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  Gallbladder disease and thus surgery are extraordinarily common; whereas most cholecystectomies occur uneventfully, there are many serious complications that can occur. Thus, the surgeon should not be lulled into a sense of complacency

  
  
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  Regardless of patient or gallbladder disease severity, each surgeon should develop a list of steps to laparoscopic cholecystectomy, which should be followed in order every time. Inability to proceed through the steps should prompt either deviation to an established “bail out” maneuver (eg, sub-total cholecystectomy), or conversion to open

  
  
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  Anatomic variations in both biliary and arterial anatomy are common; the surgeon must familiarize themselves with these variants and anticipate their existence.

Cholecystectomy is one of the most commonly performed surgeries in North America. It is commonly performed on an outpatient basis, but also makes up a large portion of surgeries done in the hospital setting. It most often goes smoothly and is considered “just another gallbladder.” However, even a modestly experienced surgeon knows that gallbladder surgery can be fraught with technical difficulties and challenges. One of the biggest mistakes the surgeon can make regarding cholecystectomy is to become complacent and not appreciate the gravity of the rare but potentially devastating complications that are possible. In this chapter we will discuss potential bail-out strategies and surgical issues in regard to gallbladder surgery.

Case Study 11.1

The hypothesis: If possible, at times it may be better to temporize cholecystitis and delay surgery until risk factors can be mitigated.

The story: An 85-year-old male is in the intensive care unit (ICU) and being treated for a pneumonia and sepsis for the last week. He is now improving from a respiratory standpoint but he had a fever and right upper quadrant (RUQ) pain, and workup has revealed only cholecystitis as the likely source. The patient’s family members note that he has had RUQ pain after eating for the last several years and at times it has been associated with fevers but the patient never wanted to go to see a physician. Patient was taken to the operating room (OR) for a cholecystectomy. Laparoscopy was converted to open and a cholecystectomy performed.

The patient’s outcome: Prolonged ICU stay, prolonged hospital course, disposition to a nursing home, never returned home.

What went wrong? It is possible that a delayed approach to the cholecystectomy with a temporizing cholecystostomy tube would have improved outcomes; however, this is debatable.

How to prevent this error in the future? The decision to operate for cholecystitis at times may be straightforward while at other times the exact risk versus benefit is not so clear. In the elderly patient with multiple comorbidities or in the setting of additional ongoing acute processes, the decision is usually not clear at all.

In the elderly specifically, data in the literature support cholecystectomy, as it appears the outcomes are better when surgery is performed on the index episode of symptoms.¹ However, in many of these discussions, those patients at highest operative risk are understandably excluded from the evaluation. This makes it hard to apply these data to all situations except to say that when possible you should remove the gallbladder.

In certain situations, the best way to avoid serious complications is to not operate in the first place or, more commonly, attempt to delay the operation until the cause of the high operative risk can be mitigated. Thus, one of the first “bail-out” options available to the gallbladder surgeon is to not perform surgery. This option should be only judiciously and sparingly employed as the alternatives are typically regarded as temporizing measures, and not definitive therapy. An alternative to cholecystectomy for temporizing or palliation in the setting of cholecystitis in extremely high-risk patients is treating with antibiotics with or without in certain situations adding cholecystostomy tube decompression of the gallbladder. Antibiotic treatment of cholecystitis to “cool it down” has been utilized in many settings. However, commonly antibiotics alone are not used in the critically ill patient where there is a need to have a quicker resolution to potential gallbladder issues as multiple processes may be occurring simultaneously. When antibiotics alone are chosen, the clinical course must be followed closely. Antibiotics do nothing to relieve the mechanical obstruction and thus do not uniformly improve symptoms; in addition, antibiotics have a definite lack of resolution and a high recurrence rate. Adding a percutaneous cholecystostomy tube will decompress the gallbladder and should be utilized early when there is concern for ongoing gallbladder issues, especially in the critically ill patient. In the critically ill patient, acalculous cholecystitis is common and perhaps contributes to the success of tube drainage in these situations. The cholecystostomy tubes will decompress the obstructed and distended gallbladder and have a fairly successful rate of clinical response.² In some institutions, they can be placed at the bedside or perhaps more commonly in a procedure suite. They provide a good “bail-out option” in high-risk patients but they are often a temporizing or palliating measure only. Thus in the optimal scenario, the tube will provide time for the active process preventing cholecystectomy to resolve, thus allowing the operative risk to become more favorable (eg, the patient’s septic shock will have resolved and the patient will have recovered from the hospital course), or the patient will not survive and the tube is to palliate symptoms. Thus in choosing a cholecystostomy tube, the surgeon should be able to foresee a future time when the patient-related or disease-related risk factors will be resolved or improved and thus the surgical risk optimized. If the surgeon does not anticipate that the patient will survive, the temporizing measures are seen more as palliation. Of note, a Cochrane review of this issue did not conclude that there was enough evidence to clearly define the role for percutaneous tube placement versus cholecystectomy, but the described method of use is common.³

Commonly, the tube must remain in place for a minimum of 6 weeks prior to attempts at removal. This allows time for the body to form a tract around the tube and prevent free leakage of bile once the tube is out. If the plan is to proceed with cholecystectomy and not remove the tube (as the patient’s risk factors have improved), the patient should be counseled that the risks of a cholecystectomy in this setting may be elevated and the chance of needing an open operation may be higher. However, if an attempt at removal of the cholecystostomy tube is considered, a common management plan is to perform a cholangiogram via the tube to determine the patency of the cystic duct and other bile ducts and to identify any possible aberrant anatomy prior to surgery. If the cystic duct is still occluded on the cholangiogram, it is unlikely that the patient will remain asymptomatic after the tube is removed. If the cystic duct is open, it may be possible to remove the tube with a lower expectation of recurrent symptoms but the risk of recurrent cholecystitis appears to be high. If the tube is removed and symptoms do return, likely a cholecystectomy is required versus a replacement tube. However, this tube will likely be permanent. Acalculous cholecystitis in the critically ill may require fewer interval cholecystectomies as the duct may be more likely to be open, but this is not clear.

