Description: With the advent of laparoscopic cholecystectomy, the traditional open cholecystectomy has become a rarity and is generally reserved for gallbladders that are expected to be difficult to remove due to inflammation, previous operations and adhesions, or because of other medical problems, such as coagulopathy or cirrhosis. In most institutions, fewer than 10% of cholecystectomies will be begun as open procedures, and perhaps 5% of laparoscopic cholecystectomies will be converted to open cholecystectomies during the course of the operation due to technical difficulties, complications, or unexpected findings. Because of its rarity, the open cholecystectomy may be a more challenging operation for both surgeon and anesthesiologist than it was in previous decades. A small number of open cholecystectomies are performed in an urgent fashion following a complication of an attempted laparoscopic cholecystectomy and may be associated with significant instability from hemorrhage or sepsis related to an iatrogenic injury of abdominal or retroperitoneal structures.

The technical aspects of open cholecystectomy have not changed since its original description over 100 years ago. The operation can be performed through a right subcostal (Kocher), paramedian, or midline incision. Upward traction is applied to the liver or gallbladder, whereas downward traction on the duodenum exposes the region of the cystic duct and artery and common duct. Adequate exposure is critical to performing a safe operation. Depending on local conditions and the surgeon’s preference, the gallbladder may be removed from the top down, excising the gallbladder from the liver bed and isolating the cystic duct and artery as the final stage of the operation. The cystic duct and artery may be isolated and divided first, and the gallbladder removed retrograde from the gallbladder bed as the final step of the procedure. The anatomy of the biliary tree is quite variable, with the classic anatomy present in only 30% of patients, and few surgeons always remove the gallbladder in exactly the same way every time. (Fig. 7.6-1 shows exposure of the gallbladder.)

Cholangiography may be performed at the discretion of the surgeon. Some surgeons perform it in all patients, and others perform it only in patients in whom there is some clinical evidence of choledocholithiasis. The cystic duct is opened and a catheter placed into the duct and secured with a ligature, tie, or special cholangiogram clamp. Dye is injected into the biliary tree via the catheter, and x-rays are taken. If stones are found, a common duct exploration may be performed. Alternatively, an endoscopic retrograde cholangiogram (ERCP) with stone extraction may be carried out postoperatively. Cholangiography usually adds 10-15 min to the procedure.

Choledochotomy, or “common duct exploration,” is the opening and exploration of the common duct for the purpose of extracting stones. Once commonly performed, it is a procedure reserved chiefly for patients who have failed management of common duct stones with endoscopic (ERCP) or laparoscopic techniques. Common duct stones are visualized by operative cholangiography to determine number of stones, position, and the anatomy of the duct. Ducts smaller than 5 mm in diameter are at greater risk of injury with common duct exploration and should be managed endoscopically. An extensive Kocher maneuver is performed to allow exposure and palpation of the entire duct, including the intrapancreatic portion. A longitudinal incision is made in the duct, and exploration is carried out through this incision. The duct may be irrigated with NS, balloon catheters may be passed, and various instruments introduced to grasp, remove, or crush retained stones. The duct may be biopsied by this approach, and choledochoscopy—the direct visualization of the duct’s interior using a small flexible scope—can be performed. Rarely, an impacted stone may require electrohydraulic or laser lithotripsy through the choledochoscope, adding considerable time to the operation in centers equipped to perform the procedure. The choledochotomy is closed over a T-tube to allow decompression of the edematous duct and later extraction of stones missed at the initial exploration. In the past, transduodenal sphincteroplasty was utilized for stones impacted near the sphincter of Oddi, but this procedure has largely been replaced by endoscopic or percutaneous techniques at specialized centers. It is reserved for highly unusual cases, such as a patient with a previous Billroth II gastrectomy. Depending on the complexity of the findings, a common duct exploration can be expected to add from 30 min to over 1 h to the cholecystectomy. In general, the mortality of patients undergoing common duct exploration is ˜2-5 times that of a simple cholecystectomy. This difference can be explained by the fact that patients undergoing common duct exploration tend to be older and sicker or suffering from concomitant cholangitis—the opening of the duct itself is not necessarily a significant physiologic insult.

Variant procedure or approaches: Cholecystectomy remains the mainstay of treatment for symptomatic biliary stone disease. Nonsurgical treatment of cholelithiasis, particularly by oral dissolution and/or lithotripsy, has very limited usefulness and is rarely used in clinical practice. Tube cholecystostomy can be performed as an open procedure or percutaneously. It is generally reserved as a temporary measure in patients too ill to tolerate a more extensive procedure.

