What are the essential steps for safely performing a cholecystectomy, including pre‑operative preparation, antibiotic prophylaxis, achieving the critical view of safety, and criteria for conversion to open surgery?

Essential Steps for Safe Cholecystectomy

Pre-operative Preparation and Risk Assessment

Laparoscopic cholecystectomy should be attempted first in nearly all patients, including the elderly, except in cases of absolute anesthetic contraindications or septic shock. 1

Pre-operative Workup

• Obtain liver biochemical tests (ALT, AST, bilirubin, ALP, GGT) and abdominal ultrasound in all patients to assess for common bile duct stones 1
• Elevation of liver enzymes or bilirubin alone is insufficient to diagnose choledocholithiasis—further diagnostic testing with MRI or endoscopic ultrasound is required 1, 2
• Direct visualization of CBD stones on ultrasound is a very strong predictor of choledocholithiasis and warrants additional intervention 1
• Consider pre-operative ERCP with sphincterotomy for confirmed common bile duct stones to avoid unnecessary conversion to open surgery 3, 4

Risk Stratification

• Age >65 years alone does not contraindicate cholecystectomy 1
• Evaluate patient frailty using validated frailty scores and estimate surgical risk with clinical scoring systems 1
• Predictors of conversion to open surgery include: fever, leukocytosis, elevated serum bilirubin, extensive prior upper abdominal surgery, diabetes, and severe local inflammation 1, 2

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Antibiotic Prophylaxis

For uncomplicated cholecystectomy, administer a single preoperative dose of cefazolin, cefamandole, or cefuroxime (substitute with gentamicin and clindamycin if allergic), then discontinue all antibiotics within 24 hours after surgery when adequate source control is achieved. 1, 5

Antibiotic Duration by Clinical Scenario

• Uncomplicated acute cholecystitis: Stop antibiotics within 24 hours post-operatively when infection is confined to the gallbladder wall 5
• Complicated cholecystitis (Class A/B patients): Administer short-course antibiotics for 1-4 days post-operatively 5
• Critically ill patients: Extend therapy up to 7 days based on clinical condition and inflammatory markers 5
• Previous biliary infection or stenting: Use 4th-generation cephalosporins with adjustments per antibiogram 1

Special Populations

• Avoid aminoglycosides in diabetic and elderly patients due to increased drug-related toxicity risk 5
• For patients with previous biliary drainage or cholangitis: Initiate broad-spectrum antibiotics (piperacillin/tazobactam, meropenem, ertapenem) 1, 5

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Achieving Critical View of Safety

The critical view of safety is the most important technical step to prevent bile duct injury and must be achieved before clipping or dividing any structures. 1

Intraoperative Technique

• In cases of severe inflammation, adhesions, or bleeding in Calot's triangle: Consider conversion to open surgery or subtotal cholecystectomy rather than risking bile duct injury 1
• Laparoscopic or open subtotal cholecystectomy is a valid option for advanced inflammation, gangrenous gallbladder, or "difficult gallbladder" where anatomy cannot be clearly identified 1
• If bile duct injury is suspected intraoperatively: Convert to open surgery immediately for better visualization and repair 1

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Timing of Surgery

Early laparoscopic cholecystectomy should be performed as soon as possible for acute cholecystitis, ideally within 10 days of symptom onset, with earlier surgery associated with shorter hospital stay and fewer complications. 1, 2

Alternative Approaches for High-Risk Patients

• Percutaneous cholecystostomy should be considered for patients >65 years with ASA III/IV, performance status 3-4, or septic shock who are deemed unfit for surgery 1
• Use cholecystostomy as a bridge to surgery in acutely ill patients to convert them to moderate-risk status more suitable for delayed cholecystectomy 1
• Remove cholecystostomy catheter 4-6 weeks after placement if cholangiogram at 2-3 weeks demonstrates biliary tree patency 1

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Criteria for Conversion to Open Surgery

Convert to open surgery when local severe inflammation, dense adhesions, bleeding in Calot's triangle, or suspected bile duct injury prevents safe laparoscopic dissection. 1

Clinical Predictors of Conversion

• Fever, leukocytosis, and elevated serum bilirubin predict higher conversion rates 1
• Extensive prior upper abdominal surgery increases technical difficulty 1
• Diabetes mellitus is a recognized risk factor for conversion, though laparoscopic approach remains preferred 6

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Management of Bile Duct Injury

If biliary fistula, biloma, or bile peritonitis develops postoperatively, start broad-spectrum antibiotics immediately (within 1 hour) using piperacillin/tazobactam, imipenem/cilastatin, meropenem, ertapenem, or aztreonam with amikacin in shock. 1, 5

Source Control

• Percutaneous drainage is required for biloma 1
• Surgical intervention is required for bile peritonitis 1
• In severe complicated intra-abdominal sepsis with organ failure: Open abdomen therapy may be considered 1

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Common Pitfalls to Avoid

• Never continue antibiotics beyond 24 hours for uncomplicated cholecystectomy—this is the most common stewardship error 5
• Never proceed with clipping structures without achieving critical view of safety—this is the primary cause of bile duct injury 1
• Never persist with laparoscopic dissection when anatomy is unclear—convert to open or perform subtotal cholecystectomy 1
• Never assume elevated liver enzymes alone indicate CBD stones—obtain confirmatory imaging with MRI or endoscopic ultrasound 1, 2