CHAPTER 36
Cholecystectomy techniques and
postoperative problems
Morgan Bonds and Flavio Rocha
OVERVIEW
Cholecystectomy is one of the most frequently performed gen-
eral surgery procedures in the United States (US) with over
500,000 being performed annually.1 There are many reasons
for this, including the frequency of gallbladder disease and in-
dications for intervention in the US population. The advent of
laparoscopic cholecystectomy in the 1980s also resulted in a
rapid rise in the number of cholecystectomies because of the
reduced postoperative recovery, reduced pain, and ability to
complete the procedure in the outpatient setting.2,3 As familiar-
ity with laparoscopy has increased, the incidence of open cho-
lecystectomy has steadily decreased. This chapter will address
techniques of open cholecystectomy because this approach is
still used when laparoscopy is contraindicated or technically
impossible. Appropriate laparoscopic cholecystectomy tech-
niques will also be discussed, including strategies to prevent
common bile duct injuries (CBDI), which are an avoidable
source of severe morbidity with this procedure. Alternative
minimally invasive approaches and common complications will
also be addressed.
INDICATIONS
Symptomatic gallstones are the primary reason a patient re-
quires cholecystectomy (see Chapters 33 and 34). In the US,
approximately 5% to 22% of the population has cholelithiasis.4
Cholelithiasis can lead to several pathologic conditions includ-
ing biliary colic, acute cholecystitis, gallstone pancreatitis, or
choledocholithiasis, but the majority of patients with choleli-
thiasis will remain asymptomatic (see Chapter 33). As such,
prophylactic cholecystectomy in asymptomatic patients is typ-
ically not warranted. Nevertheless, cholecystectomy may be
indicated for certain populations with asymptomatic choleli-
thiasis. An example is sickle cell anemia where hepatic and
vaso-occlusive disease can be indistinguishable from acute
cholecystitis.5
Gallbladder polyps without cholelithiasis can be an indica-
tion for cholecystectomy (see Chapter 49). Resection is recom-
mended for gallbladder polyps greater than or equal to 10 mm
and in patients with biliary symptoms in the setting of gallblad-
der polyps of any size.6 Cholecystectomy is also often performed
concomitantly with other procedures. Examples include pancre-
aticoduodenectomy and major anatomic liver resections. Chole-
cystectomy at the time of bariatric surgery is controversial. It is
thought that biliary symptoms increase after extreme weight
loss. Nevertheless, a systematic review and meta-analysis re-
ported that concomitant cholecystectomy increases postopera-
tive morbidity and operative time7 (see Chapter 34).
Timing of cholecystectomy can vary by indication. Acute
cholecystitis cases should proceed to the operating room as
494
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early as possible. A recent study using a Swedish registry found
that adverse events, mortality, and CBDIs were higher in pa-
tients who underwent cholecystectomy more than 4 days after
admission.8 These data suggest the optimal timing for cholecys-
tectomy is within 48 hours of admission for acute cholecystitis.
LAPAROSCOPIC CHOLECYSTECTOMY
TECHNIQUES
Laparoscopy has become the standard access for removing the
gallbladder. Multiple studies have shown a decrease in postop-
erative pain, an earlier return to normal activity, a decrease in
hospital length of stay (LOS), and a reduction in incisional
hernia development for laparoscopic cholecystectomy when
compared with open cholecystectomy.9–12 Familiarity with the
anatomy of the porta hepatis, including common biliary and
vascular variations, can reduce complication rates for both
laparoscopic and open cholecystectomy, particularly for chal-
lenging cases presenting with significant inflammation.
Operating Room Setup
Before beginning any procedure, the surgeon must ensure that
all equipment is present and functional, which includes equip-
ment for potentially necessary procedures such as cholangiog-
raphy or need for conversion to laparotomy (Box 36.1).
Port Placement and Exposure
Once pneumoperitoneum is obtained, a 5- or 10-mm port is
placed in the periumbilical region. A 30-degree laparoscope is
inserted, and the abdominal cavity is inspected. One 5-mm
trocar is placed along the right anterior axillary line 2 centi-
meters below the costal margin. The other 5-mm port is
placed at the midclavicular line on the right at the edge of the
liver. A fourth port (5- or 10-mm) is placed in the subxiphoid
region and should be placed 2 to 4 centimeters below the
xiphoid depending on the location of the gallbladder and fal-
ciform ligament (Fig. 36.1). A fifth port can be placed in the
location deemed most appropriate for additional retraction, if
necessary.
