rates of 67% to 100% and specificity rates of 69% to 100%.41

US remains the initial test of choice, as it is relatively inexpensive, and may be performed at the

bedside in the ICU. However, a negative US in a patient with a high clinical suspicion for AAC may

benefit from a HIDA scan to improve diagnostic yield.43 Treatment of AAC is either a cholecystectomy

in the stable patient or more likely, PC tube placement in the critically ill, unstable patient.

Figure 61-7. CT guided placement of a 10-French cholecystostomy tube for acute cholecystitis in a nonoperative patient. Note

transhepatic (across the liver) placement. These tubes may be placed using US or CT guidance. (Image courtesy of Aarti Sekhar,

MD and David Schuster, MD, Emory University Department of Radiology.)

Chronic Cholecystitis

In most patients (>90%), gallstones are the causative factor of chronic cholecystitis and lead to

recurrent episodes of cystic duct obstruction manifesting as recurrent biliary colic. These recurrent

attacks can lead to scarring and a nonfunctioning, noncontracting gallbladder. A patient with chronic

cholecystitis present similarly to those with symptomatic cholelithiasis (i.e., biliary colic) and it is often

difficult to distinguish between the two conditions. Diagnosis is accomplished with a US documenting

gallstones in the setting of recurrent episodes of RUQ abdominal pain. Patients may exhibit atypical

symptoms or a clinician may desire confirmation of a causal relationship to the calculi seen on US, and a

HIDA scan may be useful in this situation.28 The treatment for chronic cholecystitis is cholecystectomy.

Gallstone Pancreatitis

Gallstone pancreatitis develops as a result of choledocholithiasis (gallstones that have migrated into the

CBD). Stone impaction at the distal CBD near the Ampulla of Vater, where the CBD and pancreatic duct

join, may interfere with the flow of exocrine pancreatic secretions resulting in reflux into the pancreatic

duct with subsequent autolysis secondary to release of digestive enzymes. It is the second most common

cause of pancreatitis after alcohol abuse. The clinical diagnosis of pancreatitis is made by the

constellation of upper abdominal pain, serum amylase or lipase >3 times the upper level of normal,

and/or imaging studies demonstrating acute inflammation of the pancreas, although imaging is not

generally required.44

Treatment for pancreatitis is dependent on the severity of the local and systemic response and beyond

the scope of this chapter. However, the underlying cause, the lodged stone, must be addressed. Recent

guidelines from the International Association of Pancreatology (IAP),44 suggest that the majority of

stones will pass by themselves, and only if there is evidence of cholangitis (see below under cholangitis)

should endoscopic retrograde cholangiopancreatography (ERCP) be performed for stone extraction.

Regardless of the need for stone extraction, the gallbladder should be removed to prevent further

episodes of pancreatitis.

The timing of the cholecystectomy in the setting of gallstone pancreatitis is controversial. It was

previously thought that given the acute inflammation, the risk of injury to the CBD or other structures

was too high for immediate surgery and an interval cholecystectomy (4 to 8 weeks from the initial

admission) was indicated. Evidence now supports early intervention with cholecystectomy being

performed during the index admission.45,46

CHOLECYSTECTOMY

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Historical Perspectives

Laparoscopic cholecystectomy is the most common gastrointestinal surgical procedure performed in the

United States, with more than 750,000 procedures performed yearly. Carl Langenbuch was the first to

describe the open cholecystectomy in Germany in 1882. A century later, laparoscopic cholecystectomy

was introduced and has since become the preferred method for removal of the gallbladder with over

90% of elective procedures and 70% of urgent cholecystectomies being performed laparoscopically.25

True contraindications to the laparoscopic approach to cholecystectomy, include (i) patient inability

to tolerate pneumoperitoneum, (ii) bleeding diatheses, and (iii) decompensated cirrhosis, given the risk

of fracturing of the liver and bleeding.22 Patients at higher risk for complications following the

laparoscopic approach are those with AC, morbid obesity, previous upper abdominal surgery, and wellcompensated cirrhosis.

