- Email: [email protected]
Open cholecystectomy in the laparoendoscopic era
The American Journal of Surgery 195 (2008) 108 –114
Review
Open cholecystectomy in the laparoendoscopic era Brendan C. Visser, M.D.a,*, Rowan W. Parks, M.D., F.R.C.S.(Ire)b, O. James Garden, M.D., F.R.C.S.(Ed)b a
Department of Surgery, Stanford University School of Medicine, Palo Alto, CA, USA b Department of Surgery, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK Manuscript received February 20, 2007; revised manuscript April 3, 2007
Abstract Laparoscopic cholecystectomy has all but replaced the traditional open approach. Hence open cholecystectomy (OC) is principally reserved for cases in which laparoscopy fails, leaving fewer surgeons with experience in the procedure required for the most challenging cases. This review of OC includes discussion of the indications for a primary open approach, conversion from laparoscopy, technical aspects of OC, and alternatives (cholecystostomy and subtotal cholecystectomy). Strategies for safe OC must be formally addressed in residency programs. © 2008 Excerpta Medica Inc. All rights reserved. Keywords: Open cholecystectomy; Cholecystostomy; Conversion; Surgical training; Subtotal cholecystectomy; Open common bile duct exploration
Since its introduction in the late 1980s, laparoscopic cholecystectomy (LC) has all but replaced open cholecystectomy (OC). The laparoscopic approach, used in 75% to 95% of cases, is now referred to widely as the “gold standard” for management of symptomatic gallstone disease [1,2]. There is overwhelming evidence that LC offers patients less pain, shorter hospitalization, and faster recovery [3]. The decreasing frequency of OC in clinical practice is, of course, reflected in a reduction in training opportunities. Nonetheless, the procedure remains the fallback gold standard in the operating theater and the courtroom with respect to safety and success, particularly in complicated cases [4,5]. OC is thus reserved principally for cases where laparoscopic surgery fails with the resulting paradox that fewer surgeons have experience of the technique required for the most difficult cases. This review of OC includes discussion of the indications for a primary open approach, conversion from LC (which underpins any discussion of OC in the modern era), technical aspects of OC and its alternatives, and considerations in training young surgeons to perform safe OC in the laparoendoscopic era. Indications for OC After the initial introduction of LC, there were several “relative” contraindications to laparoscopy—previous upper abdominal surgery, pregnancy and cirrhosis. Subsequently, * Corresponding author. Tel.: ⫹1-650-849-1910; fax: ⫹1-650-852-3430. E-mail address: [email protected]
LC has been proven to be feasible and safe, if not superior in each of these settings [6 – 8]. The physiologic changes associated with pneumoperitoneum favor laparotomy very occasionally in patients with severe cardiopulmonary disease [9,10]; however, with careful anesthetic management, preoperative morbidity is not per se a contraindication to attempting LC [11,12]. Hence, after 15 years of evolving technique and experience with LC, there are very few strict indications for beginning a cholecystectomy as an open operation. The most common reason for OC is likely that the cholecystectomy is to be performed in conjunction with another procedure requiring laparotomy, whether the cholecystectomy is required for the operation (eg, during right hepatectomy) or because the patient suffers biliary colic in addition to the more pressing reason for laparotomy (eg, during colectomy). In this setting, the gallbladder is typically minimally diseased and the operation is straightforward. Only 2 specific gallbladder-related diseases demand OC. Suspected gallbladder cancer is widely considered as a strong indication for open cholecystectomy [13,14]. While not precluding further radical resection [15], LC prior to definitive management appears to worsen the prognosis of gallbladder cancer [14,16]. Hence, in cases where gallbladder cancer is suspected based on prior imaging, the patient should be referred to a surgeon prepared in the first instance to perform a “radical” cholecystectomy, including a partial segment IV/V liver resection and lymphadenectomy of the hepatoduodenal ligament [14]. However, it is worth noting
