CHAPTER 95 • Liver and Biliary System 1843

bile ducts. Closure of the gallbladder incision is performed in hepatic fossa. Encircling ligatures or monopolar or bipolar
a simple continuous inverting pattern with 2-0 to 4-0 mono- cautery can be used for occlusion of larger vessels or small bile
filament absorbable suture material, depending on the thick- ducts that might be encountered during gallbladder exposure.
ness of the gallbladder wall. Some hemorrhage is usually encountered during this dissec-
tion. In animals with severe gallbladder inflammation, necro-
Cholecystectomy sis, or rupture, adhesions to the liver or omentum may be
Traditional “Open” Cholecystectomy Demonstration extremely vascular. Dissection should be continued down the
of common bile duct patency by duct catheterization is rec- cystic duct to its junction with the common bile duct. Double
ommended in animals undergoing cholecystectomy because ligation of the cystic duct and artery should be performed
removal of the gallbladder rules out the possibility of a cho- with 0 or 2-0, nonabsorbable suture material. The duct is
lecystoenterostomy in cases in which extrahepatic biliary clamped and transected between the clamp and the ligatures,
tract decompression is found to be necessary. If performed and the gallbladder is removed. The stump is carefully
as part of management of a gallbladder mucocele, flushing inspected for any leakage of bile or residual hemorrhage, and
the common bile duct to ensure that all gelatinous bile is the area is thoroughly lavaged before closure. The gallbladder
removed from the common bile duct may reduce the risk for should be submitted for histopathologic examination, and the
persistent postoperative obstruction or cystic duct leakage gallbladder wall or bile should be submitted for aerobic and
after cholecystectomy. anaerobic bacterial culture and sensitivity.

Technique The gallbladder is usually dissected out of the Laparoscopic Cholecystectomy Current indications for
hepatic fossa before ligation of the cystic duct (Figure 95.11). laparoscopic cholecystectomy are for management of uncom-
In some patients, initial sharp transection of attachments plicated gallbladder mucocele and symptomatic cholelithiasis
between the gallbladder wall and liver capsule with scissors or cholecystitis not associated with extrahepatic biliary obstruc-
may be necessary to expose an appropriate plane for dissec- tion, gallbladder rupture, or choledocholithiasis.103,140,156,213a
tion. Using a combination of cotton-tipped applicators or the Because the common bile duct is not catheterized during the
single-port inner cannula of a Poole suction tip (outer cannula procedure, the approach should be used only when common
removed), the gallbladder is bluntly dissected out of the bile duct patency is ensured.

Technique The dog is placed in dorsal recumbency. A

four-port technique is used, including a subumbilical camera
port (10 mm) and three instrument ports (5 mm): one placed
5 to 8 cm lateral and 3 to 5 cm cranial to the umbilicus on
the left side and two located 3 to 5 cm and 5 to 8 cm lateral
to the umbilicus on the right side. Laparoscopic cholecystec-
tomy can also be performed through a single-port device
placed at the umbilicus; recently a small number of clinical
cases were described using this technique.156 In some of these
cases one extra port was used, in addition to the single-port
device, to facilitate the technique.
Cranial retraction of the gallbladder is achieved with a
5-mm fan retractor placed through the left-sided port to
elevate the gallbladder so that the cystic duct is visible. Five-
or 10-mm right-angle dissecting forceps are used to dissect
around the cystic duct. A variety of techniques can be used
to achieve cystic duct and artery ligation, including intra-
corporeal suturing, vessel sealing devices, hemostatic clips,
A or extracorporeally tied knots. Two or three extracorporeally
tied modified Roeder knots of 0 or 2-0 polydioxanone or
nonabsorbable monofilament suture can be placed around the
cystic duct. If the cystic duct is of normal size and thickness,
medium or large hemostatic clips may be used for cystic duct
ligation alone. Sharp sectioning of the cystic duct between
sutures or clips is then performed, ideally leaving two liga-
tures or clips in place around the cystic duct. Once the cystic
duct and artery have been sectioned, it is also possible to
augment the cystic duct ligation using a loop ligature placed
around the cystic duct stump. A recent investigation in a
cadaveric model evaluated the use of a vessel sealing device,
in comparison to various-sized Endo Clips, to seal the cystic
duct of dogs.137 Although the vessel sealing device appeared
to provide a seal comparable to that of large Endo Clips,
in vivo and long-term efficacy is unknown. Therefore this
B technique in isolation should be used with caution in clinical
patients with mucoceles until further in vivo studies have been
Figure 95.11 Cholecystectomy. A, Hepatic parenchyma is dis- performed.137
sected bluntly from the gallbladder wall; vessels entering the Once ligation and sectioning of the cystic duct is complete,
gallbladder capsule are sealed with bipolar cautery or hemoclips. the gallbladder is dissected out of its fossa with the aid of
B, The cystic duct (black arrowhead) and cystic artery (white a vessel sealing device. After it has been dissected free, the
arrow) are exposed and double ligated collectively. (Courtesy Dr. gallbladder is placed into a specimen retrieval bag passed
Karen M. Tobias, University of Tennessee, Knoxville, TN.) through the subumbilical port. The retrieval bag is partially
1844 SECTION VII • Digestive System

