The Bad Gallbladder

Milos Buhavac, MD*, Ali Elsaadi, MD, Sharmila Dissanaike, MD

KEYWORDS
 Laparoscopic cholecystectomy  Open cholecystectomy
 Intraoperative cholangiogram  Acute cholecystitis  Bad/difficult gallbladder
 Percutaneous cholecystostomy tube  Subtotal cholecystectomy
 Common bile duct stones

KEY POINTS
 The Bad Gallbladder is a difficult problem not only to define but also to manage.
 Surgeons should be familiar with bailout procedures and adjuncts to surgery to avoid
damage to vital structures when the Bad Gallbladder is encountered.
 Surgeons should know how to perform both an open cholecystectomy and how to
manage common bile duct stones depending on their technical comfort and available
resources.

WHAT IS A “BAD” GALLBLADDER?

According to the 2018 Tokyo guidelines, cholecystitis can be stratified into grades I, II,
and III based on the severity of the illness as well as patient comorbidities.1 Using the
American Society of Anesthesiologists physical status classification and Charlson co-
morbidity index, patients can be categorized into how sick they are, which will help the
surgeon to decide on which management option is safest for the patient. Ashfaq and
colleagues2 defined the “bad gallbladder” as one that is necrotic or gangrenous, con-
tains Mirizzi syndrome, has extensive adhesions, required conversion to an open
operation, an operation that lasted more than 120 minutes, had prior tube cholecys-
tostomy or has known gallbladder perforation.2 Other definitions include the Parkland
Grading Scale for Cholecystitis and the American Association for the Surgery of
Trauma grading scale for acute cholecystitis.3,4 A recent multicenter validation study
found that the Parkland Grading Scale outperformed the American Association for the
Surgery of Trauma grading scale in correctly predicting the need for a surgical
“bailout” (subtotal or fenestrated cholecystectomy, or cholecystostomy), conversion
to open, surgical complications (bile leak, surgical site infection, bile duct injury), all
complications, and operative time.5 Definitions like these are a step in the right

The authors have nothing to disclose.

Texas Tech University Health Sciences Center, Department of Surgery, 3601 4th Street, Lubbock,
TX 79430, USA
* Corresponding author.
E-mail address: [email protected]

Surg Clin N Am - (2021) -–-

https://doi.org/10.1016/j.suc.2021.06.004 surgical.theclinics.com
0039-6109/21/ª 2021 Elsevier Inc. All rights reserved.

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2 Buhavac et al

direction to inform us on how technically challenging the surgery may be and will allow
us to have more informed conversations with our patients about the potential out-
comes of their operation.

IF WE PLAN TO PERFORM LAPAROSCOPIC CHOLECYSTECTOMY FOR ACUTE

CHOLECYSTITIS, SHOULD WE DO IT SOONER RATHER THAN LATER?

