ERCP AND OPEN CHOLECYSTECTOMY

Patients with bile duct stones and gallstone disease coupled with any systemic complications like kidney failure, respiratory failure or severe cardiac disease may exclude the patient from being suitable for general anaesthesia. Patients with systemic sepsis with or without co-morbid conditions are likely to have higher risk for laparoscopic surgical procedures. Once the bile duct stone is managed by ERCP with stone extraction, then the gall bladder removal procedure has to be done. In patients with severe sepsis with gall stone induced complications like gangrene or perforation or pus formation necessitates early gall bladder removal and, in that case, the open surgery will be a better option.  

There are some advantages of ERCP even in open cholecystectomy. They are:

• Early removal of bile duct stone with placement of stent in the bile duct, which reduces the biliary infection and also prevent systemic infection.
• By avoiding bile duct opening during ERCP, risks associated with bile duct opening are reduced. The complications related to bile duct opening are bile leak from the opened bile duct, bile duct stricture and need for the placement of a tube in a bile duct for longer duration.
• The presence of stent in the bile duct which can be felt during surgery will give some technical support to identify and preserve the bile duct, in case of complicated gall bladder removal surgery either by laparoscopic or open surgical technique.

In open gall bladder surgery, the procedure is done under general anaesthesia or regional anaesthesia. The abdomen is usually opened through right sub costal incision. Then the gall bladder is reached by positioning the retractors in place.

Usually, three retractors are placed to expose the gall bladder. One retractor retracts the liver upwards. Second retractor retracts the colon downwards. Third retractor is placed to retract the duodenum medially. Gall bladder is exposed. Adhesions are released if any.  After doing this, the dissection will be started from a place called Calot’s triangle which represents the area of bile duct and gall bladder junction.  The idea of this dissection is to identify the cystic artery and cystic duct separately and ligate both structures individually and cut, without damaging the bile duct. In case of severe adhesions there may be technical difficulty in identifying these structures in the Calot’s triangle. In such cases there are alternative technique to proceed with open cholecystectomy.

 The commonly used alternative 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 from the liver bed then the haemostasis is checked and abdomen will be closed with non-absorbable sutures. Extreme care should be taken to avoid bleeding from the gall bladder bed. Harmonic scalpel and monopolar and bipolar diathermy are the equipments used to stop bleeding during the surgery.

The placement of drainage tube will be optional depending up on the situation. In case of any technical difficulty, severe infection or in case of chronic liver disease, 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.