Take-home point: In summary, cholecystectomy is the preferred management strategy for cholecystitis in most patients. However, in the very high-risk operative candidate, a common “preemptive bail-out strategy” is a temporizing or palliative cholecystostomy tube.

Case Study 11.2

The hypothesis: Optimal laparoscopic port site access can be difficult in the hostile abdomen and is determined by the situation and the surgeon’s experience.

The story: A 58-year-old male presents with a history and physical consistent with acute cholecystitis. He has a surgical history significant for multiple abdominal operations via a midline laparotomy. Two of these operations were for bowel obstruction. Attempt is made for left upper quadrant (LUQ) port placement. On entry, a large amount of blood was identified. The abdomen was rapidly opened and mesenteric vessels ligated for appropriate hemostasis.

The patient’s outcome: The case was completed open and with an uneventful postoperative course.

What went wrong? Technical error: Vascular injury on attempt at laparoscopic port access in the hostile abdomen.

How to prevent this error in the future? Gaining laparoscopic access to the hostile abdomen carries risk of significant and at times life-threatening complications. True “level 1” evidence for optimal access to the peritoneal cavity in the standard-risk or high-risk setting is lacking. The few standard approaches include: open Hasson technique, Veress needle access, and Optiview access. Specialty and training appear to be the most likely factors for determining which approach is preferred by the surgeon.⁴ In a Cochrane review of techniques, no clear method was felt to have evidence supporting its superiority related to injuries, but an open technique may be more likely to be successful.^4,5

Reported complications from laparoscopic access include a variety of issues, but bleeding from mesenteric or major vessels and bowel injury appear to be commonly reported serious complications. Again, no particular method of entry has demonstrated superiority and thus the method most familiar to the operative surgeon is likely the safest in any given setting. However, as with any operative skill, the surgeon should know multiple options as likely no one option is perfect for every patient and situation.

Likely the most common access site, the umbilicus, is commonly also the site of previous incisions and therefore the risk of underlying adhesions to bowel or other intra-abdominal organs is high in this area. In these situations, where the risk of adhesions is high and the risk of entry higher than normal, the ability of the surgeon to alter his or her standard approach becomes critical. A commonly discussed alternative entry site is “Palmer’s point.” This is located in the LUQ, in the midclavicular line a few finger breadths below the costal margin.^4,6 Data that this is the ideal entry point are lacking. Further, as in our case here, the required access is the RUQ and thus access from the left may still be blocked by adhesions to the midline scar. However, the logic appears sound thatgaining access off the midline or away from a previous surgical scar may be safer than through the midline scar.⁴ Thus access laterally through an open technique where there is no scar is often felt to be safer when there is a midline scar and a likely hostile abdomen. Once initial entry has been achieved, additional access should be via direct visualization in clear areas.

Another consideration in the hostile abdomen that cannot be overlooked for access to the peritoneal cavity is going directly to an open surgery. This obviously must take many things into consideration, but safety must remain paramount and at times the open incision will be the safer option. In summary, in the hostile abdomen, a lateral open approach appears to be preferred for initial laparoscopic access. However, an open operation may also be the optimal approach.

Another port site complication could be bleeding from an abdominal wall vessel. This may commonly be the epigastric vessels but others may bleed. This is usually identified during or just after placement of the trocar or when the trocar is removed and is no longer occluding the vessel. This possible tamponade by the port itself or the pressure of the pneumoperitoneum is the logic behind the recommendation that port sites should be watched for bleeding when the ports are removed as the intra-abdominal pressure decreases. When abdominal wall bleeding is identified, a few options for control exist. At times a suture passer and suture ligation of the port site will control the bleeding. There are a few proprietary devices that assist with passing suture around a port site for closure that may be helpful to stop bleeding if they are readily available. In thinner abdominal walls, it may be possible to extend the port site and cut down on the bleeding to suture ligate the bleeding vessel. This becomes more difficult in the thicker abdominal wall. A temporizing and possibly definitive option is “Foley tamponade.” The surgeon can leave the port in place, then pass a Foley (that is small enough to fit) through the port, expand the balloon, and then retract the port and Foley until the Foley balloon is applying pressure to the abdominal wall. The external side of the Foley can be clamped in order to squeeze the port site and create pressure. This will commonly slow or stop the bleeding while definitive options can be organized. At times, with enough time, this pressure may be definitive. In some situations, for example with very thick abdominal walls, endovascular embolization could be used if available.

Take-home point: When port site access causes intra-abdominal bleeding, the results can be disastrous and there have been reports of death from major vascular injury. This commonly involves major retroperitoneal vessels and at times mesenteric vessels. In the situation where large amounts of bleeding are encountered, the most judicious option is likely to open and repair the injury with standard operative techniques. Some may describe approaching this bleeding laparoscopically, but usually these injuries are with the initial port and the other ports are not in place yet. In this situation, only the slowest bleeding would be approachable in this fashion as rapid bleeding needs to be addressed emergently as the patient’s life is in danger. The take-home point is that the patient’s life is not worth a small incision: open up!