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CHOLECYSTOGASTROSTOMY
INDICATIONS
This procedure may be utilized in poor-risk patients having a limited life expectancy because
of inoperable malignant disease obstructing the common duct that cannot be decompressed
with

endoscopic

retrograde

cholangiopancreatography

(ERCP)

or

transhepatic

cholangiopancreatography (THCP) passage of a stent. The cystic duct must be opened and
the common-duct malignancy should be quite low, with an expectation that the process will
not reach the cystic duct region for several months. In making this short-circuiting
anastomosis, it is preferable to utilize the nearest portion of the upper gastrointestinal tract
that can be approximated easily to the gallbladder without tension. This is usually the
mobilized duodenum rather than the stomach. A direct anastomosis to the upper jejunum may
be done. If a long-term survival is anticipated, the gallbladder or common duct is
anastomosed to a Roux-en-Y arm of mobilized jejunum. A cholecystogastrostomy is done
rarely. However, the technique shown is more frequently used to anastomose the gallbladder
to the duodenum. The gallbladder should not be utilized in an attempt to relieve obstructive
jaundice if the cystic duct is obstructed or if the lower end of the common duct is to be
removed in a radical resection. Visualization of the gallbladder and ducts by contrast media
may be worthwhile to prove beyond any doubt the site of obstruction.
PREOPERATIVE PREPARATION
Although the operation is a simple one, the patients are such poor risks that they require
careful preparation to avoid fatality. Nutritional needs may require total parenteral nutrition

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(TPN) support. As a rule, the patient is deeply jaundiced and there is already serious liver
damage. Blood products and large doses of vitamin K are indicated until the prothrombin level
returns to a normal range.
ANESTHESIA
See Cholecystectomy, Retrograde Method.
POSITION
The position of the patient is adjusted as described for cholecystectomy (see
Cholecystectomy, Retrograde Method, Figure 1); if local anesthesia is used, this position may
be modified for the patient's comfort.
OPERATIVE PREPARATION
The skin is prepared in the usual manner.
INCISION AND EXPOSURE
Usually, a midline incision reaching from the xiphocostal junction almost to the umbilicus is
made. However, either a transverse or a Kocher oblique incision is satisfactory for those
familiar with these approaches to the gallbladder. Bleeding and oozing points in the wound or
within the peritoneal cavity are meticulously ligated. Exploration is carried out to determine
the nature of the disease causing the obstruction, i.e., whether there is a tumor located in or
about the common duct or in the head of the pancreas, whether the tumor is primary or
metastatic, or whether there is a common duct stone. In the presence of malignant disease
obstructing the common duct without distant metastasis, the duodenum should be mobilized
and the operability of the lesion determined. Involvement about the portal vein contraindicates
surgery. If extensive involvement or dislocation of the duodenum by tumor is apparent, a
gastroenterostomy may be planned to avoid possible late obstruction. A determined attempt
should be made to prove the suspicion of tumor, even though extra effort may be required to
obtain the biopsy. For biopsy purposes, mobilization of the duodenum may be indicated to
expose the posterior side of the head of the pancreas, if the tumor seems more superficial
there.
DETAILS OF PROCEDURE
If the lesion is inoperable and the life expectancy short, the surgeon must determine whether
it is easier to anastomose the distended gallbladder to the stomach, the duodenum, or the
jejunum as a palliative measure. The same type of anastomosis is used whichever viscus is
chosen. The more complicated but efficient types of anastomosis, such as a Roux-en-Y
anastomosis is not necessary unless there is a reasonable chance of prolonged life
expectancy.