0002-9610/08/$ – see front matter © 2008 Excerpta Medica Inc. All rights reserved. doi:10.1016/j.amjsurg.2007.04.008
B.C. Visser et al. / The American Journal of Surgery 195 (2008) 108 –114
109
that the recommendation favoring OC in cases of preoperatively suspected gallbladder cancer remains somewhat problematic, given that as many as two thirds of gallbladder cancers are discovered incidentally at surgery or in the specimen [17,18]. The second indication for OC, Mirizzi syndrome, is similarly challenging to diagnose with certainty preoperatively [19]. Type I Mirizzi syndrome, with extrinsic compression of the hepatic duct, may be treated successfully by laparoscopic means in experienced hands [20,21]. However, whether diagnosed preoperatively or intraoperatively, type II Mirizzi syndrome (cholecystobiliary fistula) remains a clear indication for OC [19,22,23]. The management of the choledochal defect encountered with type II Mirizzi is often complex, requiring biliary-enteric bypass or occasionally more creative solutions [24,25]. Hence, both of the indications for primary OC should likely be referred to surgeons with significant experience in complex biliary surgery. Conversion During Laparoscopic Cholecystectomy Thus, while a small proportion of OC are performed open primarily, the majority of OC currently follow conversion from LC. The range of conversion rates reported in the literature is quite wide; however, in most series it is less than 10%, and in some closer to 1% to 2% [26,27]. Often conversion is reported as a “complication” of LC, and individual surgeons and institutional series trumpet low conversion rates. A number of important “risk factors” have been identified that predict conversion—male gender, extreme old age, obesity, previous surgery, severe disease, and emergency LC for acute cholecystitis [27]. Ultimately, however, the individual surgeon is left with their own subjective intraoperative assessment, weighing the severity of the inflammatory changes, clarity of the anatomy, and his or her own skill/comfort in proceeding. Yet our surgical culture subtly suggests that conversion to OC represents failure. In addition, many young surgeons, given little experience with OC, may be more comfortable continuing to struggle laparoscopically than to simply convert. In those cases that ultimately require conversion to safely remove the gallbladder, these factors may contribute to unnecessarily long operative times, or worse, avoidable bile duct injuries. Although the early surge seen in the 1990s has subsided, the incidence of bile duct injury during LC remains between 1 per 200 and 1 per 500 cases, twice that seen in the era of OC [28]. This iatrogenic catastrophe is associated with significant short- and long-term morbidity and even mortality, and almost uniformly results in costly litigation against the injuring surgeon [5]. Misinterpretation of the perceived anatomy rather than any fault in technical skill is the overwhelming cause of bile duct injury during LC [29]. A variety of operative dissection strategies have been described to minimize the risk of bile duct injury; the most reliable is likely the “critical view” technique described by Strasberg [30]. To achieve the “critical view,” the triangle of Calot is dissected free of all tissue except for the cystic duct and artery, and the base of the liver bed is exposed (Fig. 1). Thus, the 2 structures entering the gallbladder can only be the cystic duct and artery, and the common bile duct need not be exposed. Though more controversial, another
Fig. 1. Strasberg’s “critical view.” The triangle of Calot is dissected free of all tissue except for cystic duct and artery, and the base of the liver bed is exposed. Reprinted from [71], with permission from The American College of Surgeons.