Dissection and Critical View of Safety
An atraumatic grasper is placed through the most lateral port
and grasps the fundus of the gallbladder to retract it cephalad
and laterally. This raises the liver edge and exposes the neck of
the gallbladder and the porta. With the gallbladder retracted
cephalad, a second atraumatic grasper is placed through the
midclavicular port to manipulate the infundibulum of the gall-
bladder. Adhesions should be taken down until the gallbladder
infundibulum can be seen. Retraction of the infundibulum
caudally and to the right exposes the triangle of Calot. A cau-
tery instrument placed through the xiphoid port opens the
 A. Gallstones and Gallbladder Chapter 36 Cholecystectomy Techniques and Postoperative Problems 495

Attention is next turned to obtaining the critical view of

BOX 36.1 Equipment for Laparoscopic Cholecystectomy
safety (CVS).13 This technique has been shown to reduce the
Laparoscopic Viewing Equipment rates of iatrogenic bile duct injuries14 (see Chapters 32 and 42).
• Camera light source In fact, a recent multisociety consensus statement recom-
• Laparoscope (5-mm and 10 mm, 30 degree) mended CVS for identification of the cystic duct and cystic
• Monitors (one over each shoulder) artery during laparoscopic cholecystectomy, and when CVS
• Insufflator and tubing
was not attainable, a subtotal cholecystectomy should be per-
• Trocars (multiple 5-mm trocars and at least one 10-mm)
formed rather than attempting a fundus-first approach15 (see
Instruments for Dissection and Removal of Gallbladder Chapter 34).
• Clips (5-mm and 10-mm variety) Attachments at the neck of the gallbladder are dissected us-
• Electrocautery ing a combination of blunt and cautery assisted dissection. It is
• Suction useful to serially retract the infundibulum medially and laterally
• Irrigation to fully dissect the triangle of Calot. Carrying dissection to the
• Atraumatic graspers level of the common bile duct (CBD) is not indicated because
• Maryland grasper (or laparoscopic right angle grasper) this only increases the risk for iatrogenic injury. Blunt dissec-
• Endoscopic retrieval bag tion with a Maryland grasper or right-angle grasper can help
create a window behind the cystic duct by spreading in the
Instruments for Unusual Circumstances
• Endoloop
avascular tissue. The gallbladder is dissected off the liver edge,
• Laparoscopic needle driver exposing the cystic plate. The criteria for CVS have been met
• Absorbable hemostatic agent when (1) there are only two structures seen entering the gall-
• Staplers bladder, the cystic duct and cystic artery; (2) the lower third of
• Argon laser the cystic plate is exposed; and (3) tissue has been cleared from
• Cholangiography equipment (catheter, injectable contrast, c-arm the hepatocystic triangle so that all structures can be clearly
for fluoroscopy) identified anteriorly and posteriorly (Box 36.2).16 These views
• Open cholecystectomy tray and instruments are demonstrated in Fig. 36.3. If any question or doubt about
the anatomy is encountered, a cholangiogram should be per-
formed to reorient the surgeon (see Chapter 24).
peritoneum in the triangle of Calot (Fig. 36.2). This should be Most surgeons attempt the CVS during laparoscopic chole-
started at the edge of the gallbladder neck to avoid iatrogenic cystectomy, but in practice it is rarely achieved. An evaluation
injury to aberrant hepatic vasculature or bile ducts. Dissection of 160 online videos of laparoscopic cholecystectomy found
of the peritoneum is continued on both sides of the gallbladder only one video accomplished a passing CVS score.17 The safe
1 to 2 mm from the liver edge. cholecystectomy curriculum can be found free of charge at the

Gallbladder Laparoscope
Liver

A
A B
FIGURE 36.1 Positions for insertion of trocars during laparoscopic cholecystectomy. The laparoscope (A) is positioned in the periumbilical region,
the graspers for gallbladder retraction (B) and manipulation (C) are positioned in the right upper quadrant (RUQ) along the subcostal region, and the
subxyphoid region (D) is used for the dissector, diathermy, and clip appliers.

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496 PART 5 BILIARY TRACT DISEASE SECTION I Inflammatory, Infective, and Congenital
A. Triangle of
cholecystectomy
B. Triangle of
Calot
FIGURE 36.2 A, Triangle of cholecystectomy limited by the common
hepatic duct, right hepatic duct, cystic duct, and inferior liver edge.
B, The triangle of Calot limited by the common hepatic duct, cystic duct,
and cystic artery.
BOX 36.2 Doublet Scoring for Critical View of Safety
Criteria for Achieving Critical View of Safety
Two structures connected to gallbladder:
• Only two structures clearly seen entering the gallbladder.
Cystic plate:
• Approximately 1/3 of cystic plate is clearly visible.
Clearance of hepatocystic triangle:
• Hepatocystic triangle is cleared of tissue so visibility of cystic
structures and plate is unimpeded and the surgeon is certain no
other structures are in the hepatocystic triangle.
Society of American Gastrointestinal and Endoscopic Surgeons
(SAGES) website.18
Completion of Cholecystectomy
Once all critical anatomy is confirmed, the cystic artery and
duct are clipped and divided. Care should be taken to avoid
Anterior view
FIGURE 36.3 A, Critical view. Hepatocystic triangle is dissected free of all tissue except for the cystic duct and artery, and one-third of the cystic
plate on the liver bed is exposed. When this view is achieved, the two structures entering the gallbladder can only be the cystic duct and artery.
