Is open cholecystectomy (surgical removal of the gallbladder) a viable option for managing cholecystitis (inflammation of the gallbladder) in a pregnant patient when laparoscopic surgery is not available?

Open Cholecystectomy for Cholecystitis in Pregnancy When Laparoscopy is Unavailable

Yes, open cholecystectomy is a viable and acceptable option for managing cholecystitis in pregnant patients when laparoscopic surgery is not available, though it carries higher maternal and fetal complication rates compared to the laparoscopic approach. 1, 2

Evidence Supporting Open Cholecystectomy as a Viable Alternative

Open cholecystectomy remains a feasible option, particularly in settings of resource limitations or when laparoscopic equipment is unavailable. 1 The World Society of Emergency Surgery explicitly recognizes that open cholecystectomy is frequently performed in low-income countries and resource-limited settings, with outcomes that are acceptable when laparoscopic surgery is not accessible. 1

Comparative Safety Profile in Pregnancy

The evidence clearly demonstrates that while laparoscopic cholecystectomy is superior, open cholecystectomy is still safer than conservative management:

• Laparoscopic cholecystectomy shows maternal complications of 3.5% and fetal complications of 3.9%, compared to open cholecystectomy with maternal complications of 8.2% and fetal complications of 12.0%. 2
• Despite these higher complication rates, surgery (including open approach) is recommended as first-line therapy to avoid complications and potential drug toxicity to the fetus. 2
• Conservative management carries significant risks, including higher rates of spontaneous abortion, threatened abortion, and premature birth compared to patients who underwent cholecystectomy. 2

When Open Cholecystectomy is Particularly Indicated

Several clinical scenarios make open cholecystectomy the appropriate choice even when laparoscopy might theoretically be available:

• Risk factors predicting conversion from laparoscopic to open include: age >65 years, male gender, acute cholecystitis, thickened gallbladder wall, diabetes mellitus, and previous upper abdominal surgery. 1
• In cases of gallbladder perforation, prompt surgical intervention (open or laparoscopic) is critical, as delayed intervention is associated with elevated morbidity and mortality rates. 1
• When anatomic structures cannot be clearly identified and the critical view of safety cannot be established, subtotal cholecystectomy (which can be performed open) prevents bile duct injury. 3

Timing Considerations for Pregnant Patients

The second trimester is the optimal time for surgical intervention due to higher risk of miscarriage and anesthetic toxicity in the first trimester and technical difficulties related to uterine size in late third trimester. 2 However, this applies to both laparoscopic and open approaches.

For biliary pain presenting late in the third trimester, postponing surgical intervention until delivery may be reasonable if it doesn't pose a risk to maternal or fetal health. 2

Alternative Bridging Options

If open cholecystectomy poses excessive risk in specific circumstances:

• Percutaneous cholecystostomy tube placement can be used as "bridging" therapy in the first trimester (to bridge to the second) or in the third trimester to bridge to the postpartum period. 2
• Cholecystostomy is a safe and effective treatment for acute cholecystitis in critically ill patients with multiple comorbidities who are unfit for surgery. 1

Critical Pitfall to Avoid

The most important pitfall is choosing conservative management over surgery when surgery is feasible. 2, 4 Studies show that recurrent biliary symptoms develop in 60% of pregnant patients with gallstone disease treated conservatively, leading to high numbers of hospitalizations. 2 Conservative management also increases the likelihood of cesarean birth. 2

Practical Algorithm for Decision-Making

1. If laparoscopic surgery is available and expertise exists → perform laparoscopic cholecystectomy 1, 2
2. If laparoscopic surgery is unavailable but open surgery is feasible → perform open cholecystectomy 1
3. If patient is critically ill or unfit for any surgery → consider cholecystostomy as bridging therapy 1, 2
4. If late third trimester and patient is stable → may consider delaying until postpartum 2

The key principle is that surgical intervention (whether laparoscopic or open) is superior to conservative management for preventing maternal and fetal complications in pregnant patients with cholecystitis. 2