key strategy for avoiding bile duct injuries is routine (or at least very liberal) cholangiography [28]. Cholangiography likely reduces the risk of bile duct injury, and certainly results in more prompt recognition if an injury does occur [31,32]. Neither of these strategies will allow safe removal of the gallbladder in all situations. In difficult cases, be it due anatomic confusion, fusion of dissection planes, failure to progress, or poor visualization, the prudent maneuver remains conversion to OC. Conversion to conventional OC does translate clearly into longer operative times, longer hospitalization, and higher morbidity compared to successful LC [26]. However, given the predictors for conversion, most morbidity associated with conversion to OC may be ascribed to the patients’ comorbidities and severity of gallbladder disease, rather than the conventional incision itself. The results of routine OC in the pre-laparoscopic era [33,34] and the few randomized trials available [3] demonstrate that LC offers shorter hospital stay and a quicker convalescence but no noteworthy difference in significant complications or mortality. Furthermore, the morbidity related to conversion to a safe OC is clearly much less than that of iatrogenic bile duct injury. Open Cholecystectomy: Technical Aspects OC can be performed by 2 basic techniques: “antegrade” (beginning the dissection medially in the hepatoduodenal ligament) or “retrograde” (from the fundus downward). As in LC, the former technique commences with dissection of the peritoneum overlying the triangle of Calot to allow identification of the cystic artery and duct, achieving the same “critical view” as during LC. Once the artery and duct are ligated and divided (and cholangiogram performed if appropriate), the gallbladder is freed from the cystic plate in the subserosal plane. This can be accomplished either from the infundibulum up (in the manner of LC) or from the fundus down (more common in OC). The advantages of
110
B.C. Visser et al. / The American Journal of Surgery 195 (2008) 108 –114
early dissection of the cystic duct/artery are that their identification may be easier in a bloodless field, and that freeing the gallbladder from the liver bed may be less bloody. The more traditional method of OC is the retrograde (“topdown”) technique, in which the dissection begins at the fundus and proceeds toward the hepatoduodenal ligament. This strategy allows sure identification of the cystic duct and artery, as they remain the sole attachments once the gallbladder is freed from the cystic plate. In cases where the gallbladder is normal or minimally inflamed, the antegrade technique may be convenient, bloodless, and particularly appropriate for teaching anatomy to junior trainees. Interestingly, in a recent audit of cholecystectomy at the Royal Infirmary of Edinburgh, almost half of OCs since 2000 were performed in antegrade fashion, possibly because the younger surgeons responsible for much of the emergency general surgery are more comfortable with this technique (unpublished data). However, the retrograde technique for OC may have advantage in certain settings. In acute cholecystitis, acute inflammation and induration render the initial dissection within the triangle of Calot less safe, particularly given that most OCs have been converted from LCs for just this reason. However, even the traditional retrograde technique will not avoid trouble in all cases. Occasionally, as a result of severe acute on chronic inflammation, the medial aspect of the infundibulum is fused to the common bile duct, obliterating the triangle of Calot. Persistence in these cases may not only result in bile duct injury, but occasionally in life-threatening injuries to the vascular structures of the hepatoduodenal ligament. For the general surgeon faced with a difficult OC, the first and perhaps best option is an intraoperative consultation with a colleague more experienced in hepatobiliary surgery. This may serve to reduce the chance of misadventure, and mitigates the consequences of litigation if an injury does occur. If this option is not available, the best tactic may be retreat. Although taught traditionally to come away with a prize, the surgeon must appreciate that the benefit to the patient of completing the cholecystectomy is never as important as avoiding injury. Occasionally, cholecystostomy represents the best approach, but most often, subtotal cholecystectomy provides a definitive but safe solution. Alternatives: Cholecystostomy and Subtotal Cholecystectomy In particularly difficult cases, 2 alternatives to OC may be employed that have received little attention in recent years, cholecystostomy and subtotal cholecystectomy. OC was historically performed under local anesthesia for elderly patients suffering from acute cholecystitis who were deemed to be too high-risk for general anesthesia [35,36]. Percutaneous cholecystostomy has largely supplanted its open counterpart in critically ill patients, because it can be performed at the bedside under ultrasound guidance and avoids the morbidity of the (albeit small) incision [37,38], though perhaps at a cost of a higher rate of local complications [39,40]. Hence, few young surgeons have performed an open cholecystectomy. Nonetheless, cholecystostomy remains a “bail out” option in cases where severe inflammatory changes, difficult anatomy, or bleeding make the in-
Fig. 2. Open cholecystostomy. The Malecot drain is secured into the fundus with a purse-string suture. Reprinted with permission from [35].