B, Critical view of safety during laparoscopic cholecystectomy.
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tenting the CBD with clips placed too distally on the cystic
duct. The tips of the clip should be directly visualized to be free
before closing to avoid inadvertent injury to other structures
and ensure the clip completely occludes the artery or duct. If it
is not possible to secure a clip completely across a structure, an
Endoloop device can be used to ligate it. Scissors are used to
divide the cystic artery and duct. In rare cases with a large in-
flamed cystic duct that cannot accommodate clips, endovascu-
lar staplers can be used to divide and secure the duct. These
situations, however, should raise the level of concern regarding
possible injury to the CBD, and the surgeon should consider
intraoperative cholangiography if there is any concern whatso-
ever regarding the anatomy. Cautery is avoided for division
because of the increased risk for necrosis resulting in clip slip-
page. The gallbladder is dissected off the cystic plate from the
infundibulum to the fundus with electrocautery. Blindly placing
clips, clamps, or cauterizing at this time risks causing hemor-
rhage or inadvertent injury to the hepatic blood supply, super-
ficial biliary pedicles, or middle hepatic vein branches and
should be avoided (Fig. 36.4). Before completely freeing the
gallbladder from the liver, the gallbladder is used for retraction
to inspect the cystic plate for hemostasis and inspect that clips
are still securely placed on the cystic duct and artery.
Specimen removal is performed through the periumbilical
incision because it is easy to enlarge this incision to extract
large gallstones. Bag extraction is performed with videoscopic
visualization to ensure the bag does not rip and specimen con-
tents are not lost. Spilled bile or debris should be completely
irrigated and cleared with suction to prevent subsequent migra-
tion or abscess formation. The fascia of port sites greater than
10 mm are closed to prevent development of incisional hernias
although some surgeons elect not to close the epigastric site
because herniation is unlikely in that location.
Three-Port and Two-Port Techniques
Attempts to improve on the traditional four-port laparoscopic
cholecystectomy by decreasing the number of port sites have
been introduced. The series reporting these techniques are
small but suggest that these techniques are feasible and safe.
Proponents cite the reduced cost related to fewer trocars, fewer
scars, and reduced cost.19,20 Typically, the right upper quadrant
ports are eliminated by using suture to retract the gallbladder
Posterior view
 A. Gallstones and Gallbladder Chapter 36 Cholecystectomy Techniques and Postoperative Problems
FIGURE 36.4 Blind placement of clips or clamps for hemostasis can
result in injury to the hepatic artery or bile duct.
in their stead.21 A small randomized controlled trial (RCT)
with 217 patients compared four-port with three-port cholecys-
tectomy and found no difference in length of operation or
morbidity, including iatrogenic bile duct injuries; however,
there was also no difference in pain medication required be-
tween groups.22 Currently, there are no obvious advantages that
these techniques offer over the four-port technique.
Single-Incision Laparoscopic Cholecystectomy
Single-incision laparoscopic cholecystectomy (SILC) is the
extreme attempt at reducing the number of ports for laparo-
scopic cholecystectomy. SILC is performed through a single
transabdominal incision, usually at the umbilicus. There are
specifically designed single-port systems and instruments avail-
able that have been approved by the US Food and Drug Ad-
ministration (FDA).
Several RCTs comparing SILC with standard laparoscopic
cholecystectomy have been performed, although most are
hampered by low accrual. A 2017 trial from Egypt enrolled
187 patients. SILC had a statistically significant longer operat-
ing time and conversion rate compared with three-port laparo-
scopic cholecystectomy; the only advantage to SILC in this
study was the aesthetic score.23 In addition to the absence of
benefit to the patient, SILC induces significantly more stress
on the surgeon. A double-blind RCT measured surgeon heart
rate and salivary cortisol before being randomized to either
SILC or traditional laparoscopic cholecystectomy, after clip-
ping the cystic duct and while closing skin. SILC was associ-
ated with higher heart rates and cortisol levels. Surgeons also
reported the surgical workload was more demanding with
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497
SILC.24 Careful patient selection is necessary to optimize the
use of this technique. It is critical to understand that the CVS
should be obtained regardless of the number of laparoscopic
ports used to reduce the risk of vasculobiliary injury during
minimally invasive cholecystectomy.
Robotic-Assisted Laparoscopic Cholecystectomy
The use of robotic assisted laparoscopic surgery has signifi-
cantly increased in recent years. This upswing in robotic sur-
gery is because of a combination of aggressive marketing re-
sulting in patient demand. This platform is attractive to
surgeons as well because it offers the benefits of 3-dimen-
sional (3D) visualization, improved ergonomics, and an easier
learning curve compared with laparoscopy. Robotic laparo-
scopic cholecystectomy has been proposed as an ideal tool to
improve skill and confidence using the robotic platform25 (see
Chapter 127A).
