OPEN CHOLECYSTECTOMY

A traditional open cholecystectomy is a major abdominal surgery in which the surgeon removes the gallbladder through a 5-7 inch incision. Patients usually remain in the hospital at least 23 days and may require several additional weeks to recover at home. This procedure will therefore leave a right-sided subcostal scar. Most are performed to address symptoms related to biliary colic from cholelithiasis, to treat complications of gallstones (eg, acute cholecystitis, biliary pancreatitis), or as incidental cholecystectomies performed during other open abdominal procedures. Currently, most cholecystectomies are done using the laparoscopic technique.

INDICATION
Indications for cholecystectomy, either open or laparoscopic, are usually related to symptomatic gallstones or complications related to gallstones. Biliary colic, biliary pancreatitis, cholecystitis, and choledocholithiasis are the most common indications for cholecystectomies. Other indications include biliary dyskinesia, gallbladder cancer, and, although controversial, prophylactic cholecystectomy during various intraabdominal procedures. Prophylactic cholecystectomy at the time of a splenorenal shunt has been proposed based on the acute pain syndrome that these patients can develop postoperatively often related to gallbladder symptoms as well as the high likelihood of the formation of gallstones in this subset of patients with liver disease. The procedure of choice for most of these indications has shifted from an open approach to a laparoscopic approach. However, some situations still require a traditional open cholecystectomy. Based on the clinical situation, the procedure can either begin as an open operation or require conversion from a laparoscopic approach. Some indications for foregoing laparoscopy and proceeding with an open operation include suspected or confirmed gallbladder cancer, type II Mirizzi syndrome (cholecystobiliary fistula), gallstone ileus, and severe cardiopulmonary disease. When gallbladder cancer is suspected or confirmed preoperatively or intraoperatively, an open cholecystectomy should be performed with consultation from an experienced hepatobiliary surgeon if the primary

surgeon is not comfortable with liver resections and hepatobiliary surgery. If expertise is not available, the patient can be referred to a hepatobiliary surgeon for re-exploration, since prior exploration, either laparoscopic or open, does not appear to adversely affect long-term survival.[1] The recommendation for open cholecystectomy for gallbladder cancer, however, remains somewhat problematic, since most gallbladder cancers are discovered incidentally during surgery or in the specimen.[2, 3] Open cholecystectomy should also be considered in patients with cirrhosis and bleeding disorders as well as pregnant patients. In patients with advanced cirrhosis and bleeding disorders, potential bleeding may be difficult to control laparoscopically, and an open approach (or a percutaneous cholecystostomy tube) may be more prudent. Also, patients with portal hypertension often have a recannulized umbilical vein, and placing ports in these patients may cause significant hemorrhage. Although laparoscopic cholecystectomy has been proven to be safe in all trimesters of pregnancy, an open operation should be considered, especially in the third trimester, since laparoscopic port placement and insufflation may be difficult. Although rare, open cholecystectomy is also indicated in patients who have trauma to the right upper quadrant and in the rare cases of penetrating trauma to the gallbladder. Most open cholecystectomies result from conversion of a laparoscopic procedure, often because of bleeding complications or unclear anatomy. Conversion rates for laparoscopic cholecystectomy vary widely, with reported ranges from 1-30%.[4] However, most series report the incidence to be less than 10%, and some series report incidence closer to 1-2%.[5, 6, 7] Predictors of conversion to open cholecystectomy include age >60 y, male sex, weight >65 kg, the presence of acute cholecystitis, previous upper abdominal surgery, the presence of diabetes and high glycosylated hemoglobin levels, and a less experienced surgeon.

OPERATIVE POSITION
Patients are positioned supine with arms extended. Placing a folded blanket or bump underneath the patient's right back or inverting the table may be beneficial.

INCISION SITE

SKIN PREPERATION

INSTRUMENTS USE
Equipment for open cholecystectomy includes instruments common to a major instrument tray. This includes the following: Kelly clamps,Kocker forceps, needle holders, scissors, clips, suctions, knife/knife handles, forceps, retractors, right angle clamps, Kitner dissectors, and electrosurgical devices should be assembled. Balfour retractors, Bookwalter retractors, or other self-retaining retractors can be used, based on the surgeon's preference.

Sutures or clips can be used to control the cystic duct and artery, based on the surgeon's preference and the size of structures (see Technique section below). Long instruments may be needed, depending on the body habitus of the patient.

Allis-F o r c e p s w i t h i n w a r d - c u r v i n g t o o t h e d b l a d e s a n d a r a t c h e t e d handle. Designed for grasping fascia and tendons.

Richardson-is a surgical instrument that separates the edges of a s u r g i c a l incision or wound, and holds back underlying organs a n d tissues, so that body parts under the incision may be accessed. Theyare available in many shapes, sizes, and styles.

PROCEDURE
To begin the operation, the patient is anesthetized and placed in the supine positionon the operating table. A scalpel is used to make a small incision at the umbilicus. Using either a Veress needle or Hasson technique the abdominal cavity is entered. The surgeon inflates the abdominal cavity with carbon dioxide to create a working space. The camera is placed through the umbilical port and the abdominal cavity is inspected. Additional ports are placed inferior to the ribs at the epigastric, midclavicular, and anterior axillarypositions. The gallbladder fundus is identified, grasped, and retracted superiorly. With a second grasper, the gallbladder infundibulum is retracted laterally to expose and open Calot's Triangle (the area bound by the cystic artery, cystic duct, and common hepatic duct). The triangle is gently dissected to clear the peritoneal covering and obtain a view of the underlying structures. The cystic duct and the cystic artery are identified, clipped with tiny titanium clips and cut. Then the gallbladder is dissected away from the liver bed and removed through one of the ports. This type of surgery requires meticulous surgical skill, but in straightforward cases can be done in about an hour. SPECIMEN TAKEN

OPEN CHOLECYSTECTOM Y

Submitted to: Mrs. Mary joy Guadalupe, RN Clinical instructor

Submitted by: Joseph Montao BSN IV-A