tended cholecystectomy unsafe. Cholecystostomy may be performed both laparoscopically or after conversion to laparotomy. In order to perform an OC, a purse-string suture is first placed in the fundus and a small incision made to allow evacuation of bile and removal of any accessible stones. A large Malecot or mushroom catheter is introduced into the gallbladder, secured with the purse-string, and brought out a separate stab wound in the abdominal wall (Fig. 2). Placing the omentum around the tube facilitates tract formation and may reduce the risk of bile leakage into the peritoneal cavity. Finally, a separate subhepatic drain should be placed. Although an important alternative to OC, cholecystostomy does suffer several drawbacks. This technique cannot be readily performed for true gangrenous cholecystitis or following significant surgical trauma to the gallbladder during dissection aimed at cholecystectomy. Furthermore, even after resolution of the acute process, the local complications and morbidity associated with the tube are significant (including tube dislodgement or obstruction, biliary fistula, abscess, bile leak/peritonitis). The management of cholecystostomy tubes after resolution of the acute episode can be controversial, especially given that they are often utilized in patients with significant comorbidities or very severe illness. In cases of true acalculous cholecystitis, once the physiologic stress has resolved and hence inflammation resolved, cholecystectomy is not mandatory [41]. However, if the patient is deemed appropriate for interval cholecystectomy, the tube should be left in place until the time of surgery. An adequate delay, approximately 3 months, is desirable to allow resolution of the inflammation and results in a lower rate of conversion at subsequent LC [42]. For those patients deemed poor candidates for interval cholecystectomy, a cholecystogram is performed after 10 to 14 days. If contrast passes freely into the bile duct and duodenum, and a fistulogram from the skin confirms a well-formed tract (without leakage of contrast into the peritoneal cavity), the tube may be withdrawn safely. The bile fistula will close over the course of a few days. Finally, though occasionally reported, endoscopic cholecystolithotripsy is rarely indicated [43]. Overall, while cholecystostomy may be definitive in selected patients [38,44], the majority of patients do require subsequent interval cholecystectomy [45]. The preferred alternative to OC in difficult cases is therefore subtotal cholecystectomy. This operation was de-
B.C. Visser et al. / The American Journal of Surgery 195 (2008) 108 –114
111
wall of the gallbladder abutting the cystic plate may be left in place to avoid inadvertent injury to the tributaries of the middle hepatic vein in the gallbladder bed. Diathermy is applied to the exposed mucosa to reduce the theoretical risk of mucocele, and a drain should be left in place. Routine and determined efforts to suture the orifice of the cystic duct cannot be recommended, given that the cystic duct is almost uniformly obstructed and the significant risk of misadventure in the context of anatomic distortion caused by severe inflammation. If a postoperative biliary fistula occurs, it can be managed safely later by endoscopic stenting. Subtotal cholecystectomy often provides a definitive but safe solution and avoids the potential complications associated with cholecystostomy. Both of the above alternatives to cholecystectomy can, of course, be performed laparoscopically. Laparoscopic cholecystostomy has been offered as an alternative to conversion to open surgery when inflammation precludes safe LC [48,49]. The technique is similar to that of its traditional open counterpart but uses a 16-F Foley catheter (through the midclavicular 5 mm port site) rather than a Malecot [48]. Although this strategy can prove successful, it should likely be reserved for very rare cases. For most patients, it is preferable to convert to OC and complete the cholecystectomy at the first anesthetic (keeping in mind that despite the above description of alternatives to OC, in the great majority of LC cases that require to conversion, the gallbladder can be safely removed via laparotomy). Similarly, laparoscopic subtotal cholecystectomy has been offered as an alternative to conversion [50]. The advantages of this approach are most striking in patients with cirrhosis [51]. Experienced laparoscopic surgeons do employ this strategy with safety and acceptable morbidity (bile leaks, spilled/lost stones, recurrent problems with stones in the remnant) in cases of severe acute cholecystitis [8,52]. However, although no meaningful direct comparison of subtotal LC versus conversion to OC (completing the cholecystectomy in most cases) will ever be possible, the latter should likely remain the default choice for most general surgeons. Again, for most patients the drawbacks of OC do not merit the potential risks and morbidity of subtotal LC in less experienced hands. In particular, the use of the endoscopic linear stapler (eg, Endo-GIA; Tyco/US Surgical, Norwalk, CT) to divide and close the infundibulum during attempted subtotal LC may result in very serious common duct injuries. Fig. 3. Subtotal cholecystectomy as classically described by Bornman and Terblanche. They recommended over-sewing the cut edge for hemostasis (B), and tying or purse-stringing the cystic duct where possible (B, inset). Reprinted from [47], with permission from Mosby.
