PREPRINT
jkl keys enabled
2214 views

Open Cholecystectomy for Gallstone Disease

Abstract

Gallstone disease is one of the most common disorders affecting the digestive tract. Most individuals with gallstones are asymptomatic and do not require treatment. For symptomatic patients, however, cholecystectomy is recommended. Cholecystectomy is one of the most common abdominal surgeries performed worldwide. Indications include moderate-to-severe symptoms, stones obstructing the bile duct, gallbladder inflammation, large gallbladder polyps and pancreatic inflammation due to gallstones. Here, we report the case of a 53-year-old man with stones in his biliary duct. Despite having uncomplicated disease, the patient was treated with a primary open cholecystectomy because laparoscopy was not available.

Case Overview

Background

Gallstones are solid masses formed by bile precipitates and form in the gallbladder or bile ducts. The prevalence of gallstones is related to many factors, including diet, age, gender, BMI, and ethnic background. Women are more likely to develop gallstones than are men, and first-degree relatives of patients with gallstones are at increased risk, possibly indicating a genetic predisposition. There are two main types of gallstones: cholesterol and pigment.1 Cholesterol stones account for 80% of all gallstones and are formed from supersaturation of bile with cholesterol. Pigment stones are typically formed in conditions of stasis. Most individuals with gallstones remain symptom free; however, if a gallstone lodges in a duct and causes obstructions, there may be symptoms such as right upper quadrant or epigastric pain, nausea, vomiting, bloating, and fever. Ultrasonography or computed tomography are used to visualize the stones in the gallbladder, while magnetic resonance cholangiopancreatography or endoscopic retrograde cholangiopancreatography can better visualize stones within the bile ducts.

Focused History of the Patient
A 53-year-old male presented with a 1-year history of recurrent right upper quadrant pain that radiated to the back. Ultrasound revealed a non-thickened gallbladder with presence of intraluminal stones. The liver was normal and biliary ducts were not dilated. Surgical removal of the patient’s diseased gallbladder and stone was indicated because of recurrent bouts of biliary colic.

Physical Exam

Classic biliary colic is characterized by constant right upper quadrant or epigastric pain lasting 20 minutes to 3 hours. Up to 60% of patients with biliary colic complain of pain that radiates to the right shoulder pain or back, as in our patient. Typical time of onset is more than 1 hour after eating, often at night. The pain is not relieved by position changes or by evacuation of the bowels.1

Imaging

The imaging modality of choice is transabdominal ultrasound, which has a sensitivity as high as 89% and a specificity of 99%.2 If there is a discrepancy between the clinical diagnosis of acute cholecystitis and the ultrasound findings, scintigraphy of the biliary tract may be performed using technetium-labeled hydroxy iminodiacetic acid. Scintigraphy is more sensitive than ultrasound (97% vs 89%) and has equivalent specificity.

Natural History

Regardless of whether the patient has symptoms, between 1% and 3% of individuals with gallstones will experience complications. These include acute and chronic cholecystitis, choledocholithiasis, acute cholangitis, acute pancreatitis, empyema in the gallbladder, obstructive jaundice, choledochoduodenal fistula, and gallbladder perforation.1

Options for Treatment

Patients with symptomatic gallstones are usually treated surgically, whereas those with asymptomatic disease may be treated expectantly. Laparoscopic cholecystectomy is the procedure of choice in places in the developed world. Primary open cholecystectomy is performed in areas of the world where laparoscopic procedures are not often performed, because of lack of availability of proper equipment or because of costs, as was the case with our patient.

Rationale for Treatment

The primary reason to perform cholecystectomy is to prevent the complications referenced above. A secondary rationale is prevention of recurrent bouts of biliary colic, as was the case with our patient. Most patients with histories of biliary pain are likely to experience recurrences.

Special Considerations

The contraindications to open cholecystectomy are limited to severe physiological derangements or conditions that preclude administration of general anesthesia.

Discussion

We present a patient who had right upper quadrant pain radiating to the back lasting more than a year. On ultrasound, the patient was noted to have gallstones and an open cholecystectomy was performed because he lives in the rural Philippines and cannot afford the more expensive laparoscopic procedure that could be performed in an urban area.

Cholecystectomy is the removal of a diseased gallbladder, performed through an open or laparoscopic approach. Open cholecystectomy is performed through an incision on the right side under the rib cage. Open cholecystectomy was first performed in 1882 by Carl August Langenbuc.3 It used to be the mainstay of treatment of gallstones; however, there has been a gradual shift in the treatment since the introduction of laparoscopic cholecystectomy, which was first performed by Philippe Mouret in Lyon, France.4-6 Laparoscopic cholecystectomy is currently considered the gold standard treatment for gallstones because of reduced pain, faster return to activity and shorter length of hospital stay.7 However, patients with hemodynamic instability, uncontrolled coagulopathy, frank peritonitis, severe obstructive pulmonary disease or congestive heart failure may not tolerate the increased intra-abdominal pressures of pneumoperitoneum; these are contraindications that may require open cholecystectomy. Acute cholecystitis, gangrene and empyema of the gallbladder used to be relative contraindications to laparoscopic cholecystectomy; however, they are now considered risk factors for a potentially difficult cholecystectomy and do not preclude an attempt at laparoscopy.

In the laparoscopic era, primary open cholecystectomy for uncomplicated gallbladder disease may be becoming a lost art. Nevertheless, surgeons should become familiar with the technique, particularly for treatment of patients with contraindications to laparoscopic procedures.

Equipment

Standard equipment.

Disclosures

Nothing to disclose.

Statement of Consent

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.

Acknowledgments

World Surgical Foundation

Citations

  1. Ibrahim MO, Sarvepalli SH, Morris-Stiff G, et al. Gallstones: Watch and wait, or intervene. Clevel Clin J Med. 2018;85:323-31. doi:10.3949/ccjm.85a.17035.
  2. Shea JA, Berlin JA, Escarce JJ, et al. Revised estimates of diagnostic test sensitivity and specificity in suspected biliary tract disease. Arch Intern Med. 1994;:2573–2581. doi:10.1001/archinte.1994.00420220069008.
  3. Gadacz TR, Talamini MA. Traditional versus Laparoscopic Cholecystectomy. Am J Surg. 1999;161:336-8. doi:10.1016/0002-9610(91)90591-Z.
  4. McSherry CK. Open Cholecystectomy. Am J Surg. 1993;165:435-9. doi:10.1016/s0002-9610(05)80936-5.
  5. Ji W, Li LT, Li JS. Role of Laparoscopic Subtotal Cholecystectomy in the treatment of complicated cholecystitis. Hepatobilpancreat Dis Int. 2006;5(4):584-9.
  6. Cuschieri A. Laparoscopic Cholecystectomy. J R Coll Surg Edinb. 1999;44:187-92.
  7. Strasberg SM. Clinical practice acute, calculus cholecystitis. N Engl J Med. 2011;358(26):2804. doi:10.1056/NEJMcp0800929.