Many studies have looked at early versus late laparoscopic cholecystectomy, with
data to be found supporting both approaches. Vaccari and colleagues6 looked at pa-
tients who underwent cholecystectomy 72 hours after symptom onset and showed a
higher mortality rate, longer hospital stay, and higher rate of conversion to open in this
subset of patients, compared with patients who waited 6 weeks after symptoms onset
for an interval cholecystectomy. This group had no mortality (vs 5% mortality in the ur-
gent cholecystectomy group), and a conversion rate of only 4% compared with the
18% seen in the early group.6 There is, however, a much larger body of literature,
including randomized prospective studies and meta-analyses that show significantly
lower morbidity, length of stay and hospital costs for immediate/early laparoscopic
cholecystectomy versus delayed.7 Gurusamy and colleagues8 have performed
meta-analyses and Cochrane reviews that confirm the safety of early laparoscopic
cholecystectomy, showing no difference in bile duct injuries or conversion to open
cholecystectomy.
One of the challenges in evaluating all this data is that there is no standard definition
for early versus late, with studies variously defining early intervention as during the
initial hospital admission, versus within 72 hours from symptom onset, to 24 hours
from admission.
Taking into account all the available literature, it is our practice and opinion that
there is little benefit in waiting up to 6 weeks for inflammation to subside and that it
is preferable to operate as soon as it is safe to do so. Using basic principles derived
from trauma and sepsis management, 2 conditions familiar to acute care surgeons,
performing surgery to obtain definitive source control as soon as physiologic derange-
ments have been addressed with adequate resuscitation seems to be the logical
approach. In the authors’ experience, although difficult to quantify in the literature, ad-
hesions in the very early stages of infection tend to be edematous rather than fibrous,
and clear instead of thick, allowing easier and safer dissection. Theoretically, the
sooner the operation is performed, the shorter the hospital stay may have to be, which
represents significant cost savings in today’s cost-conscious world of health care. The
next step forward would be to perform a randomized control trial to compare laparo-
scopic cholecystectomy within 24 hours and 72 hours to redefine early cholecystec-
tomy, and the potential benefits of performing the surgery as soon as possible.
There used to be a theory that, beyond 72 hours from symptom onset in acute
cholecystitis, patients should not undergo cholecystectomy. This theory was partly
based on observations that, during the first 2 to 4 days of symptoms, there would
be edematous cholecystitis, followed by necrotizing and then suppurative cholecys-
titis, which could make laparoscopic cholecystectomy more dangerous.9 However,
retrospective case control studies have shown that even beyond 72 hours laparo-
scopic cholecystectomy seems to be safe.10–12 In a single-center, randomized trial
from Switzerland that specifically looked at operating after 72 hours of symptoms
versus operating after initial antibiotics and 6 weeks to allow for inflammation to
resolve, the patients who were operated on after 72 hours still had less overall
morbidity, a shorter hospital stay and duration of antibiotics, and decreased costs
when compared with the delayed cholecystectomy group.13 Although these data

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 The Bad Gallbladder 3

may be encouraging, the body mass index of these patients, and their overall health is
starkly different from the patient population that many surgeons in America have to
deal with. It is our practice to take all patients who are medically fit enough for surgery
to the operating room, regardless of symptom duration.

WHEN SHOULD WE PROCEED WITH A LAPAROSCOPIC CHOLECYSTECTOMY

VERSUS PLACING A PERCUTANEOUS CHOLECYSTOSTOMY TUBE?

The first decision branch point we encounter as surgeons is often whether or not to operate;
should we “heal with steel,” or would a nonoperative approach be safer for the patient?
When source control is required and the patient cannot tolerate the added risk of surgical
intervention, a percutaneous cholecystostomy tube is often used. After the publication and
adoption of the Tokyo guidelines, it became common for critically ill patients to undergo
percutaneous cholecystostomy tube placement instead of laparoscopic cholecystectomy.
Turiño and colleagues14 implemented nonoperative measures for 201 patients with
acute calculous cholecystitis. Of these patients, 97 underwent a cholecystostomy
tube placement. These patients typically had more comorbidities, were older, and
had worse inflammatory markers on admission. Of the 97, the rate of readmission
was 38%, and the rate of recurrent cholecystitis was 25%.14 A retrospective analysis
from 2019 looking at more than 180,000 cases of cholecystitis showed somewhat
similar outcomes. In 3167 patients undergoing cholecystostomy tube placement for
acute cholecystitis, the readmission rate was just over 20%. Patients who underwent
cholecystectomy had a readmission rate of 6.7% with a lower in-hospital mortality and
cost. Factors contributing to the decision to place a cholecystostomy tube included
cirrhosis, congestive heart failure, chronic atrial fibrillation, and sepsis.15 Similar out-
comes were seen by Dimou and colleagues,16 who showed higher readmission rates
at 30 days, 90 days, and 2 years after cholecystostomy tube placement. Considering
these data, a cholecystostomy tube is not necessarily causative, and it may instead be
a marker for a sicker patient population.
Another nonoperative route is antibiotic therapy alone, which is usually reserved for
patients with milder disease. The pitfalls of this approach include the risk of recurrent
symptoms that may lead to readmission and a more difficult operation later on. In a
systematic review and pooled analysis of 1841 patients treated nonoperatively for
acute calculous cholecystitis, 87% of patients responded favorably initially; however,
22% developed a subsequent gallstone-related problem.17 Two Norwegian random-
ized controlled trials involving 201 patients showed that 45% required interval surgery,
which was also associated with higher overall costs.18