scribed initially in classical operative texts [46], and more recently championed by Bornman and Terblanche (Fig. 3) [47]. During retrograde OC, when it becomes apparent that further dissection toward the hepatoduodenal ligament is unsafe, the gallbladder is transected to leave a 1- to 2-cm rim of the infundibulum/Hartmann’s pouch, avoiding the dangerous dissection into the thickened cystic plate that fuses the posterior wall of the gallbladder to the at-risk right hepatic and common hepatic ducts. In cases of very severe inflammation or any bleeding diathesis, the entire posterior
Open Common Bile Duct Exploration To a greater degree than even OC, open common bile duct exploration (CDE) has become rare in clinical practice— declining almost 85% since the popularization of endoscopic retrograde cholangiopancreatography (ERCP) in the 1980s [53]. The bulk of choledocholithiasis is managed by ERCP, and much of the recent literature centers on the relative merits of ERCP versus the emerging technology of laparoscopic bile duct exploration [54,55]. Laparoscopic duct exploration during LC requires fewer procedures overall, shortens hospitalization, and is less expensive. However, this technique has not gained widespread popularity because of both the technical expertise required, and the time and equipment demands in the operating theatre. In the era of
112
B.C. Visser et al. / The American Journal of Surgery 195 (2008) 108 –114
OC, open CDE was demonstrated superior to ERCP in successfully clearing the bile duct and was associated with many fewer procedures [55–57]. If choledocholithiasis is discovered during LC on intraoperative cholangiogram and laparoscopic CDE fails or is not available, conversion to laparotomy for open CDE remains is not routinely recommended. However, if OC is required for other reasons, common duct stones should be ideally removed at the same time [58]. Furthermore, if choledocholithiasis is diagnosed preoperatively and preoperative ERCP fails to clear the duct, conversion is certainly preferable to further attempts at endoscopic duct clearance. As open CDE becomes exceptional in many operating theaters, a surgeon’s request for a T-tube is met with blank stares, and the stone forceps may have been prematurely sent to a museum. Efforts should be made to hold on to these basic tools and retain the skill set to perform open CDE. Alarmingly, as experience in open CDE diminishes, the rate of complications has risen quite markedly—approximately 5-fold since the popularization of ERCP in a recent analysis of US national hospital discharge data [53]. Given this concerning trend, open CDE, like its newer laparoscopic counterpart, is progressively becoming “specialized” biliary surgery. Cases where open CDE is anticipated preoperatively should be referred appropriately. Surgeons with little training in open CDE should enlist a more experienced colleague whenever possible. However, if during OC unanticipated choledocholithiasis is found and a surgeon experienced in open CDE is not available, it might be prudent to forego open exploration in favor of postoperative ERCP. Training Surgeons in Open Biliary Surgery The ascendancy of LC and ERCP in clinical practice has left relatively few training opportunities in open biliary surgery. In the United States, the average general surgical resident completing training in 2004 had performed just 12.6 OCs (declining further from 15.5 in 2000), in contrast to more than 90 LCs [59]. Trainees in the United Kingdom face a similar paucity of open cases [60]. Open CDEs are even more scarce— down from an average of just 7.3 for 1993 US trainees [61], to 1.7 for those graduating in 2005 (with a mode of 1) [59]. Furthermore, very few of these cases are straight-forward, often making them less appropriate as “teaching cases.” The potential for this problem in training adequately surgeons in open biliary surgery was recognized early in the evolution of LC. In 1994, in an invited commentary