Cholecystectomy

Surgical approaches and exploration

The classic approach to the biliary organs is an incision made parallel to the costal margin. In surgical practice, Fedorov or Kocher approaches are used for this.

Any intervention begins with a thorough exploration. The surgeon inspects and palpates the gallbladder itself, the biliary tract, and assesses the condition of the portal vein and hepatic artery. If necessary, for better visualization, the peritoneum of the hepatoduodenal ligament (lig. hepatoduodenale) is incised.

Retrograde cholecystectomy (from the neck)

In this approach, isolation of structures begins from the neck of the gallbladder. This allows immediate control of blood supply and bile outflow.

Main stages:

1. Locating vessels and ducts. The surgeon spreads the connective tissue and finds the area where the cystic duct empties into the common bile duct (CBD). Above this area, the cystic artery (a. cystica) is located, which usually branches off from the right hepatic artery.
2. Ligation of the artery. The vessel is securely ligated with two silk threads and transected between them.
3. Managing the duct. The cystic duct is isolated before the gallbladder itself is removed. It is ligated near the neck, and a second (not yet tied) ligature is passed below. The duct is incised with scissors, and a thin polyethylene catheter or a special cannula is inserted into it, secured with the prepared thread.
4. Diagnostics. Intraoperative cholangiography (using a water-soluble contrast agent) is performed through the catheter, as well as debitometry or cholangiomanometry.
5. Removal. If no pathologies are identified, the catheter is removed. The duct is ligated with a silk thread and transected. The peritoneal incision is continued around the gallbladder, and the organ is enucleated from its bed by blunt and sharp dissection.

Antegrade cholecystectomy (from the fundus)

This method involves the mobilization and removal of the organ in the reverse direction—from top to bottom.

Execution Technique:

• Mobilization. The peritoneal fold covering the organ is incised from the fundus toward the neck. The peritoneum is gently pushed away bluntly using a Kocher probe or closed-blade scissors.
• Isolation. The fundus of the gallbladder is grasped with a fenestrated Luer forceps, pulled upward, and gradually separated from its bed.
• Management of the neck elements. After isolating the gallbladder, a. cystica is transected between two ligatures. A ligature is also applied to the cystic duct, below which it is opened to perform intraoperative cholangiography, after which the organ is finally removed.

Completion of the surgery and critical rules

Regardless of the chosen technique, the operation requires strict adherence to several topographical and anatomical rules:

• Stump length. When managing the cystic duct, the ligature must be applied strictly 0.5 cm away from its junction with the CBD. If the duct is ligated flush with the CBD, there is a high risk of narrowing its lumen. If an excessively long stump is left, it may eventually dilate and become a reservoir for the formation of new stones.
• Infection prevention. During antegrade dissection, one must act extremely carefully so as not to breach the lumen of the gallbladder, otherwise infected contents will enter the abdominal cavity.
• Peritonization and drainage. After thorough hemostasis, the gallbladder bed is covered. The leaves of the serosa over the bed and along the lig. hepatoduodenale are sutured with interrupted catgut sutures. In the antegrade method, the duct stump is buried into the incised ligament. According to indications, gauze packs and a rubber drain are placed near the bed and the epiploic foramen (Winslow's foramen). The anterior abdominal wall wound is closed.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Topography of the hepatoduodenal ligament (lig. hepatoduodenale)
• Technique of intraoperative cholangiography and debitometry
• Variations of the cystic artery origin (a. cystica)
• Methods of peritonization of the gallbladder bed
• Indications for drainage of the epiploic foramen

Other topics in the "Abdominal Surgery" section

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