DOES THE PRESENCE OF ANTITHROMBOTIC THERAPY INFLUENCE OUTCOMES AND

SHOULD IT AFFECT THE SURGEON’S TREATMENT STRATEGY?

The presence of antithrombotic therapy may influence the surgeon to consider a

nonoperative strategy owing to the concern for surgical bleeding. Multiple studies
have looked at the impact of antithrombotic therapy in patients with acute cholecys-
titis. In a 2017 study by Yun and colleagues,19 67 patients on antithrombotic therapy
were separated into an emergency versus elective group; the elective group stopped
antithrombotic therapy 7 days before surgery, whereas the emergent group either did
not stop or stopped within 3 days of surgery. Patient outcomes were similar in terms of
morbidity, hospital stay, and mortality. The major difference was that 6 patients in the
emergent group developed acute blood loss anemia and 3 required a postoperative
blood transfusion.19 Another single-institution experience actually showed similar re-
sults with 21 patients on anticoagulation or antiplatelet therapy. In this study, no

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4 Buhavac et al

significant difference in complications, blood loss, or conversion to open were noted in

patients operated on while on therapeutic anticoagulation.20
Although underpowered studies cannot provide strong recommendations, they do
provide the framework for larger studies to be conducted. A 2020 systematic review
by Sagami and colleagues21 looked at the use of various endoscopic drainage pro-
cedures versus laparoscopic cholecystectomy in patients on antithrombotic therapy.
Of 2578 patients undergoing laparoscopic cholecystectomy, 354 were receiving
antithrombotic therapy. The results showed no significant differences between pa-
tients with continued and discontinued antiplatelet therapy (aspirin and/or thienopyr-
idine) in intraoperative blood loss, operative time, conversion rate to open surgery, 30-
day morbidity, or bleeding complications requiring blood transfusion.21
It is these authors’ practice to continue antiplatelet therapy without interruption in
patients undergoing laparoscopic cholecystectomy. Many patients are on these drugs
to prevent thrombosis of drug-eluting cardiac stents, a potentially lethal complication
that can be harder to correct than postoperative bleeding. For patients who are on
therapeutic anticoagulation for atrial fibrillation, cardiac valve replacement, or coagu-
lation disorders, we routinely transition these agents to either low-molecular-weight
heparin or intravenous heparin and perform the operation during a short, planned win-
dow off anticoagulation. The duration of this window and the timing of resumption of
anticoagulation after surgery are predicated on balancing the risk of stroke and throm-
bosis (which varies greatly based on underlying disease, but can usually be approxi-
mated based on established calculations such as CHADS score for atrial fibrillation)
against the risk of bleeding, in each individual case.

SHOULD A POTENTIAL “BAD” GALLBLADDER OPERATION BE STARTED

LAPAROSCOPICALLY?