Despite similar outcomes, robotic surgery is associated with
significantly higher costs than laparoscopy. The upfront cost of
purchasing a robotic console is approximately 2 million dollars.
In addition, there is the cost of maintenance and replacement
of disposable instruments. A single institution analysis reported
lower readmission rates with robotic cholecystectomy in pro-
pensity matched patients, but the overall hospital costs and
operative time were significantly larger.26 These cost discrepan-
cies must be considered when deciding on the optimal mini-
mally invasive approach to cholecystectomy.
CONTRAINDICATIONS
Contraindications to this procedure are divided into two cate-
gories: (1) contraindications to cholecystectomy and (2) con-
traindications to laparoscopy. Absolute contraindications to
operative cholecystectomy include refractory coagulopathy and
intolerance of general anesthesia (see Chapter 35). The 2018
Tokyo Guidelines do not discourage cholecystectomy for pa-
tients with severe sepsis and end-organ failure (Grade III cho-
lecystitis) if supportive care is available and the operating sur-
geon feels the patient can withstand the procedure.27
Relative contraindications include severe cardiopulmonary
disease, pregnancy, and cirrhosis with portal hypertension,
but ultimately the decision is made based on clinical judgment
(see Chapter 75). The presence of cirrhosis can complicate
many abdominal surgical interventions. Laparoscopic chole-
cystectomy in cirrhotic patients is especially challenging be-
cause it can be difficult to retract the stiff, friable liver and
avoid the potential for bleeding from the associated coagu-
lopathy. Outcomes between Childs-Pugh A/B cirrhotic pa-
tients undergoing laparoscopic cholecystectomy and those
with normal liver function are similar with the exception that
operative times are longer and there is a trend towards in-
creased rates of conversion to open cholecystectomy28 in the
former. Laparoscopic cholecystectomy is also feasible in cir-
rhotics with portal hypertension.29 When performing laparo-
scopic cholecystectomy in a cirrhotic patient, the surgeon
must be aware of aberrant portosystemic venous collateraliza-
tion in the liver bed, porta hepatis, and abdominal wall. It is
recommended that an energy-sealing device be available to
limit blood loss during dissection. Hemostatic agents and ar-
gon beam should be readily available to assist with hemostasis.
The procedure should be converted to an open procedure for
significant bleeding.
498 PART 5 BILIARY TRACT DISEASE SECTION I Inflammatory, Infective, and Congenital
CONVERSION TO OPEN
Although laparoscopy is the preferred approach for cholecys-
tectomy, there are many situations that may necessitate conver-
sion to open procedure. The decision and timing of intraopera-
tive conversion to laparotomy depends on the surgeon’s
experience, comfort with laparoscopic and open techniques,
and patient factors (anatomy and pathology). There is no con-
sensus on when conversion is necessary as long as patient safety
is the ultimate priority. Contemporary conversion rates are re-
ported to be between 5% to 15%.30,31
Reasons to consider conversion include unclear anatomy
despite cholangiography, intraoperative complication, failure to
progress, and pathology not amenable to laparoscopic or post-
operative endoscopic techniques. Independent factors associ-
ated with conversion to open cholecystectomy include prior
upper abdominal surgery, pericholecystic fluid, acute cholecys-
titis, and emergent cholecystectomy.32 Conversion has been
described as a “complication” of laparoscopy by some; how-
ever, this view is untenable and conversion should be regarded
as mature judgment because it can prevent disastrous compli-
cations in challenging cases.
OPEN TECHNIQUE
Incision
The traditional incision used for an open cholecystectomy is
a right subcostal or Kocher incision. This incision is created
2 centimeters below the right costal margin and extends from
the midline to the lateral edge of the right rectus muscle. This
incision can be extended superiorly along the midline if further
exposure is needed.
Dissection
Retrograde Cholecystectomy
When performing a retrograde cholecystectomy, the critical
view of safety must be identified before removing the gallblad-
der from the liver. Although this is the usual approach during
laparoscopic cholecystectomy, it can be more difficult for an
unexperienced surgeon without the magnification of laparos-
copy and difference in exposure. The same principles must be
maintained to prevent inadvertent biliary injury.
The fundus of the gallbladder is grasped with a Kelly or
similar clamp. Peritoneum overlying the infundibulum is in-
cised. The incision is extended along the anterior and posterior
gallbladder, being careful to stay close to the edge of the gall-
bladder. Once the cystic duct is identified, a suture ligature is
passed around it and used to place tension on the duct for bet-
ter exposure and to prevent stone migration into the CBD. The
CVS has been achieved once all fibroadipose tissue is cleared
from the hepatocystic triangle, only two structures are seen
clearly entering the gallbladder, and a third of the cystic plate
is seen (see Box 36.2). Any stones palpated within the cystic
duct are “milked” back into the gallbladder. The cystic artery
can be ligated with either clips or sutures then divided. If chol-
angiography is indicated, it is performed at this time. Ligation
and division of the cystic duct occurs next.
