Most difficult cholecystectomies can be anticipated. Before surgery, note male sex, older age, raised BMI, previous upper abdominal surgery, repeated or recent attacks of cholecystitis, a thick-walled or contracted gallbladder on ultrasound, an impacted stone, and a previous percutaneous cholecystostomy. Grade the expected difficulty, and plan the list, the assistant and the bail-out options accordingly. During surgery, aim for the critical view of safety and be ready for subtotal cholecystectomy when it cannot be achieved, rather than pushing on into the hepatocystic triangle.
- List risk factors for difficulty in the preoperative note
- Put a predicted difficult case on a list with senior support
- Achieve the critical view of safety before dividing any structure
- Know when to convert or perform a subtotal cholecystectomy
Why it matters
Bile duct injury often happens in a gallbladder that could have been predicted to be hard.
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