Once the decision for surgery has been made, an operative plan needs to be dis-
cussed and implemented. Should one initially start with laparoscopic surgery for the
“bad gallbladder”? If a laparoscopic approach is taken, when should bail-out maneu-
vers be attempted? Is converting to open operation still the standard next step?
A 2016 study published by Ashfaq and colleagues2 sheds some light on our first
question. They studied 2212 patients who underwent laparoscopic cholecystectomy,
of which 351 were considered “difficult gallbladders.” A difficult gallbladder was
considered one that was necrotic or gangrenous, involved Mirizzi syndrome, had
extensive adhesions, was converted to open, lasted more than 120 minutes, had a
prior tube cholecystostomy, or had known gallbladder perforation. Seventy of these
351 operations were converted to open.2 The indications for conversion included se-
vere inflammation and adhesions around the gallbladder rendering dissection of trian-
gle of Calot difficult (n 5 37 [11.1%]), altered anatomy (n 5 14 [4.2%]), and
intraoperative bleeding that was difficult to control laparoscopically (n 5 6 [1.8%]).
The remaining 13 patients (18.5%) included a combination of cholecystoenteric fistula,
concern for malignancy, common bile duct exploration for stones, and inadvertent
enterotomy requiring small bowel repair. Comparing the total laparoscopic cholecys-
tectomy group and the conversion groups, operative time and length of hospital stay
were significantly different; 147  47 minutes versus 185  71 minutes (P<.005) and
3  2 days versus 5  3 days (P 5 .011), respectively. There was no significant differ-
ence in postoperative hemorrhage, subhepatic collection, cystic duct leak, wound
infection, reoperation, and 30-day mortality.2 From these findings, we can glean
that most cholecystectomies should be started laparoscopically, because it is safe
to do so. It is the authors’ practice to start laparoscopically in all cases.

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 The Bad Gallbladder 5

BAILOUT PROCEDURES: WHAT, WHERE AND WHEN?

Despite the best efforts of experienced surgeons, it is sometimes impossible to safely

obtain the critical view of safety in a bad gallbladder with dense inflammation and even
scarring in the hepatocystic triangle. Continued attempts to dissect in this hazardous
region can lead to devastating injury, including transection of 1 or both hepatic ducts,
the common bile duct, and/or a major vascular injury (usually the right hepatic artery).
Therefore, it is imperative that any surgeon faced with a bad gallbladder have a toolkit
of procedures to safely terminate the operation while obtaining maximum symptom
and source control, rather than continue to plunge blindly into treacherous terrain.
If the critical view of safety cannot be achieved owing to inflammation, and when
further dissection in the hepatocystic triangle is dangerous, these authors default to
laparoscopic subtotal cholecystectomy as our bail-out procedure of choice. The ratio-
nale for this approach is that it resolves symptoms by removing the majority of the gall-
bladder, leading to low (although not zero) rates of recurrent symptoms. It is safe, and
can be easily completed laparoscopically, thus avoiding the longer hospital stay and
morbidity of an open operation.22
There is now significant data supporting this approach. In a series of 168 patients (of
whom 153 were laparoscopic) who underwent subtotal cholecystectomy for bad gall-
bladders, the mean operative time was 150 minutes (range, 70–315 minutes) and the
average blood loss was 170 mL (range, 50–1500 mL). The median length of stay for
these patients was 4 days (range, 1–68 days), and there were no common bile duct in-
juries.23 There were 12 postoperative collections (7.1%), 4 wound infections (2.4%), 1
bile leak (0.6%), and 7 retained stones (4.2%), but the 30-day mortality was similar to
those who underwent a total laparoscopic cholecystectomy.23 A systematic review
and meta-analysis by Elshaer and colleagues24 showed that subtotal cholecystectomy
achieves comparable morbidity rates compared with total cholecystectomy. These
data support the idea that we should move away from the idea that the only acceptable
outcome for a cholecystectomy is the complete removal of a gallbladder, especially
when it is not safe to do so. This shift toward subtotal cholecystectomy has been appro-
priately referred to as the safety first, total cholecystectomy second approach.25