To complete the retrograde cholecystectomy, the gallbladder
is dissected off the cystic plate using cautery. The dissection
plane is kept close to the gallbladder to avoid entering the cystic
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plate and deeper liver parenchyma. Brisk bleeding from liver
parenchyma lacerations tend to be venous in nature because
distal branches of the middle hepatic vein can be located im-
mediately deep to the cystic plate (see Chapter 2). These can
usually be treated by holding constant pressure over the area for
5 to 10 minutes. Hemostatic agents may be beneficial in these
instances as well. If these techniques fail, deep hemostatic su-
tures can be placed. Nevertheless, one must be aware of the
location of the right portal pedicle and its anterior branch,
which can be close to the base of the gallbladder fossa.
Antegrade, or Fundus-Down Cholecystectomy
Antegrade cholecystectomy is an alternate technique for chole-
cystectomy, but this technique should not be used in the pres-
ence of severe inflammation that obstructs visualization of the
cystic duct. As with the fundus-down laparoscopic technique,
there is still significant risk of biliary injury in these cases with-
out proper visualization of the cystic duct and artery.
A clamp is used to grasp the fundus of the gallbladder; an-
other clamp is used to grasp the peritoneum on the liver edge
to provide countertraction. An incision is made in the gallblad-
der serosa approximately 5 millimeters from the liver edge with
cautery. A dissection plane is developed between the superior
gallbladder wall and the cystic plate. Again, care is taken to
avoid entering the cystic plate and lacerating the liver paren-
chyma. This plane is continued medially and laterally toward
the gallbladder neck. An energy-sealing device can be used on
edematous or vascularized peritoneum. Dissection is per-
formed posterior and lateral to fully free the gallbladder from
the cystic plate. This best exposes the cystic artery and duct.
The cystic artery is ligated and transected as it enters the gall-
bladder wall. The infundibulum is dissected free to expose the
cystic duct. One should not dissect more than 1 centimeter of
the cystic duct because this increases risk of CBDI. Once the
cystic duct is visualized, it can be ligated with suture or clips
and divided. The gallbladder is removed, and the abdomen is
closed.
PARTIAL OR SUBTOTAL CHOLECYSTECTOMY
Subtotal cholecystectomy is the recommended technique for
treating severely inflamed gallbladders when the CVS cannot
be safely obtained16 (see Chapter 34). Fibrosis and inflamma-
tion can cause the cystic duct to shorten and fuse with the
CBD; this can lead to the surgeon mistaking the CBD for the
cystic duct (Fig. 36.5). In these cases, it is best to err on the side
of caution and avoid dissecting in the hepatocystic triangle.
Cholecystitis can be managed safely until inflammation has
subsided, but CBDIs have significant long-term morbidity. In
these cases, a partial or subtotal cholecystectomy, in which a
portion of the gallbladder is removed and gallstones are ex-
tracted while leaving the posterior wall of the gallbladder in
place, is the procedure of choice for source control and surgical
management.
This technique can be used either open or laparoscopically,
and the technique is similar for both. To perform a safe subtotal
cholecystectomy, all dissection should be performed above the
“the line of safety,” which runs between the sulcus of Rouvi-
ere.33 These landmarks are seen in Fig. 36.6. The gallbladder is
drained and opened with cautery at the fundus. Bile, stones,
and debris are suctioned or set aside for future extraction in
a specimen bag in a laparoscopic approach. This incision is
 A. Gallstones and Gallbladder Chapter 36 Cholecystectomy Techniques and Postoperative Problems
FIGURE 36.5 The common hepatic duct can be mistaken for the
cystic duct when the region of the infundibulum cannot be delineated
because of fibrosis and inflammation.
Line of safety
Hilar plate
Sulcus of rouviere
FIGURE 36.6 The limit of proximal dissection for subtotal cholecystec-
tomy is the “line of safety” between the sulcus of Rouviere and hilar
plate. The ensures dissection occurs away from the common bile duct
in the setting of severe inflammation. (From Purzner RH, Ho KB,
Al-Sukhni E, Jayaraman S. Safe laparoscopic subtotal cholecystectomy
in the face of severe inflammation in the cystohepatic triangle: A retro-
spective review and proposed management strategy for the difficult
gallbladder. J Can Chir. 2019;62:402–411.)
extended to the gallbladder neck without dissecting the cystic
duct or artery. The anterior wall of the gallbladder is then com-
pletely removed, and the posterior wall is left on the cystic plate
(Fig. 36.7). The remnant mucosa is then coagulated with either
cautery or argon beam. A drain should be placed near the gall-
bladder stump to drain potential bile collection.