Technique

The procedure traditionally is performed using four ports. The abdomen is typically entered near the

umbilicus and the abdomen is insufflated to 15 mm Hg. Three further operating ports are placed under

direct visualization: two 5-mm ports in the RUQ subcostally in a position to grasp the fundus of the

gallbladder and retract it cephalad and another in a position to grasp the infundibulum (often in the

anterior axillary and midclavicular lines, respectively), and a third 5-mm trocar or 10/12-mm trocar is

placed in the subxiphoid/midepigastric region (Fig. 61-8).

The fundus and infundibulum are grasped to retract the gallbladder cephalad exposing the cystic duct

and the triangle of Calot (defined by the liver edge, cystic duct, and common hepatic duct), which holds

the cystic artery (Fig. 61-8). The dissection of the lymphatic and fatty tissue within the triangle should

allow for visualization of two distinct structures entering the gallbladder (the cystic artery and cystic

duct) creating what is known as the critical view. The cystic duct and artery are fully encircled and

individually controlled with two surgical clips placed toward the porta hepatis and one toward the

gallbladder and then divided. The peritoneum surrounding the gallbladder is then incised, and using the

two 5-mm RUQ ports, the gallbladder is maximally retracted in order to develop the adventitial plane

between the gallbladder and Glisson capsule (Fig. 61-9). The gallbladder is then removed off the liver

from the infundibulum toward the fundus. Hemostasis within the gallbladder fossa is assured and the

gallbladder is extracted through the umbilical port, which may need to be enlarged in the setting of

significant calculi, within an impermeable plastic bag, which decreases the risk of infection at the site of

removal. This is especially true if the gallbladder is acutely inflamed, gangrenous, or perforated as the

risk of infection at the extraction site is increased.

Figure 61-8. A: Trocar placement for laparoscopic cholecystectomy. The laparoscope is placed through a 10-mm port just above

the umbilicus. Additional ports are placed in the epigastrium, subcostally in the midclavicular, and near the anterior axillary lines.

B: The “critical view” of safety. The triangle of Calot is dissected free of all tissue except for the cystic duct and artery, and the base

of the liver bed is exposed. When this view is achieved, the two structures entering the gallbladder can only be the cystic duct and

artery. Visualization of the common bile duct is not necessary.

If the anatomy is unclear, a cholangiogram may be useful and can be performed laparoscopically via

access of the gallbladder infundibulum or proximal cystic duct. A cholangiogram is performed by

ligating the cystic duct or gallbladder proximally and incising the anterior surface of the gallbladder

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infundibulum or proximal cystic duct for placement of a cholangiocatheter. At this point, a radio-opaque

contrast agent is injected, and under fluoroscopy the biliary ductal anatomy is defined. Newer

techniques of fluorescent-assisted cholangiogram using systemically injected near-infrared dyes, such as

indocyanine green or methylene blue, may assist in identification of the critical structures without

requiring intraoperative catheter placement or ionizing radiation exposure making the procedure less

technically demanding.47

Laparoscopic cholecystectomy in the elective setting for symptomatic cholelithiasis, or as an interval

operation in the setting of AC, can often be performed in the outpatient setting. Factors that may

influence admission include starting the operation later in the day, uncontrolled pain or nausea, and

longer operative time (greater than 1 hour).48

Other Approaches

As practitioners and patients have become more exposed and familiar with the laparoscopic treatment of

various surgical conditions, desire for even more minimally invasive, and to a certain degree cosmetic

approach has increased. This led to the development of the single-incision approach to laparoscopic

cholecystectomy (SILS). This is performed by placing a multiport access device through the umbilicus

and inserting various instruments through the single port in order to dissect the critical structures and

the gallbladder. The safety of SILS in elective cholecystectomies has been proven in various clinical

trials.49,50 The proponents of SILS espouse the cosmetic appeal, although this metric was not supported

in a Cochrane review.50 Detractors point to the increased operative time and increased hernia rates.51