FENESTRATED VERSUS RECONSTITUTING SUBTOTAL CHOLECYSTECTOMY

When performing a subtotal cholecystectomy, the next decision point is which type of
subtotal cholecystectomy is best: fenestrated or reconstituting? In a fenestrating sub-
total cholecystectomy, the gallbladder is excised except for a small rim of infundib-
ulum around the cystic orifice and the posterior wall adherent to the liver. This
remainder of gallbladder acts as a shield over the hepatocystic triangle, preventing iat-
rogenic injury. Stones and other debris are extracted (Fig. 1). In the reconstituting sub-
type, the gallbladder is excised down to just above the infundibulum and stapled off.
This strategy creates a small residual infundibulum (Fig. 2). While preventing the bile
leak that is almost inevitable with the fenestrating variety, it has been hypothesized
that the creation of a residual gallbladder remnant may lead to recurrence of cholecys-
titis. A 2016 article published by Van Dijk and associates26 showed there to be no dif-
ference in reintervention rates between the 2 types: 32% in the fenestrating subtotal
cholecystectomy group and 26% in the reconstituting subtotal cholecystectomy
group (P 5 .211). However after 6 years follow-up (interquartile range, 5–10 years),
the recurrence rate of biliary events was lower after fenestrating than reconstituting
subtotal cholecystectomy (9% vs 18%, respectively; P<.022). Completion cholecys-
tectomy was performed significantly more in patients after fenestrating subtotal cho-
lecystectomy (9% vs 4%; P<.022).26 A 2017 study by Santos and colleagues27

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6 Buhavac et al

Fig. 1. Subtotal fenestrated cholecystectomy, reproduced with permission from Elsevier.46

suggests that the fenestrating subtype is preferred owing to the lower risk of biliary
stone formation and the chance for an even more difficult completion cholecystec-
tomy with a reconstituting type. In general, it seems to be a matter of technical ability
and preference whether one opts to do a fenestrating versus reconstituting subtotal
cholecystectomy. Complication profiles varies with reconstituting cholecystectomy
leading to recurrent stones and symptoms, and fenestration leads to increase risk
of bile leak. Matsui and colleagues28 showed that, by modifying the fenestration tech-
nique with a free omental patch, they could decrease the bile leak rate to 1% versus
44% in the no omental plug group. It is our practice to perform a laparoscopic fenes-
trated subtotal cholecystectomy and then suture a piece of pedicled omentum into the
gallbladder infundibulum to help obliterate the cystic duct opening and decrease our
risk of bile leak. We routinely leave drains to manage any bile leak that may result, and
in cases of persistent or high volume bile leak we use biliary stenting via endoscopic
retrograde cholangiopancreatography to decrease this duration. In general, drains can
be removed in clinic approximately 2 to 6 weeks after the procedure, with a few pa-
tients requiring longer periods to control drainage and develop a tract to prevent recur-
rent biloma. To encourage the formation of a defined fibrous tract around the drain, we
tend to use latex or rubber drains rather than the more common silicon drains.22

WHAT IS THE ROLE OF OPEN CHOLECYSTECTOMY?

Another important question that must be asked is whether there is even a role for open
cholecystectomy as a fallback option in the modern laparoscopic era, when resident

Fig. 2. Subtotal reconstituting cholecystectomy, reproduced with permission from Elsevier.46