on the issue, Jonathan Sackier stated that “there is no dilemma,” because the means to ensure adequate training remain “a thorough knowledge of the basic sciences, requisite technical skills, sufficient clinical experience, and the integrity and humility to make sound judgment calls” [62]. He compares the evolution from OC to LC to the transition to arthroscopy in orthopedics and transurethral prostatectomy in urology. While this comparison has some merit, it is clear that there remains a need for open gallbladder surgery. Furthermore, there is widespread pressure in surgery to move towards increasing centralization of complex operations given the growing recognition of the relationship between volume and outcome for many procedures [63], including specifically
pancreaticobiliary surgery [64,65]. Among Sackier’s principles of training, 2 of the 4 are potentially problematic: “requisite technical skills” and “sufficient clinical experience.” These cannot be taught exclusively in a classroom and they may not be entirely transferable between minimally invasive and traditional techniques. Nevertheless, there are some solutions. In completing 5 or more years of clinical training, surgical residents have participated in a large number of emergency gastrointestinal and trauma operations. The principles learned and experience gained from these cases are applicable to urgent biliary surgery. Furthermore, strategies to deal with rare but challenging situations (eg, Ladd’s procedure for midgut volvulus) are taught throughout residency. Given the relative paucity of these cases, greater attention to training in open biliary surgery should be given in formal and informal teaching. Elective operations for pancreaticobiliary tumors, chronic pancreatitis, and biliary-enteric bypass also provide valuable occasions to teach principles of open biliary surgery. However, these solutions are rooted in the traditional “apprenticeship” model of surgical training. In recent years, surgical educators in North America and the United Kingdom are placing greater emphasis on structured curriculums that stress objective assessment of competence [66 – 68] and, particularly in laparoscopic surgery, laboratory-based skills training [69]. It is unclear whether this trend could impact training in open biliary surgery. Perhaps if an appropriate simulation model for laparoscopic CDE is developed and manufactured, such a model could be used to acquaint trainees with the techniques and tools of open CDE. Fundamentally, however, the “requisite technical skills” and “sufficient clinical experience” must still be taught in the operating theater, but during fewer and fewer discrete opportunities. Conclusions In the era of LC and ERCP, OC and open CDE grow increasingly rare in training and clinical practice. We must therefore, as Strasberg suggests, “change the culture of cholecystectomy” [70]. Efforts to improve formal training in LC, aimed particularly at avoidance of bile duct injury, must continue. OC and open CDE can no longer be regarded as routine general surgery operations. Hence the acquisition of these skills during general surgery training must not be taken for granted, and strategies for safe OC must be formally addressed in residency programs. Surgeons who are inexperienced in these procedures should have a low threshold for recruiting assistance or referring to colleagues with greater expertise in biliary surgery. References [1] Sain AH. Laparoscopic cholecystectomy is the current “gold standard” for the treatment of gallstone disease. Ann Surg 1996;224:689 –90. [2] Begos DG, Modlin IM. Laparoscopic cholecystectomy: from gimmick to gold standard. J Clin Gastroenterol 1994;19:325–30. [3] Keus F, de Jong JA, Gooszen HG, van Laarhoven CJ. Laparoscopic versus open cholecystectomy for patients with symptomatic cholecystolithiasis. Cochrane Database Syst Rev 2006:CD006231. [4] McSherry CK. Cholecystectomy: the gold standard. Am J Surg 1989; 158:174 – 8.
