OPEN CHOLECYSTECTOMY

        Open cholecystectomy means removal of gall bladder through open technique. Open cholecystectomy is a rarely done procedure today, but this is the ultimate surgical technique to remove the gall bladder in case of any technical difficulty.

        The common indications for open cholecystectomy are,

1. Difficult laparoscopic cholecystectomy.
2. Associated large common bile duct stones which cannot be removed through ERCP.
3. Previous upper abdominal surgery with anticipated dense adhesions or technical difficulty.
4. Poor general condition of the patient who cannot withstand laparoscopic technique.
5. History of previous gastric surgery like distal gastrectomy or presence of gastric outlet obstruction like chronic duodenal ulcer with obstruction cannot have routine ERCP for the bile duct stones. In this situation open surgery is a justified option. Here the procedure performed is open cholecystectomy with bile duct exploration with T-tube drainage. Hepaticojejunostomy or Choledochoduodenostomy are the alternative procedures for T-tube drainage if required
6. Non availability of experienced laparoscopic surgical team.

PROCEDURE:

    Usually done under general anaesthesia. Can also be done under regional analgesia. Intravenous antibiotics will be given. After preparing and draping the area for surgery, abdomen is entered through right subcostal incision. After safe entry, three retractors are used to retract the liver upward, duodenum medially and hepatic flexure of colon downwards for better visualisation of the operating area. Important point to be remembered is that identification of cystic duct and cystic artery without injuring common bile duct. There are various techniques to identify these structures, but commonly used technique is “Fundus First Method” in which gall bladder dissection is started from the fundus of the gall bladder. Here the only disadvantage of this technique is that there may be bleeding from the liver bed during surgery and that can be avoided by the careful surgical technique. Once gall bladder is dissected from the gall bladder bed, dissection will be proceeded towards Calot’s triangle. At this area cystic artery and cystic duct are identified and ligated separately. Extreme care should be taken to avoid injuries to main biliary apparatus and also to accessary ducts if any.

        Once the gall bladder is removed, the haemostasis is checked and abdomen will be closed with non-absorbable sutures. The placement of drainage tube will be optional depending up on the situation. In case of any technical difficulty or severe infection, leaving a drainage tube will be ideal.

    Carefully done open cholecystectomy will also have good result except for little more pain. But availability of current pain relief techniques like epidural analgesia definitely takes away the pain. It is very important to note that at the end of the day safety of the procedure is more important than actual technique.

          Even during open cholecystectomy, there may be technical difficulty in removing entire gall bladder. The common reason is severe acute or acute on chronic inflammation of Calot’s triangle in which demonstration of junction between cystic duct and common hepatic duct will be difficult. In such cases the ideal option will be leaving behind a cuff off gall bladder over this critical area. Usually, gall bladder is opened and all the contents (Gall stones and other contents) will be evacuated. After that maximum amount of gall bladder will be removed and remanent gall bladder will be sutured with absorbable sutures (SUBTOTAL CHOLECYSTECTOMY). This will be the solution for the acute condition. There is a possibility of developing pain after this procedure due to the presence of stones in the residual gall bladder or development of newer stone in the residual gall bladder. But this can be managed later. Post operative MRCP evaluation of remanent gall bladder will give an idea about the nature of remanent gall bladder. MRCP also reveals the presence of stones in the remanent gall bladder.