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 The Bad Gallbladder 7

experience with open cholecystectomies is ever decreasing? A 2013 retrospective

analysis by McCoy and coworkers29 showed that resident experience with open cases
overall has decreased significantly in the past 12 years, with the average resident per-
forming only 10 open cholecystectomies. This trend is well-documented with regard to
open operations, because minimally invasive approaches become the norm.
The crucial question: has this decrease in operative experience affected the ability
of young surgeons to perform open cholecystectomy safely and effectively? Using a
cadaveric animal model, residents’ open versus laparoscopic skills were tested by
board-certified surgeons. Twenty-two percent of the trainees had no previous laparo-
scopic and 62% had no previous open cholecystectomy experience. Significant differ-
ences were found in the overall score (median difference of 1; 95% confidence
interval, 1–1; P<.001), gallbladder perforation rate (73% vs 29%, P<.001), safe dissec-
tion of Calot’s triangle (98% vs 90%; P 5 .001), and duration of surgery (42  13 mi-
nutes vs 26  10 minutes; mean differences, 17.22; 95% confidence interval, 15.37–
19.07; P<.001), all favoring open surgery.30 Therefore, it seems that even without
much clinical experience, residents were able to perform open cholecystectomy
safely. It could therefore be argued that, when absolutely necessary, open cholecys-
tectomy can be performed safely, even by the surgeons of tomorrow. Nonetheless,
given that these were cadaveric animal bench models that were unlikely to have se-
vere inflamed acute cholecystitis, these findings are perhaps more generalizable to
an incidental cholecystectomy for gallstone disease during an open abdominal oper-
ation, versus as a rescue procedure in a difficult bad gallbladder.
It is our practice to opt for open cholecystectomy in cases where there are dense
adhesions to the colon, duodenum, or other fragile structures that may be injured
by prolonged laparoscopic dissection and where the additional benefit of tactile feed-
back may be invaluable in avoiding iatrogenic injury. We also convert to open for any
case where there is a suspicion of cancer or for bleeding that cannot be quickly and
completely controlled laparoscopically. Open cholecystectomy remains an important
skillset for the general surgeon; however, we prefer to use it for the indications
mentioned elsewhere in this article, rather than as the default for severe inflammation.

WHEN SHOULD WE USE AN INTRAOPERATIVE CHOLANGIOGRAM?

The next question to address is the role of intraoperative cholangiogram (IOC).

Although it could be argued that IOC is not necessary for routine cases, there may
be some benefits in identifying unsuspected stones in the CBD. A study by Andrews
and colleagues31 found that in 1085 routine cholecystectomies, 2.3% had retained
stones, with a median stone size of 5 mm. In a smaller retrospective study looking
at 61 patients who underwent laparoscopic cholecystectomy without IOC, the median
time to presentation for a retained stone was 4 years after surgery.32 Therefore, it
could be argued that routine IOC may prevent missed CBD stones, albeit in a very
small (<5%) proportion of cases. This benefit has to be weighed against the additional
effort, time, cost, and radiation required to perform a routine IOC.
Apart from identifying stones, IOC is used to avoid or detect inadvertent common
bile duct injury. A study published by Flum and colleagues33 looking at the rate of com-
mon bile duct injury in laparoscopic cholecystectomy with IOC versus without IOC
showed that IOC significantly decreased the incidence of common bile duct injury
from 0.33% to 0.20%. Interestingly, as a surgeon uses IOC more, their rate of common
bile duct injury goes down. Comparing surgeons who performed IOC more than 75%
of the time versus those who did not, the rate of common bile duct injury was 1.6%
compared with 6.3%, respectively.33 A 2016 study by Zang and colleagues34 showed

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8 Buhavac et al

that selective magnetic resonance cholangiopancreatography can be used similar to

