disease with portal hypertension, uncontrolled coagulopathy, and advanced pregnancy. These conditions are associated with high morbidity and mortality rates, and alternative management strategies may be more appropriate. According to the guidelines on acute calcolous cholecystitis in elderly population 1, old age (> 65 years) by itself does not represent a contraindication to cholecystectomy for acute cholecystitis. However, certain conditions such as severe cardiopulmonary disease, diffuse peritonitis, or septic shock that has not been adequately controlled may represent absolute contraindications due to the high risk of complications or death. Some key points to consider when evaluating a patient for cholecystectomy include:

• The patient's ability to tolerate general anesthesia and the surgical procedure itself
• The presence of any underlying medical conditions that may increase the risk of surgery, such as end-stage liver disease or uncontrolled coagulopathy
• The patient's overall health status and life expectancy
• The potential benefits and risks of alternative management strategies, such as percutaneous cholecystostomy. As stated in the guidelines 1, the role of cholecystostomy as a bridging therapy until cholecystectomy or as a definitive treatment in elderly patients is uncertain, and future research should focus on developing and validating a reliable prognostic score in assessing frailty that can guide the management of acute calculous cholecystitis. In general, the decision to perform a cholecystectomy should be made on a case-by-case basis, taking into account the individual patient's unique circumstances and medical history. It is essential to weigh the potential benefits of surgery against the potential risks and to consider alternative management strategies when necessary. Ultimately, the goal of treatment should be to minimize morbidity and mortality while improving the patient's quality of life. As recommended in the guidelines 1, the evaluation of the risk for elderly patients with acute cholecystitis should include mortality rate for conservative and surgical therapeutic options, rate of gallstone-related disease relapse and the time to relapse, age-related life expectancy, and consideration of patient frailty evaluation by the use of frailty scores. By carefully considering these factors and individualizing treatment, healthcare providers can provide the best possible care for patients with acute cholecystitis.

From the Research

Absolute Contraindications to Cholecystectomy

There are no absolute contraindications to cholecystectomy that are universally agreed upon. However, certain conditions may increase the risk of the procedure, making it a relative contraindication.

• Conditions that may increase the risk of cholecystectomy include:
  • Cirrhosis and portal hypertension 2, 3
  • Bleeding disorders 2
  • Acute cholecystitis, although this is often considered a relative contraindication rather than an absolute one 4, 5, 6
  • Morbid obesity and previous upper abdominal surgery, which are also considered relative contraindications 4

Relative Contraindications

Relative contraindications to cholecystectomy are conditions that may increase the risk of the procedure, but do not necessarily preclude it. These conditions include:

• Acute cholecystitis, which may increase the risk of conversion to open cholecystectomy 4
• Morbid obesity and previous upper abdominal surgery, which may increase the risk of complications 4
• Cirrhosis and portal hypertension, which may increase the risk of bleeding and other complications 2, 3

Alternative Treatments

In some cases, alternative treatments may be considered for patients who are at high risk for cholecystectomy. These alternatives include:

• Percutaneous cholecystostomy, which may be used as a definitive treatment or as a bridge to surgery 5, 6