Usual preop diagnosis: Symptomatic cholelithiasis; acute cholecystitis; chronic cholecystitis; biliary dyskinesia; gallbladder polyps or carcinoma; choledocholithiasis

See Anesthetic Considerations for Biliary Tract Surgery, p. 580.

Description: Biliary drainage procedures may be performed for malignant and nonmalignant indications, and the type of drainage procedure performed depends on factors such as the nature of the biliary obstruction, the patient’s overall condition and prognosis, the need for other surgical procedures, and institutional expertise. Most drainage procedures of the biliary tree are performed with endoscopic and/or transhepatic techniques. These techniques allow concomitant treatment of biliary stone disease, decompression of obstructive jaundice, relief of cholangitis and delineation of the anatomy of the biliary tree. There remain a significant number of patients, however, for whom a traditional surgical procedure is the most appropriate. With the advent of laparoscopic cholecystectomy, surgical bile duct injuries have become the most common reason for surgical biliary drainage procedures. In general, the
complexity of the different operations that may be performed and the morbidity attendant to these has more to do with the indications for operation than with the procedure that is performed.

All of these operations are performed under GA through an upper midline or right subcostal incision. Self-retaining retractors are used to retract the liver superiorly to expose the region of the porta hepatis. If the gallbladder will not be used for the bypass procedure (cholecystojejunostomy), then it usually is removed as the first step in the procedure (see Open Cholecystectomy, p. 572). If the patient has had previous upper right quadrant surgery, the complexity and duration of the procedure and blood loss may increase significantly. Any associated hepatic cirrhosis may make the procedure particularly demanding. Most patients undergoing surgical biliary drainage procedures have had several nonsurgical instrumentations of the bile duct prior to presenting for surgery. Indwelling stents result in colonization of the biliary tract with any number of bacterial or fungal organisms from which the patient may have already suffered bouts of cholangitis. It is not unusual for the patient to develop bacteremia during the operation while these stents are being manipulated.

Transduodenal sphincteroplasty for benign obstruction of the ampulla of Vater or for extensive choledocholithiasis has largely been abandoned in favor of the more well-tolerated and less-invasive endoscopic sphincterotomy. It remains the treatment of choice for rare cases of early ampullary carcinoma. Endoscopic sphincterotomy and/or placement of an internal stent is the most commonly performed technique for opening the ampulla and usually is performed by gastroenterologists outside the OR with iv sedation. Open sphincteroplasty is usually reserved for patients in whom endoscopic retrograde cholangiopancreatogram (ERCP) has been unsuccessful or in whom a laparotomy is required for other reasons. For these open procedures, the second portion of duodenum is incised over the region of the ampulla, and the ampulla is cannulated. A longitudinal incision is made over the course of the ampulla, and the mucosa of the ampulla is sutured to the mucosa of the duodenum with fine interrupted sutures with care being taken not to compromise the pancreatic duct. The duodenum is closed with suture, a small closed suction drain is placed, and the wound is closed. A postop stay of 5-7 d can be expected.

Cholecystojejunostomy usually is performed as palliation for malignant obstruction of the distal bile duct. Its advantage is that it does not require dissection of the portal triad, but the long-term results are poor as biliary obstruction typically recurs as the malignancy advances. The abdomen is opened as described above, and the region of the porta hepatis examined to ensure that the cystic duct is not imminently compromised by tumor. The jejunum is then brought up to the gallbladder, usually bypassing the jejunum through the transverse mesocolon. The anastomosis may be performed either to an intact loop of jejunum (loop cholecystojejunostomy) or to a Roux-en-Y loop of jejunum (Roux-en-Y cholecystojejunostomy) and is carried out with one or two layers of sutures, depending on surgeon’s preference. If a Roux-en-Y is created, a second jejunojejunal anastomosis must be performed. This procedure has largely been replaced by transhepatic and endoscopic techniques.

Choledochoduodenostomy is an archaic procedure in which the bile duct is incised longitudinally and anastomosed directly to the adjacent duodenum. This was performed historically in patients with gallstones impacted at the ampulla. However, loss of the normal sphincter mechanism at the ampulla allows reflux of duodenal contents directly into the bile duct. Patients may suffer from repeated episodes of cholangitis or obstructive jaundice from debris occluding the anastomosis. Secondary biliary cirrhosis may occur, and the author has seen one case proceed to liver transplantation in which a cast of the biliary tree comprised of fibrous food material was extracted from the choledochoduodenal anastomosis. Roux-en-Y choledochojejunostomy or hepaticojejunostomy