Dr. Jeffrey Ponsky, Professor of Surgery at the Cleveland Clinic Lerner College of Medicine and Department of Surgery and Dr. John Rodriguez, Professor of Surgery at Cleveland Clinic Lerner College of Medicine,
Acute Cholecystitis: Simple Versus Complicated CasesFor straight forward case of choleycystitis in good surgical candidate…I would offer cholecystectomy on this admission…as soon as possible.
For [complicated cases] medical specialists needed to assess risk factors… if prohibitive operative risk: admit to hospital, give broad spectrum antibiotics for 2 days. If no improvement then consider percutaneous cholecystostomy tube through liver into gallbladder.
Management of Cholecystostomy TubeI like to wait 4 to 6 weeks and do cholangiogram through the tube to make sure cystic duct is open. If cystic duct is not patent they will get recurrent episode.
After The Tube: Operative Planning for Sick PatientsI still get a cholangiogram ahead of time through the tube and I don’t take it out because its useful to use tube to do intraoperative cholangiogram. Stress test if its indicated. If they are on antiplatelet therapy especially some of the newer generation medications…I have them see their cardiologists and discuss…safe timespan for stopping them before surgery and when to start them safely after surgery. Some times they even need to get cardiac catheterization and stents before surgery to improve their cardiac function.
Operative Technique for Simple Acute Cholecystitis99% of the time my approach is laparoscopic. Because I do bariatric surgery I use optical entries… I have four trocars and I extract gallbladder through umbilical 12 mm port
A lot of omentum: I would start by lysing adhesions gently with cautery especially if I can visualize colon and duodenum. If you don’t control bleeding from omentum early on it can impede visualization. Sometimes I use harmonic but good hook electro-cautery is a fine dissecting tool and it tends to be hemostatic.
Tense Gallbladder: I have a very low threshold for decompressing gallbladder before starting to grab. We have long needle that is reusable needle in most of our laparoscopy sets.
Visualizing Calot’s Triangle: I take perineum high up on gallbladder. Once you get down on gallbladder wall you can start gently and patiently teasing tissue down towards duodenum. I use sucker a lot. I also dissect up towards body of gall bladder to gain length because as long as you are on gallbladder you know you are safe. Once you take Calot’s node down you can visualize junction between cystic duct and gallbladder. The Maryland is a great tool [for] gentle dissection there.
Transcystic Antegrade Sphincterotomy
If flushing and glucagon don’t work I like to use transcystic duct exploration kits. The key for this kit is to place a wire under fluoroscopic guidance distally into duodenum and if you can get the wire to go down then kit has a couple of instruments that can be helpful to extract stone
I would decompress gallbladder and…I am aggressive about going top down and I stay laparoscopic. In these more severe cases going open and trying to be heroic and going for that cystic duct is not that safe either. My decision would be either between opening gallbladder and doing partial cholecystectomy or leaving part of back wall of gallbladder on liver.