Subtotal cholecystectomies, both open and laparoscopic, are
being performed more frequently, and conversion to open pro-
cedure is becoming less common.34 As one may expect, there is
a higher risk of bile leaks and subphrenic collection with subto-
tal cholecystectomy compared with standard cholecystectomy.
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499
B
FIGURE 36.7 A–B, Laparoscopic subtotal cholecystectomy and open
subtotal cholecystectomy demonstrating the anterior wall excised and a
small strip of the posterior wall left attached to the liver. The remnant
mucosa can then be either removed or coagulated with cautery or argon
laser.
One study found the relative risk of bile leak after subtotal cho-
lecystectomy was as high as 3-fold; these were more common if
the gallbladder remnant was left open.33
ANATOMIC VARIATIONS
An intimate knowledge of gallbladder and biliary anatomy, as
well as common variations, is essential to perform a safe chole-
cystectomy (see Chapter 2). Variations in gallbladder anatomy
such as duplicated, left-sided, bilobed, or congenitally absent
gallbladder are rare, and they are typically identified preopera-
tively. As such, this section will focus on relevant biliary anatomy
and variations that can potentially lead to inadvertent injury (see
Chapter 42).
Significant variations of the cystic duct and hepatic duct
junction exist (Fig. 36.8; see Chapter 2). The common hepatic
duct can range in length from 1 to 7.5 centimeters. A large series
of magnetic resonance cholangiopancreatographies demon-
strated that 40.7% of patients had some variant in biliary tree
anatomy. In this study, 5% of subjects had medial cystic duct
insertion.35 Anomalous extrahepatic bile ducts occur in up to
12% of patients, with the most common being an anomalous
right sectoral duct that empties into either the common hepatic
or cystic duct.36 Fig. 36.9 demonstrates common anatomic bili-
ary variation of the right sectoral ducts. When these variations
occur, they often represent the only biliary drainage for the cor-
responding segment(s) of the liver. Thus injury or obstruction of
these ducts results in liver atrophy or obstructive cholangitis in
that segment. It should be noted that true duplication of the
500 PART 5 BILIARY TRACT DISEASE SECTION I Inflammatory, Infective, and Congenital

A B
FIGURE 36.8 A, Variations in the confluence of the cystic duct and common hepatic duct. B, High insertion of the cystic duct demonstrated on
endoscopic retrograde cholangiopancreatography.

B
A
FIGURE 36.9 A, Variations in the confluence of the extrahepatic bile ducts and cystic duct. B, Cholangiogram demonstrating a cystic duct inserting
into the right anterior section bile duct.

cystic duct is exceedingly rare, and cholangiography should be POSTOPERATIVE MANAGEMENT

performed if the surgeon believes such an anomaly has been
encountered (see Chapter 24).
Arterial anatomic variations are also common and can con-
tribute to morbidity after cholecystectomy (see Chapter 2).
Typically, the cystic artery originates from the right hepatic
artery (76%) but may also branch off the left, common, or
proper hepatic arteries.37 Arterial injury may accompany a bile
duct injury resulting in a combined vasculobiliary injury. The
right hepatic artery is involved in 92% of these injuries because
of its proximity to the CBD and can significantly add to the
difficulty of bile duct repair38 (see Chapter 42).
Most patients undergoing elective laparoscopic cholecystectomy
are discharged the same day because of the decreased pain pro-
file associated with this minimally invasive technique. A patient
admitted with acute cholecystitis is often observed in the hospi-
tal overnight postoperatively because of infectious concerns.
Elderly patients, comorbid patients, patients requiring signifi-
cant analgesia postoperatively, and patients with complicated
procedures may also benefit from postoperative admission. The
patient is allowed a diet shortly after surgery. Oral narcotics for
postoperative incisional pain can be prescribed for pain control,

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 A. Gallstones and Gallbladder Chapter 36 Cholecystectomy Techniques and Postoperative Problems
but many patients recover with only over-the-counter pain
medications, including nonsteroidal antiinflammatories and ac-
etaminophen. Routine follow-up by the surgeon in clinic can
occur between 1 and 4 weeks after surgery.
IMMEDIATE POSTOPERATIVE COMPLICATIONS
Biliary Injury
Biliary injury remains the most feared complication of cholecys-
tectomy (see Chapters 28 and 34). It has been shown that bile
duct injuries have a 30-day mortality rate of 2% in a large data-
base study.39 Another prospective cohort of 800 patients with
CBDI referred to a single center reported the mean survival
after iatrogenic biliary injury was 17.6 years, and patients also
had a worse physical quality of life and loss of productivity; at
long-term follow-up, 34.9% were receiving disability benefits.40
Although these injuries are rare, occurring at a rate of 0.08%
and 0.25%, the impact on patients is significant.