Robotic SILS was developed to improve upon the limitations of standard SILS (reduced visualization

and limited traction). The intuitive computer software assists in triangulation of the arms through the

single umbilical port and due to proprietary port design (Fig. 61-10), the issue of instrument

interference is decreased. This approach, however, may significantly increase the overall cost to the

patient and healthcare system with no proven benefit to date in terms of outcomes when compared to

conventional laparoscopy. Nonetheless, given the new technology it is still early in the experience and

further studies are required to truly determine the niche, if any, for robotic and SILS

cholecystectomies.52–54

Open cholecystectomy has been relegated to a relative rare operation since the introduction and wide

spread acceptance of laparoscopic surgery. The open technique is still employed in certain clinical

settings, such as (i) the need for a potential second procedure, like concurrent CBD procedure, (ii)

known complicated anatomy, or (iii) need for conversion from a laparoscopic procedure to an open

procedure due to inability to identify anatomy or unexpected findings in approximately 10% to 15% of

planned operations.55 Open cholecystectomy can be performed through either an upper midline or right

subcostal (Kocher) incision. Unlike laparoscopic cholecystectomy, dissection often begins at the fundus

and proceeds in a retrograde, dome-down fashion toward Calot triangle with identification of the cystic

artery and duct at the gallbladder neck.

Serious complications of laparoscopic or open cholecystectomy are rare and the associated mortality

rate is <0.3%. The most severe complication of cholecystectomy is a biliary tract injury. The incidence

of bile duct injury following laparoscopic cholecystectomy is between 0.3% and 0.6% (vs. 0.2% and

0.3%, historically for open surgery). Major vascular injuries, especially to the right hepatic artery, may

occur in association with biliary injuries due to their close anatomic relationship. Otherwise, vascular

injuries to hepatic vessels and other major causes of bleeding are rare.

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Figure 61-9. A: The peritoneum overlying the cystic duct–gallbladder junction is opened with blunt dissection. B: The cystic duct

is isolated. C: The cystic duct is clipped proximal and distal and divided with the hook scissors. D: The cystic artery is dissected,

clipped, and divided. E: The gallbladder is dissected from the liver by scoring the serosa with electrocautery.

Spillage of stones into the peritoneal cavity during laparoscopic cholecystectomy occurs in 5% to 40%

of cases. Intra-abdominal abscess, subcutaneous abscess, and fistulization of stones through the

abdominal wall have all been described and therefore every attempt should be made to remove spilled

stones. Large stones or massive spills should be removed as best possible to prevent delayed

complications, but mandatory laparotomy does not appear necessary.56

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Figure 61-10. (A) Single port robotic (umbilical placement) and (B) conventional port positioning for robotic cholecystectomy:

red, green, and yellow = robot arms (arms 1, 2, and 3, respectively); blue = camera port; white = assistant port if needed.

Special Considerations

Gallbladder Cancer

A gallbladder containing an unsuspected cancer is removed in 0.2% to 3% of all laparoscopic

cholecystectomies.57 If cancer is suspected preoperatively (30% of cases), the gallbladder should be

extracted in an impermeable bag to reduce the risk of seeding the peritoneum and/or port sites. If a

gallbladder cancer is discovered, additional hepatic resection may be required and appropriate referral

to a hepatobiliary specialist is indicated. Of note, severe AC may present in a similar manner on

imaging as a gallbladder cancer and complicate management decisions as to whether an upfront en-bloc

resection should be performed (Fig. 61-11).

