What to do during laparoscopic cholecystectomy (lap chole) with a hemorrhagic gallbladder (GB), adhesions, and lost normal anatomy?

Management of Difficult Laparoscopic Cholecystectomy with Hemorrhagic Gallbladder and Lost Anatomy

In a laparoscopic cholecystectomy with a hemorrhagic gallbladder, adhesions, and lost normal anatomy, conversion to open cholecystectomy is the safest approach to minimize the risk of bile duct injury and manage bleeding effectively. 1, 2

Assessment of the Situation

When faced with a hemorrhagic gallbladder, adhesions, and lost normal anatomy during laparoscopic cholecystectomy, the surgeon must prioritize patient safety by recognizing this as a high-risk situation for:

• Bile duct injury (BDI)
• Uncontrolled hemorrhage
• Injury to adjacent structures

Key Risk Factors Present

• Hemorrhagic gallbladder - indicates severe inflammation
• Adhesions - obscuring normal anatomical landmarks
• Lost normal anatomy - inability to identify the Critical View of Safety (CVS)

Decision Algorithm

1. First attempt to establish Critical View of Safety (CVS)

   • If successful → continue with laparoscopic approach
   • If unsuccessful → proceed to step 2

2. Consider bailout procedures

   • Laparoscopic subtotal cholecystectomy if:
     • Bleeding is controlled
     • Partial anatomy can be identified
     • Surgeon has adequate experience with this technique

3. Convert to open cholecystectomy if:

   • Severe local inflammation persists
   • Bleeding from Calot's triangle is uncontrolled
   • Anatomy remains unclear despite laparoscopic attempts
   • Suspected bile duct injury

Rationale for Open Conversion

The 2020 WSES guidelines strongly recommend conversion to open surgery in cases of severe local inflammation, adhesions, bleeding from Calot's triangle, or suspected bile duct injury 1. With a hemorrhagic gallbladder and lost anatomy, the risk of bile duct injury is significantly elevated, making open conversion the safest approach.

While subtotal cholecystectomy is a valid bailout option in difficult cases 1, the presence of active hemorrhage makes visualization even more challenging and increases the risk of complications during laparoscopic subtotal cholecystectomy. The hemorrhagic component specifically increases the risk of uncontrolled bleeding that may be better managed with the direct access and visualization provided by open surgery 3.

Important Considerations

• Conversion to open surgery should not be considered a failure but a prudent decision to ensure patient safety 2
• Hemorrhage from the gallbladder bed is one of the main reasons for conversion to open cholecystectomy 4
• Recent evidence shows that converted cases have higher rates of complications when conversion is delayed too long 5
• In cases of hemorrhagic cholecystitis, the risk of gallbladder rupture and massive intra-abdominal hemorrhage increases the urgency for definitive management 3

Pitfalls to Avoid

1. Persisting with laparoscopy despite poor visualization

   • This significantly increases the risk of bile duct injury
   • Bleeding can rapidly worsen, leading to emergency conversion under suboptimal conditions

2. Delaying the decision to convert

   • Early conversion when indicated results in better outcomes than delayed conversion after complications occur
   • Continuing laparoscopy in difficult cases can lead to increased operative time and complications

3. Attempting laparoscopic subtotal cholecystectomy without adequate expertise

   • While subtotal cholecystectomy is a valid option, it requires significant experience in difficult cases
   • With hemorrhage already present, this approach carries higher risk

Conclusion

While laparoscopic cholecystectomy remains the gold standard for gallbladder removal, the combination of hemorrhagic gallbladder, adhesions, and lost normal anatomy creates a high-risk scenario where patient safety must be prioritized. The World Society of Emergency Surgery guidelines provide strong recommendations for conversion to open surgery in such difficult cases to minimize the risk of bile duct injury and manage bleeding effectively 1.