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CHOLECYSTECTOMY FROM FUNDUS DOWNWARD

INDICATIONS

Cholecystectomy from the fundus downward is the desirable method in many cases of acute

or gangrenous cholecystitis, where exposure of the cystic duct is difficult and hazardous.

Extensive adhesions, a large, thick-walled, acutely inflamed gallbladder, or a large calculus

impacted in the ampulla of the gallbladder makes this the safe and wiser procedure. Better

definition of the cystic duct and cystic artery is ensured with far less chance of injury to the

common duct. Some prefer this method of cholecystectomy as a routine procedure.

PREOPERATIVE PREPARATION

In the presence of acute cholecystitis, the preoperative treatment depends on the severity

and duration of the attack. Early operation is indicated in patients seen within 48 hours after

the onset, as soon as fluid balance and antibiotic coverage have been established. Frequent

clinical and laboratory evaluation over a 24-hour period is necessary. Constant gastric suction

may be advisable. Antibiotic therapy is given. Regardless of the duration of the acute

manifestations, surgical intervention is indicated if there is recurrence of pain, a mounting

white cell count, or an increase in the signs and symptoms suggesting a perforation. The

gallbladder may show advanced acute inflammation despite a normal temperature and white

count and negative physical findings. About 75 percent of the patients will respond to

conservative treatment, and surgery in this group can be delayed a few days until fluid and

electrolyte intake returns to normal. Approximately one patient in five with acute cholecystitis

will not progressively improve and may worsen. Such patients require operation as an "off-

schedule" urgent procedure, especially if they have diabetes mellitus.

ANESTHESIA

See Cholecystectomy, Retrograde Method.

POSITION

The patient is placed in the usual position for gallbladder surgery. If local anesthesia is used,

the position may be modified slightly to make the patient more comfortable.

OPERATIVE PREPARATION

The skin is prepared in the usual manner.

INCISION AND EXPOSURE

Incision and exposure are carried out as shown in Cholecystectomy, Retrograde Method. The

omentum must be separated carefully by either sharp or blunt dissection from the fundus of

the gallbladder, care being taken to tie all bleeding points. An oblique incision below the

costal margin is preferred, especially if the mass presents rather far laterally.


DETAILS OF PROCEDURE

The appearance of the fundus and the patient's general condition determine whether it is

safer to drain the gallbladder or to remove it from the fundus downward, or to proceed with

the retrograde cholecystectomy. Blunt dissection only is utilized to free the omentum and

other structures from the gallbladder wall. It is safer to empty the contents immediately to

decrease the bulk and to give more exposure. A short incision is made through the serosa of

the fundus, a trocar introduced, and the liquid contents are removed by suction. Cultures are

taken. A fenestrated forceps is introduced deep into the gallbladder to remove any calculi in

the ampulla. The opening is closed with a pursestring suture, which prevents further soiling

and serves as traction.

An incision is made into the serosa of the gallbladder with a scalpel along both sides about 1

cm from the liver substance (Figure 1); otherwise, excessive traction will result in avulsion of

the gallbladder from the liver bed. Separation is accomplished by blunt or scissors dissection,

especially since the loose tissue beneath the serosa is edematous in the presence of acute

cholecystitis (Figure 2). The cuff of gallbladder serosa in the region of the fundus is held with

forceps, while the gallbladder is further freed by scissors dissection (Figure 3).

As an alternative method, since the contents have been aspirated and are frequently sterile,

the opening in the fundus is enlarged, permitting the index finger or a gauze sponge to be

inserted to give counterresistance and to aid in dissecting within the developed cleavage

plane.

The serosa is incised on each side down to the ampulla of the gallbladder. Since there may

be difficulty from oozing because the cystic artery is intact, all bleeding points should be

meticulously clamped. As the cuff at the margin of the liver is held by a curved, half-length

clamp, a relatively dry field is obtained if the cuff is closed with interrupted sutures as the

dissection progresses down to the ampulla (Figure 4). Most surgeons, however, leave the cuff

edges free. Great care must be taken in isolating the ampulla from the common duct. It may

be possible by finger compression to dislodge a calculus impinged in the ampulla and to

separate the distorted ampulla from the adjacent structures. Alternate sharp and gauze

dissection is advisable until the majority of adhesions have been separated. The gallbladder

is retracted medially and outward to assist in identifying the cystic duct and cystic artery. After

the ampulla is defined, the cystic duct is isolated with a right-angle clamp cautiously

introduced from the lateral side to avoid injury to the common duct and to the right hepatic

artery (Figure 4). The cystic artery is isolated with any accompanying indurated tissue. The

artery may be much larger than normal, and the right hepatic artery may be in an anomalous

position. It is safer to isolate the cystic artery as near the gallbladder wall as possible. The

cystic artery and adjacent tissues are divided between a half-length and a right-angle clamp

(Figure 5) and ligated.

The cystic duct is palpated carefully, especially if acute cholecystitis is present, to ensure that

a stone has not been overlooked. The common duct is palpated carefully, and exploration is

avoided unless the cholangiogram showed clear-cut evidence of a calculus there. If


choledochostomy is not indicated, the cystic duct is divided between right-angle and half-

length clamps (Figure 6) and tied unless a cholangiogram is planned through the cystic duct.

After thorough inspection of the area for oozing, the clamp is removed from the liver margin.

Since inflammation and technical difficulties have made this procedure necessary, a closed-

system suction catheter made of Silastic is inserted down beyond the region of the cystic duct

into Morison's pouch. Because of bile leakage, if raw liver surface has been exposed,

drainage is always indicated. The bile is cultured for bacterial growth and antimicrobial

sensitivities.

PARTIAL CHOLECYSTECTOMY If a classic open cholecystectomy appears hazardous because of advanced inflammation, or

if the gallbladder is partially buried in the liver, or if structures in the cystic duct region cannot

be safely identified, the full thickness of the gallbladder is left within the liver bed. A very

specific indication for this procedure occurs in patients with cirrhosis of the liver and portal

hypertension. Attempts to remove the back wall of the gallbladder will result in significant

hemorrhage that can be extremely difficult to control. The gallbladder is aspirated, and

traction is exerted on the fundus. The inferior surface is divided cautiously down to the

ampulla, which may be densely adherent to the adjacent structures (Figure 7). Calculi

impacted in the ampulla or cystic duct are removed with fenestrated forceps (Figure 8). The

gallbladder wall beyond the liver margin is excised, and any bleeding points are controlled

with electrocautery or interrupted sutures. The mucosa in the retained portion of the

gallbladder head is destroyed by electrocoagulation. If the cystic duct can be intubated with a

small catheter (Figure 9), a cholangiogram may be performed. Often the gangrenous cystic

duct cannot be found and Silastic closed suction system drains are placed in the general

region of the duct as well as in Morison's pouch. Fortunately, the spiral valves in the retained

cystic duct stump usually scar shut. The Silastic drains are withdrawn beginning 7 to 10 days

after surgery, depending upon their output.

CLOSURE

The customary closure is made. The catheter and drains may be brought out through a

separate stab wound.

POSTOPERATIVE CARE The care described in Choledochostomy, Transduodenal Approach is observed. Bile drainage

is expected from the tube or about the drain. After systemic and local signs of inflammation

have disappeared and drainage has subsided, a cholangiogram should be considered before

the catheter is removed. The drains are withdrawn beginning 7 to 10 days after operation.

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