retracted through the camera portal, and tension is created

by lifting the bag upward until a small area of the gallbladder
can be directly visualized (while still in the bag) through the
small 10-mm subumbilical port incision. The gallbladder is
carefully punctured with the tip of a scalpel blade, and bile
is suctioned from within the bag using a suction device. After
bile has been suctioned, the now empty gallbladder can be
removed from the abdomen. Thorough abdominal lavage of
the gallbladder fossa is performed, followed by aspiration of
fluid. The gallbladder should be submitted for histopatho-
logic examination, and the gallbladder wall or bile should
be submitted for aerobic and anaerobic bacterial culture and
sensitivity.

Cholecystoenterostomy
Cholecystoduodenostomy and cholecystojejunostomy are the
most common techniques used to reroute the biliary system
in dogs and cats because the common bile duct is usually too
small and friable to permit choledochoduodenostomy. Physi-
ologically, a cholecystoduodenostomy should be chosen,
assuming the gallbladder can be brought into a position adja-
cent to the proximal duodenum without excessive tension on
or twisting of the cystic duct or the proposed anastomosis. If
this is anatomically impossible, the anastomosis can be made
to the proximal jejunum, which is generally more mobile. The
significance of allowing bile to continue to be secreted into
the duodenum, as occurs in a cholecystoduodenostomy, relates
to the physiologic control of gastric acid secretion. In dogs,
diversion of bile from the duodenum can lead to duodenal
ulceration.97 Normally, presence of bile in the duodenum
inhibits gastric acid secretion through a hormonal mechanism; A
if this inhibitory feedback is lost, gastric acid oversecretion and
subsequent ulceration may occur.179

Technique The gallbladder must first be mobilized from

the hepatic fossa by blunt dissection with Metzenbaum scis-
sors, cotton-tipped applicators, or the inner cannula of a
Poole suction tip. Care must be taken to avoid twisting of the
cystic duct or damage to the cystic artery during gallbladder
manipulation. Any bleeding from the hepatic parenchyma can
be controlled by application of a sheet of oxidized cellulose
hemostatic agent (Surgicel) to the area.
For a cholecystoduodenostomy the mobilized gallbladder
is positioned adjacent to the antimesenteric border of the
duodenum. The duodenocolic ligament can be transected to
increase duodenal mobility. An incision is created through the
long axis of the gallbladder, and bile is removed with suction.
A duodenotomy of similar dimension is created; if a duode-
notomy has already been created over the site of the major B
duodenal papilla for common bile duct flushing, that same
incision in the duodenum can usually be used for anastomosis. Figure 95.12 Cholecystoenterostomy. A, A cholecystoduode-
For cholecystojejunostomy a loop of proximal jejunum is nostomy has been performed to alleviate extrahepatic biliary tract
aligned alongside the gallbladder lumen, and incisions of obstruction in this cat. B, The edges of the gallbladder and duo-
similar lengths are created. The far and near walls of the two denum are apposed with a simple continuous suture pattern along
incisions are sutured with 3-0 or 4-0 monofilament absorbable each side of the incision. (B from Fossum TW, editor: Small animal
material in a separate simple continuous pattern on each side surgery, ed 3, St Louis, 2007, Mosby/Elsevier.)
(Figure 95.12). An additional simple interrupted suture can
be added to pexy the gallbladder to the duodenum at each
end of the anastomosis. Some authors recommend a two-layer
closure, although this tends to narrow the lumen further, 30-mm Endo GIA device (Medtronic) has been described for
which is not desirable. All techniques will likely result in some this purpose and was associated with few complications.158
narrowing of the stoma site in time, although mucosal apposi- After the Endo GIA stapler was fired to create the anastomo-
tion has been shown to result in relatively little stoma nar- ses, the remaining connection between the duodenum and
rowing.232 The stoma should be created as long as possible gallbladder lumen was closed with simple interrupted sutures.
because a small stoma (<2.5 cm) may predispose to obstruc- A tension-relieving suture was placed at the oral end of the
tion from stricture formation, resulting in the retention of staple line to reduce tension in that area.158
intestinal chyme within the gallbladder and subsequent Possible complications associated with cholecystoduodenos-
ascending cholangiohepatitis.91,138,232 The anastomosis can also tomy include hemorrhage, incisional dehiscence, stricture of the
be completed with surgical stapling devices. The use of a stoma, ascending cholangitis, and gastric ulceration.29,138,139,158,178