Intraoperative cholangiography has been proposed to re-
duce iatrogenic bile duct injury during laparoscopic cholecys-
tectomy41 (see Chapter 24). Nevertheless, recent retrospective
studies show a higher incidence of CBDI when intraoperative
cholangiogram is performed (0.25% vs. 0.12%). This is likely
because cholangiography is used more frequently during chal-
lenging cases.42 Proper biliary anatomy identification and inter-
pretation of the cholangiography images are required for it to
aid in prevention of CBDI. The CVS, as described earlier, re-
mains the current standard technique to reduce the incidence
of CBDI during cholecystectomy.
Inflammation of the gallbladder increases the risk of CBDI.
As the grade of cholecystitis severity increases, the risk of CBDI
rises.43 The “classic injury” occurs when the CBD is mistaken
for the cystic duct and ligated. This is thought to occur when
the gallbladder is retracted too aggressively to the right, causing
the cystic duct to lie parallel and adjacent to the CBD. Dissec-
tion is then continued along the CBD superiorly until an “aber-
rant” or “duplicated” duct is encountered. If this duct is subse-
quently divided, a more proximal bile duct injury will occur
(Fig. 36.10).
If a CBDI is identified at the time of surgery, the surgeon
must assess the extent of the injury, their own experience re-
pairing these injuries, the patient’s condition, and the hospital
resources. A hepatobiliary surgeon should be called to assess
the situation if one is available. When a specialist is not avail-
able, the best course of action is to place a drain near the porta
hepatis, close the patient, and initiate transfer to a center with
hepatobiliary expertise. Proceeding with gallbladder extraction
after identifying a biliary injury is not recommended because it
risks amplifying the injury38 (see Chapter 42).
CBDIs are often not discovered during the index procedure.
Patients with ongoing abdominal pain, fevers, or ileus should
alert the surgeon to a potential complication. The initial diag-
nostic test should start with abdominal ultrasound followed by
computed tomography (CT) of the abdomen if a complication
is suspected. If excessive peritoneal fluid is present, percutane-
ous drainage should be performed. The type of injury should be
determined next and this can be done with magnetic resonance
cholangiopancreatography (MRCP), percutaneous transhepatic
cholangiography, and/or endoscopic retrograde cholangiopan-
creatography (ERCP). Simple postoperative leaks can be man-
aged with drainage alone or drainage and ERCP placement of
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501
3
2
1
FIGURE 36.10 Pathogenesis of the “classic” injury. 1. The common
bile duct is mistaken as the cystic duct and is clipped and divided.
2. The dissection is carried up along the left side of the common hepatic
duct in the belief that this is the underside of the gallbladder. 3. The
common hepatic duct is transected while the surgeon tries to dissect
what they believe is the gallbladder from the liver bed. If the structure is
recognized as a bile duct at this point, it is often thought to be a second
cystic duct or an accessory duct. While the common hepatic duct is
divided, the right hepatic artery is often injured. (From Strasberg SM,
Helton WS. An analytical review of vasculobiliary injury in laparoscopic
and open cholecystectomy. HPB (Oxford). 2011;13:1–14.)
biliary stents.44 Several centers with advanced gastroenterolo-
gists are beginning to manage selected patients with complex
injuries with percutaneous-endoscopic rendezvous procedures
with promising long-term results.45 Further details regarding
repair of biliary injuries are discussed elsewhere in this textbook
(see Chapter 42).
Bleeding
Clinically significant bleeding occurs in 0.1% to 1.9% of lapa-
roscopic cholecystectomies. Bleeding can arise from (1) the
liver, (2) an abdominal arterial source, or (3) port sites. Sig-
nificant bleeding from the liver bed tends to be from the termi-
nal branches of the middle hepatic vein. Bleeding from the
gallbladder fossa that appears venous in nature can be con-
trolled laparoscopically with hemostatic agents and applied
pressure. Visualization can be improved by lifting the liver and
increasing the pressure of pneumoperitoneum. Clips or sutures
can be placed in the cystic plate for hemostasis if all landmarks
are identified to avoid injury to underlying portal structures. If
visualization is lost, pressure should be applied to the area with
sponge and grasper while converting to laparotomy. During
laparotomy, one should keep pressure on the venous injury
because air embolus is possible and can be severe. Acute hemo-
dynamic decline in the postoperative period should raise con-
cern for significant bleeding, which is likely because of a dis-
lodged clip. As with any laparoscopic procedure, bleeding can
occur from trocar insertion.
Retained Common Bile Duct Stones
Common bile duct stones are present in approximately 5% to
15% of patients presenting for cholecystectomy.46–48 Those
502 PART 5 BILIARY TRACT DISEASE SECTION I Inflammatory, Infective, and Congenital
suspected of having choledocholithiasis should undergo preop-
erative diagnostic MRCP or ERCP, especially if the surgeon is
not comfortable exploring the CBD laparoscopically. Choledo-
cholithiasis is not an indication for laparotomy in the modern
era. Laparoscopic bile duct exploration at the time of cholecys-
tectomy has been shown to reduce hospital LOS and overall
cost compared with endoscopic treatment followed by chole-
cystectomy49 (see Chapter 37).
