Retracted (Contracted) Gallbladder Treatment
Laparoscopic cholecystectomy is the gold standard treatment for a contracted gallbladder and should be performed by an experienced surgeon using the Critical View of Safety technique. 1
Understanding the Condition
A contracted (retracted) gallbladder is a shrunken, fibrotic gallbladder resulting from chronic inflammation, often associated with chronic cholecystitis and gallstones. 1 This condition represents chronic pathology requiring definitive surgical management rather than conservative approaches.
Definitive Surgical Management
Primary Treatment Approach
- Laparoscopic cholecystectomy is the treatment of choice, with a success rate exceeding 97% and should be performed regardless of symptom status when a contracted gallbladder is identified. 1
- The procedure offers reduced recovery time compared to open surgery and prevents future complications including acute cholecystitis, gallstone pancreatitis, and gallbladder perforation. 1, 2
- Surgery eliminates the risk of gallbladder cancer, which non-surgical therapies cannot prevent. 3
Critical Surgical Technique
- The Critical View of Safety (CVS) technique is essential to identify gallbladder elements and the hepatocystic triangle before clipping and dividing the cystic duct and artery. 1
- Only after achieving CVS should the cystic duct and artery be divided. 3
- When CVS cannot be achieved due to severe inflammation or fibrosis in a contracted gallbladder, alternative techniques must be employed: fundus-first approach, subtotal cholecystectomy, or conversion to open surgery. 1
Surgeon Experience Requirements
- Surgery must be performed by experienced surgeons to minimize bile duct injury risk, which ranges from 0.4-1.5% with laparoscopic cholecystectomy. 1
- The contracted nature of the gallbladder increases technical difficulty, making surgeon expertise particularly critical. 1
Preoperative Imaging Considerations
- Contrast-enhanced ultrasound (CEUS) can help differentiate contracted gallbladder from other gallbladder lesions. 1
- MRI/MRCP provides superior visualization of the biliary tree and can identify concurrent common bile duct stones. 1
- If common bile duct stones are identified, options include laparoscopic bile duct exploration or postoperative ERCP. 1
Why Non-Surgical Options Are Inappropriate
- Ursodeoxycholic acid (Ursodiol) is ineffective for contracted gallbladders and is only considered for select poor surgical candidates with small, floating, or radiolucent stones. 1
- The chronic fibrotic changes in a contracted gallbladder make medical dissolution therapies futile. 3
- Non-surgical therapies have approximately 50% recurrence rates and do not address the underlying gallbladder pathology. 3
- Extracorporeal shock-wave lithotripsy is limited to solitary radiolucent stones smaller than 2 cm and does not treat the contracted gallbladder itself. 1
Special Patient Populations
- Laparoscopic cholecystectomy can be performed safely in elderly patients, during pregnancy (with appropriate timing), and in patients with Child A or B cirrhosis, though with special precautions. 1
- For critically ill patients with multiple comorbidities who are truly unfit for surgery, cholecystostomy may be considered as a temporizing measure, though it is inferior to cholecystectomy. 4
Critical Pitfalls to Avoid
- Never delay surgical intervention in a contracted gallbladder, as this may lead to acute complications including perforation, cholangitis, or pancreatitis. 2
- Do not attempt the procedure without adequate laparoscopic experience, particularly given the technical challenges posed by chronic inflammation and fibrosis. 1, 5
- Maintain a low threshold for conversion to open surgery if safe laparoscopic dissection cannot be achieved. 3
- Ensure proper identification of biliary anatomy before any structure is divided to prevent bile duct injury. 1