IOC when it comes to common bile duct stones and bile duct injuries. In their study,
patients randomized to having preoperative magnetic resonance cholangiopancrea-
tography had a 0.13% of bile duct injuries compared with 0.20% in the IOC group.
No patients with preoperative magnetic resonance cholangiopancreatography
returned in 1 year with symptomatic common bile duct stones.34 One study found
that, even after preoperative magnetic resonance cholangiopancreatography followed
by endoscopic retrograde cholangiopancreatography to remove stones before lapa-
roscopic cholecystectomy, IOC still helped to identify retained common bile duct
stones. The study reported that of 56 of the 405 patients who underwent preoperative
magnetic resonance cholangiopancreatography and endoscopic retrograde cholan-
giopancreatography with sphincterotomies for common bile duct stones, 7 patients
still had stones seen on IOC.35 All this being said, should one not use IOC, the rates
of bile duct injury and retained stones are still acceptably low with 1 study of more
than 1000 patients by Lill and colleagues36 showing bile duct injury rates of 0.5%
and retained stones of 0.9%.
At our institution, we perform selective IOC in cases where we have suspicion of a
common bile duct stone such as a persistently elevated total bilirubin, liver function
enzymes 3 times the upper limit of normal, presence of pancreatitis on computed to-
mography scans, lipase levels 3 times the upper limit of normal, and a dilated duct on
ultrasound imaging.
One interesting emerging technology that presents an alternative option is laparo-
scopic ultrasound. Support for this technique includes its speed of use (9.8 minutes
vs 17 minutes) compared with IOC, cost effectiveness, and the ease of its use.37 It
is also thought to be more specific than IOC and can even detect abnormalities
such as hemobilia, diverticulum, or polyps that would likely be missed or incorrectly
characterized by IOC.37
Another emerging technology is the use of indocyanine green (ICG), either laparos-
copically or robotically, to define biliary anatomy. In a study by Maker and Kunda,38
2.5 mg of ICG was given at intubation and the Da Vinci robot’s “firefly” was used to
toggle between near-infrared fluorescent cholangiography and bright light illumination
to determine the extrahepatic biliary anatomy. In 35 robotic cholecystectomies, pa-
tients tolerated ICG well without adverse effects, no biliary injuries occurred, and
cases were completed completely robotically.38 In another larger study of 184 robotic
cholecystectomies using ICG 45 minutes before the procedure, no biliary injuries were
seen nor were conversions to open or laparoscopic surgery.39 The cystic duct, the
common bile duct, and the common hepatic duct were successfully visualized with
ICG in 97.8%, 96.1%, and 94% of cases, respectively.39 The ability to quickly toggle
to and from near-infrared fluorescence as well as the minimal requirement for extra
preoperative and intraoperative preparation makes ICG an attractive option in robotic
cholecystectomies with a difficult anatomy.

MANAGEMENT OF COMMON BILE DUCT STONES DISCOVERED INTRAOPERATIVELY

Regardless of whether one performs selective or routine IOCs, every surgeon will at
some point be confronted with a common bile duct stone that is, discovered intraoper-
atively, because 10% to 15% of patient undergoing cholecystectomy for uncompli-
cated, symptomatic cholelithiasis will have choledocholithiasis. The management
algorithm will depend on the surgeon’s training and available amenities. Taking a sys-
tematic approach, we usually define the anatomy with a cholangiogram, then start
with flushing the duct with saline. The administration of 1 mg of intravenous glucagon