B.C. Visser et al. / The American Journal of Surgery 195 (2008) 108 –114 [5] McLean TR. Risk management observations from litigation involving laparoscopic cholecystectomy. Arch Surg 2006;141:643– 8. [6] Karayiannakis AJ, Polychronidis A, Perente S, et al. Laparoscopic cholecystectomy in patients with previous upper or lower abdominal surgery. Surg Endosc 2004;18:97–101. [7] Glasgow RE, Visser BC, Harris HW, et al. Changing management of gallstone disease during pregnancy. Surg Endosc 1998;12:241– 6. [8] Ji W, Li LT, Wang ZM, et al. A randomized controlled trial of laparoscopic versus open cholecystectomy in patients with cirrhotic portal hypertension. World J Gastroenterol 2005;11:2513–7. [9] Kraut EJ, Anderson JT, Safwat A, et al. Impairment of cardiac performance by laparoscopy in patients receiving positive end-expiratory pressure. Arch Surg 1999;134:76 – 80. [10] Gebhardt H, Bautz A, Ross M, et al. Pathophysiological and clinical aspects of the CO2 pneumoperitoneum (CO2-PP). Surg Endosc 1997; 11:864 –7. [11] Stuttmann R, Paul A, Kirschnik M, et al. Preoperative morbidity and anaesthesia-related negative events in patients undergoing conventional or laparoscopic cholecystectomy. Endosc Surg Allied Technol 1995;3:156 – 61. [12] Gerges FJ, Kanazi GE, Jabbour-Khoury SI. Anesthesia for laparoscopy: a review. J Clin Anesth 2006;18:67–78. [13] Steinert R, Nestler G, Sagynaliev E, et al. Laparoscopic cholecystectomy and gallbladder cancer. J Surg Oncol 2006;93:682–9. [14] Weiland ST, Mahvi DM, Niederhuber JE, et al. Should suspected early gallbladder cancer be treated laparoscopically? J Gastrointest Surg 2002;6:50 – 6. [15] Fong Y, Jarnagin W, Blumgart LH. Gallbladder cancer: comparison of patients presenting initially for definitive operation with those presenting after prior noncurative intervention. Ann Surg 2000;232:557– 69. [16] Gall FP, Kockerling F, Scheele J, et al. Radical operations for carcinoma of the gallbladder: present status in Germany. World J Surg 1991;15:328 –36. [17] Wullstein C, Woeste G, Barkhausen S, et al. Do complications related to laparoscopic cholecystectomy influence the prognosis of gallbladder cancer? Surg Endosc 2002;16:828 –32. [18] Varshney S, Buttirini G, Gupta R. Incidental carcinoma of the gallbladder. Eur J Surg Oncol 2002;28:4 –10. [19] Lai EC, Lau WY. Mirizzi syndrome: history, present and future development. Aust NZ J Surg 2006;76:251–7. [20] Yeh CN, Jan YY, Chen MF. Laparoscopic treatment for Mirizzi syndrome. Surg Endosc 2003;17:1573– 8. [21] Rohatgi A, Singh KK. Mirizzi syndrome: laparoscopic management by subtotal cholecystectomy. Surg Endosc 2006;20:1477– 81. [22] Schafer M, Schneiter R, Krahenbuhl L. Incidence and management of Mirizzi syndrome during laparoscopic cholecystectomy. Surg Endosc 2003;17:1186 –90. [23] Tan KY, Chng HC, Chen CY, et al. Mirizzi syndrome: noteworthy aspects of a retrospective study in one centre. Aust NZ J Surg 2004;74:833–7. [24] Baer HU, Matthews JB, Schweizer WP, et al. Management of the Mirizzi syndrome and the surgical implications of cholecystcholedochal fistula. Br J Surg 1990;77:743–5. [25] Bower TC, Nagorney DM. Mirizzi syndrome. HPG Surg 1988;1:67– 