Cholecystoenteric Fistulae

Fistulization occurs in approximately 1% to 2% of all patients undergoing a cholecystectomy. The most

common site of fistulization is to the duodenum and colon.58 A fistula develops secondary to

decompression of the gallbladder into the adjacent bowel loop during an episode of AC. Complications

of a cholecystoenteric fistula are rare, but a large gallstone may pass into the bowel and cause a

mechanical bowel obstruction, usually distally in areas of narrow caliber, such as the ileocolic valve or

sigmoid colon. This obstruction is known as a gallstone ileus. If this complication occurs, the initial

management involves removal of the gallstone through an enterotomy with possible bowel resection.

Decision to proceed with removal of the biliary-enteric fistula and cholecystectomy at the time of

operation rests on surgical judgment, taking patient fitness and degree of tissue inflammation into

account.59 Staging the operative repair of the fistula and cholecystectomy to a later date should be

considered. An association between the presence of a cholecystoenteric fistula and gallbladder cancer

has been suggested, therefore a certain degree of clinical suspicion for cancer is warranted in this

scenario.

Figure 61-11. En bloc cholecystectomy and segment 4b/5 liver resection (blue arrow head) for concern of gallbladder carcinoma. A:

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Final pathology demonstrated acute on chronic cholecystitis secondary to presences of large pigmented gallstone (yellow arrow). B:

There is evidence of perforation into segment 4 of liver with resulting abscess and fibrosis (white arrow) mimicking a gallbladder

cancer on imaging.

Figure 61-12. Operative cholangiography showing calculi filling the common bile duct and common hepatic duct (A). These

calculi are still present at 48 hours (B) but have passed at 6 weeks (C). (Adapted from Collins C, Maguire D, Ireland A, et al. A

prospective study of common bile duct calculi in patients undergoing laparoscopic cholecystectomy: natural history of

choledocholithiasis revisited. Ann Surg 2004;239(1):28–33.)

Cholecystitis During Pregnancy

After appendicitis, biliary disease is the second most common gastrointestinal ailment requiring surgical

consideration during pregnancy.60 The development of biliary disease in pregnancy appears to be

secondary to the hormonal changes that occur during pregnancy which both increase the cholesterol

secretion in bile and decrease bile acid secretion and gallbladder contractility. Gallstones develop in up

to 3% of pregnant women with gallbladder sludge seen in up to 30% of cases. Medical therapy alone is

associated with a failure rate that varies depending on the trimester of pregnancy (92% for first

trimester, 69% for second trimester, and 44% for third trimester).61 Fetal demise unfortunately occurs

in 12% of nonoperatively treated woman with AC, and is significantly higher in women who develop

gallstone pancreatitis. The risk of miscarriage after an operative intervention for AC is between 2.2%

and 5.6%.62 There are no prospective studies evaluating cholecystectomy during pregnancy, but

evidence-based guidelines suggest that laparoscopic surgery is safe in any trimester, although trocar

positioning may need to be adjusted.63

CHOLEDOCHOLITHIASIS

Overview

Choledocholithiasis, defined as the presence of stones in the extrahepatic biliary tree, is a routine, yet to

a certain degree diagnostic and therapeutically challenging, gastrointestinal illness encountered by the

practicing general surgeon. The last few decades have seen considerable advancements in both the

diagnostic modalities and treatment approaches available in the management of choledocholithiasis or

as more commonly referred to CBD stones. In this section, we will discuss the clinical presentation and

management of CBD stones.

Classification and Etiology

CBD stones are typically classified as primary or secondary stones. Primary CBD stones originate within

the bile duct and are more commonly seen in patients from Southeast Asian countries. Primary CBD

stones can also develop in conditions associated with bile stasis, such as: (i) benign biliary strictures, (ii)

bile duct cysts (choledochal cysts), or (iii) sphincter of Oddi dysfunction. These stones are

characteristically pigmented stones, which form de novo as a result of bactericidal action on calcium

bilirubinate, thus producing a soft brown-pigmented stone.64,65

Secondary stones originate from the gallbladder and migrate into the bile duct. They are the most

common type of CBD stone accounting for approximately 85% of CBD stones seen in the United States

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