Management of Cholelithiasis in Patients Requiring CABG
For patients with cholelithiasis who are candidates for CABG, concomitant cholecystectomy during the same operation is safe and feasible, particularly when the right gastroepiploic artery (GEA) is planned as a conduit, provided the patient has uncomplicated gallstone disease without acute cholecystitis or choledocholithiasis. 1
Risk Stratification and Timing
Exclude High-Risk Gallbladder Disease
Before considering concomitant surgery, you must rule out:
- Acute cholecystitis - this is an absolute contraindication to concomitant cholecystectomy 1
- Choledocholithiasis (common bile duct stones) - requires ERCP with sphincterotomy and stone extraction first, which has a 90% success rate 2
- Cholangitis - requires urgent biliary decompression before cardiac surgery 2
Assess Symptom Status
- Symptomatic cholelithiasis (biliary colic, documented episodes of right upper quadrant pain): stronger indication for concomitant cholecystectomy 3
- Asymptomatic cholelithiasis: has a benign natural course with only 10-25% progression to symptomatic disease over time 3
Surgical Approach for Concomitant Procedures
Technical Considerations
The cholecystectomy is performed through an upper abdominal extension of the median sternotomy incision after completion of the CABG. 1 This approach offers several advantages:
- No additional incision required - the sternotomy can be extended superiorly without separate laparotomy 4, 5
- Optimal when using GEA grafts - allows direct visualization and harvesting of the right gastroepiploic artery while performing cholecystectomy 4, 5
- Diaphragmatic opening where the GEA pedicle passes should be closed with fibrin glue to prevent complications 4
Operative Outcomes
Based on a series of 55 patients undergoing concomitant procedures 1:
- Mean operative time: 376 minutes (approximately 6 hours)
- No increase in postoperative complications compared to CABG alone
- No intra-abdominal complications, wound infections, or bowel obstruction observed
- Feeding resumed 1 day after extubation
- Mean hospital stay: 23 days
The procedure adds minimal additional operative time and does not delay recovery or feeding 5.
Decision Algorithm
For Symptomatic Cholelithiasis + CABG Indication:
- Confirm absence of acute cholecystitis or choledocholithiasis with preoperative ultrasound and liver function tests 1
- Proceed with concomitant cholecystectomy during CABG, especially if using GEA as a conduit 1, 4, 5
- Perform cholecystectomy after completing CABG through extended sternotomy incision 1
For Asymptomatic Cholelithiasis + CABG Indication:
Concomitant cholecystectomy is reasonable for good-risk patients undergoing cardiac surgery, as it eliminates future risk of symptomatic disease without increasing perioperative morbidity. 3 However, this must be weighed against:
- The benign natural history of asymptomatic stones (50-70% remain asymptomatic) 3
- The low annual risk of developing symptoms (2-3% per year) 3
- Patient preference and operative risk profile
For Complicated Gallstone Disease:
If choledocholithiasis is present, perform ERCP with sphincterotomy and stone extraction BEFORE cardiac surgery. 2 This achieves:
- 90% success rate for stone clearance 2
- Resolution of biliary obstruction
- Allows safe subsequent CABG with or without cholecystectomy
Common Pitfalls to Avoid
- Do not perform concomitant cholecystectomy in acute cholecystitis - this significantly increases infection risk and complications 1
- Do not ignore choledocholithiasis - common bile duct stones require endoscopic clearance first, not surgical exploration during CABG 2
- Do not assume all gallstones need treatment - asymptomatic stones have a benign course and observation is appropriate for most patients not undergoing other abdominal surgery 3
- Do not delay CABG for elective cholecystectomy - if cardiac disease is urgent and gallstones are asymptomatic without complications, prioritize cardiac revascularization per ACC/AHA guidelines 6