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 The Bad Gallbladder 9

can also help to relax the sphincter and allow the stones to be flushed into the
duodenum.
If this procedure is unsuccessful, the surgeon can either proceed with laparoscopic
common bile duct exploration, delayed endoscopic retrograde cholangiopancreatog-
raphy, or on-table endoscopic retrograde cholangiopancreatography. If the surgeon
decides to proceed with laparoscopic common bile duct exploration, a decision
must be made on the transcystic approach versus a choledochotomy. Number,
size, cystic duct anatomy, and the location of the stones are the most important fac-
tors when it comes to determining operative approach.40 As a general rule, small distal
stones are approached transcystically, whereas large proximal stones are
approached via a choledochotomy. Multiple stones, as long as they are distal and
less than 6 mm in size, can be approached transcystically. Stones larger than this
size, no matter the location, require a choledochotomy. A cystic duct size of greater
than 4 mm will also allow a transcystic approach.
Another important consideration is the diameter of the common bile duct. The
recommendation is that a common bile duct less than 7 mm should not be entered
because there is a risk for stricture upon closure of the choledochotomy.40 At our insti-
tution, if flushing maneuvers fail, we proceed with laparoscopic transcystic explora-
tion. Initially, we start with either fluoroscopic-guided basket retrieval or Fogarty
balloon catheters, 3F or 4F, which can be inflated and used to withdraw the stones
into the abdominal cavity. If there is concern that the stone is too large to pass
back through the cystic duct but small enough to pass through the ileocecal valve,
we push the stone through the sphincter of Oddi. This decision is also influenced by
the length, diameter, and friability of the cystic duct.
If we are unable to clear the duct in this fashion, we dilate the cystic duct with either
Maryland forceps or an 8F Fogarty/angioplasty catheter, place a guidewire, and then
place a 12F introducer sheath through which we can place our choledochoscope.
With the choledochoscope in place, a retrieval basket can be inserted under direct
vision and the stone removed. Much less commonly, when a stone is large, that is,
more than 6 to 8 mm, on preoperative imaging, the transcystic approach is not appro-
priate and we will plan to perform a choledochotomy, preferably using a robotic
approach owing to the better visualization and control.
Another approach is to perform a laparoendoscopic procedure. This process in-
cludes a cholecystectomy with IOC and intraoperative endoscopic retrograde cholan-
giopancreatography. A 2013 study by Liverani and colleagues41 looked at 108
patients who underwent this treatment plan versus 54 patients who had delayed endo-
scopic retrograde cholangiopancreatography (endoscopic retrograde cholangiopan-
creatography after cholecystectomy). Of the 108 patients who underwent
laparoscopic cholecystectomy, IOC and intraoperative–endoscopic retrograde cholan-
giopancreatography, 94 had successful removal of common bile duct stones without
need for conversion to open or choledochotomy, with the rate of postendoscopic retro-
grade cholangiopancreatography pancreatitis being lower than those who underwent
preoperative endoscopic retrograde cholangiopancreatography. Their stay was also
shorter compared with patients undergoing a delayed endoscopic retrograde cholan-
giopancreatography, with a mean hospital time of 4.7 days compared with
6.5 days.41 The mean operative time was 130 minutes in the one stage group and it
was 95 minutes in those who underwent endoscopic retrograde cholangiopancreatog-
raphy at a later time.41 A 2020 study published by Muhammedog  lu and Kale42 pre-
sented similar findings: shorter hospital stay, decreased cost, and less anesthesia
time with a single stage laparoscopic cholecystectomy plus endoscopic retrograde
cholangiopancreatography. In a meta-analysis of 629 patients across 5 randomized

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10 Buhavac et al

controlled trials, patients who underwent intraoperative endoscopic retrograde cholan-

giopancreatography after cholecystectomy had lower rates of endoscopic retrograde
cholangiopancreatography pancreatitis, shorter hospital stay, and lower morbidity
and mortality.43 Although the evidence points to this being an ideal approach to com-
mon bile duct stones discovered intraoperatively, it is not the only approach.
Other groups compared preoperative endoscopic retrograde cholangiopancreatog-
raphy plus laparoscopic cholecystectomy versus a laparoscopic cholecystectomy
plus laparoscopic common bile duct exploration. One study analyzed 12 randomized
controlled trials. The findings showed that those who underwent preoperative endo-
scopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy
versus a 1-stage laparoscopic cholecystectomy plus laparoscopic common bile
duct exploration had a higher rate of stone clearance, lower rate of bile leak, higher
rate of endoscopic retrograde cholangiopancreatography pancreatitis, and longer
hospital stay. Overall, the morbidity and mortality rates were the same.44 Another
meta-analysis of 11 trials showed similar results with laparoscopic common bile
duct exploration plus laparoscopic cholecystectomy being associated with a shorter
hospital stay and equivalent morbidity and mortality.45 As more surgeons become
comfortable performing laparoscopic common bile duct exploration, this approach
may become more common.

SUMMARY

The bad gallbladder remains one of the most common challenges a surgeon will face
over the course of their career. Cholecystectomy has enjoyed an evolution from open
to laparoscopic and now robotic. Several adjuncts such as IOC and intraoperative ul-
trasound examination have come along to help us make decisions in the operating
room and decrease the need for further procedures beyond the initial surgical inter-
vention. At the forefront of this process is our tireless pursuit of patient safety. We
know all too well the devastating consequences of bile duct injury from attempting
completion surgery in a heavily scarred field. At our institution it seems that the pro-
portion of bad gallbladders certainly outweighs the straightforward ones, especially
on the acute care surgery service. Therefore, it is essential that every surgeon and
graduating resident who plans to practice general surgery have a systematic
approach to the bad gallbladder, with a variety of options in their toolkit.

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