Management of Contracted Gallbladder
A contracted gallbladder requires laparoscopic cholecystectomy as the definitive treatment, with subtotal cholecystectomy as the preferred alternative when anatomical identification becomes difficult during surgery. 1
Primary Treatment Approach
Laparoscopic cholecystectomy remains the gold standard for contracted gallbladder, as it addresses the underlying pathology definitively and prevents recurrent biliary complications. 2 The contracted state typically indicates chronic inflammation, which increases technical difficulty but does not contraindicate surgical intervention.
When Anatomy is Difficult to Identify
- Subtotal cholecystectomy should be performed when severe inflammation or contraction makes anatomical identification difficult, preventing iatrogenic bile duct injuries that can occur when forcing dissection in hostile anatomy. 1
- This technique is specifically recommended for cases of severe inflammation, which commonly causes gallbladder contraction. 1
- The Critical View of Safety (CVS) technique should be attempted first, but only after achieving CVS should the cystic duct and artery be clipped and divided. 2
- When CVS cannot be achieved due to contraction and inflammation, alternative techniques including fundus-first approach or subtotal cholecystectomy must be considered immediately rather than risking bile duct injury. 2
Surgical Timing Considerations
- Early laparoscopic cholecystectomy should be performed after 24-48 hours of initial conservative management if the patient presents with acute symptoms. 1
- Delaying surgery in suitable candidates is not recommended, as evidence shows early intervention is safe and effective even in challenging cases. 1
For Non-Surgical Candidates Only
If the patient absolutely cannot undergo surgery due to severe comorbidities:
- Percutaneous transhepatic gallbladder drainage (PTGBD) can be considered, though it carries significantly higher complication rates (53% vs 5% for surgery) and mortality. 3, 4
- PTGBD should only be used as a temporizing measure with plans for eventual cholecystectomy when feasible, as 49% of patients who don't undergo subsequent surgery have one-year readmissions. 4
- Observation alone leads to 30% recurrence of gallstone-related complications compared to 3% with cholecystectomy. 3
Critical Pitfalls to Avoid
- Never force dissection when anatomy cannot be clearly identified - this is the leading cause of bile duct injuries during laparoscopic cholecystectomy. 5
- Do not delay surgery based solely on the contracted appearance - experienced surgeons can safely manage these cases with appropriate techniques. 1
- Avoid overuse of drainage procedures in surgical candidates - this leads to higher mortality, longer hospital stays, and increased readmissions. 1
- Conversion to open cholecystectomy should be readily accepted when laparoscopic approach proves unsafe, with conversion rates of approximately 2.8% being acceptable. 5