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As a rule, it is easy to perform the anastomosis to the stomach, preferably 2 to 4 cm above

the pylorus and near the greater curvature. Should such an anastomosis be likely to leave the
gallbladder under tension when the patient is erect, the anastomosis should be made to the
duodenum or upper jejunum.
A portion of the bowel is held up to the gallbladder on its medial side about 2 to 3 cm below
the fundus (Figure A1). If the gallbladder is greatly distended, it may be emptied through a
trocar before the anastomosis is started; if not, a posterior row of interrupted fine
nonabsorbable sutures is placed to bring the two viscera in apposition without opening either
of them (Figure A2). These sutures should not enter the lumen. The interrupted sutures (S1)
on the either end of the posterior serosal layer are left long, and the others are cut to expose
the field where the incisions into the gallbladder and stomach are to be made (Figure A3).
The incision are then made with electrocautery paralleling the suture line, with suction used to
control the spread of any contents from either viscus (Figure A3). The incisions are then
lengthened to give a stoma of 1 to 2 cm (Figure A4). To avoid contamination some surgeons
prefer to carry out this procedure with enterostomy clamps applied to the gallbladder and
stomach. The bleeding from the mucosa of the stomach, which is the only bothersome
element, can be controlled easily by placing a mosquito snap on each of the major vessels.
The clamps should be loosened and all bleeding points ligated before closure of the anterior
layer.
When the field is dry, the operator places a series of interrupted 0000 fine sutures in the
mucosal layers (Figure A5). The anterior mucosal layer is closed with interrupted sutures with
the knots on the inside (Figure A6). After the mucosal sutures are laid, an anterior row of
interrupted sutures is placed between the serosal coats to complete the anastomosis (Figures
A7 and A8). The patency of the stoma is tested by palpation between the thumb and index
finger, and as a precaution several sutures may be inserted at either angle. The field must be
free of oozing points.
CLOSURE
After the table is leveled, the omentum is brought up about the anastomosis. A nasogastric
tube is placed since gastric emptying will be delayed. The incision is closed without drainage
in a routine fashion.
POSTOPERATIVE CARE
The administration of fluids and food by mouth is restricted for a few days, as in other
intestinal anastomoses. The appearance of bile in the stools and a decreasing icteric index
indicate that the anastomosis is functioning. A high-vitamin, high-protein, and highcarbohydrate diet is resumed as soon as tolerated. In elderly, poor-risk patients who refuse to
eat, a gastrostomy tube placed during surgery can be used for the refeeding of bile mixed
with milk and other liquids in order to hasten their recovery.

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BIOPSY OF LIVER
INDICATIONS
It is not uncommon during an exploratory laparotomy to remove a small fragment of the liver
for histologic study. Biopsy of the liver is indicated in most patients who have a history of
splenic or liver disease, or in the presence of a metastatic nodule. The specimen should not
be taken from an area near the gallbladder, since the vascular and lymphatic connections
between the liver and gallbladder are such that a pathologic process involving the gallbladder
may have spread to the neighboring liver, and as a result the biopsy would not give a true
picture of the liver as a whole.
DETAILS OF PROCEDURE
Two deep 00 sutures, a and b, are placed about 2 cm apart at the liver border (Figure B1)
using atraumatic type of needle. The suture is passed through the edge of the liver and back
through again to include about one-half the original distance (Figure B1A). This prevents the
suture from slipping off the biopsy margin with resultant bleeding. These sutures are tied with
a surgeon's knot, which will not slip between the tying of the first and second parts (Figure
B1A). The suture should be tied as snugly as possible without cutting into the liver, for the
tension under which these knots are tied is the important factor in the procedure. Such
sutures control the blood supply to the intervening liver substance. The two sutures are
placed not more than 2 cm apart, deep in the liver substance; yet as they are tied, at least 2
cm of liver are included at the free margin to increase the size of the biopsy by making it
triangular in shape. An additional mattress suture, c, may be taken at the tip of the triangular
wound (Figure B2). After the biopsy is removed with a scalpel (Figure B3), the wound is
closed by tying together the sutures, a and b, or by placing an additional mattress suture, d,
beyond the limits of the original sutures (Figures B4 and B5). The area of biopsy is covered
with some type of anticoagulant matrix and omentum.

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