Retained common duct stones after cholecystectomy are
rare. In one single center study, the incidence of postoperative
ERCP for suspected retained stones was 1.8%.50 As with pa-
tients with presumed choledocholithiasis, those suspected of
having a retained CBD stone should be studied with either
MRCP or ERCP depending on facility capabilities. Endoscopic
sphincteroplasty with stone extraction is the most widely ac-
cepted treatment for this condition in the current era. The de-
tails of CBD stone management are discussed in other chapters
(see Chapters 37 and 38).
Gallbladder Perforation
Entering the gallbladder during cholecystectomy is a common
event, particularly during the learning phase of the procedure.
Careful retraction is essential because spillage of bile and stones
can result in serious complications. Intraperitoneal spillage of
stones can lead to abscess and fistula formation.51 In patients
with incidental gallbladder carcinoma, bile spillage at the time
of cholecystectomy resulted in higher rates of carcinomatosis
(24% vs. 4%) compared with those without spillage, as well as
poorer disease-free survival52 (see Chapter 49).
DELAYED COMPLICATIONS OF
CHOLECYSTECTOMY
Remnant Gallbladder and Cystic Duct Stones
Recurrent stone formation in a remnant gallbladder or cystic
duct is rare. Most patients present with pain similar to their
precholecystectomy symptoms, and it can occur at any time
from 4 months to 25 years after surgery. Remnant gallbladder
stones are usually associated with subtotal cholecystectomy.
Diagnosis requires a study that delineates the biliary anatomy,
such as MRCP or ERCP. Endoscopic ultrasound, intraoperative
cholangiogram, and percutaneous transhepatic cholangiogram
can also be useful in obtaining a diagnosis of retained stones.53
Treatment of cystic duct stones can be managed in a variety of
ways. Some stones are amendable to endoscopic retrieval or litho-
tripsy, whereas others require a surgical intervention to extract the
stone and ligate the cystic duct closer to the common duct.54
Treatment of a remnant gallbladder typically requires resection to
prevent further stone formation. Depending on the situation and
surgeon skill set, completion cholecystectomy can be performed
either open or laparoscopically with low morbidity.55–57
Biliary Strictures
Benign strictures of the CBD occur in up to 2.7% of laparoscopic
cholecystectomies and 0.5% of open cholecystectomies.58,59
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These strictures arise from an injury to the bile duct that was
unidentified in the immediate postoperative period. Causes in-
clude incomplete transection, clipping or ligation, thermal injury,
or ischemic devascularization of the bile duct. Commonly,
patients with benign biliary strictures present with symptoms
consistent with obstructive jaundice (see Chapter 42).
Options for management of biliary strictures are varied.
Endoscopic treatment is typically the first approach, with sur-
gery reserved for those who do not respond to endoscopic
therapy.60 Endoscopic stenting has been shown to result in 67%
of patients being symptom-free for 28 months, and having a
normal ERCP after stenting was predictive of not reforming a
stricture.61 Nevertheless, surgery remains the mainstay of ther-
apy for benign biliary strictures after cholecystectomy. A recent
meta-analysis showed that a surgical approach had an 84%
long-term patency rate.62 Further description of the manage-
ment of benign and malignant biliary strictures will be ad-
dressed elsewhere in the book (see Chapters 30 and 31).
Postcholecystecomy Diarrhea
Postcholecystectomy diarrhea is defined as three or more loose
stools per day after removal of the gallbladder. It is difficult to
assess the prevalence of this disorder. Etiology is likely multi-
factorial in nature. One factor may be the increased number of
bile salts in the colon because of continuous bile flow into the
gut, which leads to secretory diarrhea.63 Recent evidence
showed that the gut microbiome of patients with postcholecys-
tectomy diarrhea is altered. Compared with healthy patients,
patients with diarrhea after cholecystectomy had significantly
higher levels of Proteobacteria, which may be pathogenic in this
process.64 Currently, the recommended therapy is the adminis-
tration of bile-acid binding agents and antidiarrheals; however,
these have variable results.63
CONCLUSION
Cholecystectomy remains the gold standard for the manage-
ment of gallbladder disease in the developed world, with the
vast majority now performed minimally invasively with excel-
lent results. Most patients now undergo this operation in an
ambulatory setting. Attempts at improving outcomes from
laparoscopic cholecystectomy will continue to drive the devel-
opment of novel surgical tools and techniques. Although rela-
tively safe, there is room to reduce the number of CBDIs be-
cause these have a significant impact on patient quality of life
and overall survival. These gains will be achieved with improved
outreach and education regarding the CVS and when to pursue
alternative procedures instead of forging ahead with total cho-
lecystectomy. As new technology arises, surgeons must always
keep in mind the safety of the patient alongside the develop-
ment of new techniques.
The references for this chapter can be found online by accessing the
accompanying Expert Consult website.

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