74. [26] Livingston EH, Rege RV. A nationwide study of conversion from laparoscopic to open cholecystectomy. Am J Surg 2004;188:205–11. [27] Tang B, Cuschieri A. Conversions during laparoscopic cholecystectomy: risk factors and effects on patient outcome. J Gastrointest Surg 2006;10:1081–91. [28] Connor S, Garden OJ. Bile duct injury in the era of laparoscopic cholecystectomy. Br J Surg 2006;93:158 – 68. [29] Way LW, Stewart L, Gantert W, et al. Causes and prevention of laparoscopic bile duct injuries: analysis of 252 cases from a human factors and cognitive psychology perspective. Ann Surg 2003;237: 460 –9. [30] Strasberg SM. Avoidance of biliary injury during laparoscopic cholecystectomy. J Hepatobiliary Pancreat Surg 2002;9:543–7. [31] Archer SB, Brown DW, Smith CD, et al. Bile duct injury during laparoscopic cholecystectomy: results of a national survey. Ann Surg 2001;234:549 –58. [32] Gigot J, Etienne J, Aerts R, et al. The dramatic reality of biliary tract injury during laparoscopic cholecystectomy. An anonymous multicenter Belgian survey of 65 patients. Surg Endosc 1997;11:1171– 8.
113
[33] Moreaux J. Prospective study of open cholecystectomy for calculous biliary disease. Br J Surg 1994;81:116 –9. [34] Roslyn JJ, Binns GS, Hughes EF, et al. Open cholecystectomy. A contemporary analysis of 42,474 patients. Ann Surg 1993;218:129 –37. [35] Glenn F. Cholecystostomy in the high risk patient with biliary tract disease. Ann Surg 1977;185:185–91. [36] Skillings JC, Kumai C, Hinshaw JR. Cholecystostomy: a place in modern biliary surgery? Am J Surg 1980;139:865–9. [37] Patel M, Miedema BW, James MA, et al. Percutaneous cholecystostomy is an effective treatment for high-risk patients with acute cholecystitis. Am Surg 2000;66:33–7. [38] Sugiyama M, Tokuhara M, Atomi Y. Is percutaneous cholecystostomy the optimal treatment for acute cholecystitis in the very elderly? World J Surg 1998;22:459 – 63. [39] Spain DA, Bibbo C, Ecker T, et al. Operative tube versus percutaneous cholecystostomy for acute cholecystitis. Am J Surg 1993;166:28 –31. [40] Ghahreman A, McCall JL, Windsor JA. Cholecystostomy: a review of recent experience. Aust NZ J Surg 1999;69:837– 40. [41] Patterson EJ, McLoughlin RF, Mathieson JR, et al. An alternative approach to acute cholecystitis. Percutaneous cholecystostomy and interval laparoscopic cholecystectomy. Surg Endosc 1996;10:1185– 8. [42] Berber E, Engle KL, String A, et al. Selective use of tube cholecystostomy with interval laparoscopic cholecystectomy in acute cholecystitis. Arch Surg 2000;135:341– 6. [43] Wong SK, Yu SC, Lam YH, Chung SS. Percutaneous cholecystostomy and endoscopic cholecystolithotripsy in the management of acute cholecystitis. Surg Endosc 1999;13:48 –52. [44] Davis CA, Landercasper J, Gundersen LH, et al. Effective use of percutaneous cholecystostomy in high-risk surgical patients: techniques, tube management, and results. Arch Surg 1999;134:727–31. [45] Weigelt JA, Norcross JF, Aurbakken CM. Cholecystectomy after tube cholecystostomy. Am J Surg 1983;146:723– 6. [46] Maingot R. Abdominal Operations. East Norwalk, CT: AppeltonCentury-Crofts; 1940. [47] Bornman PC, Terblanche J. Subtotal cholecystectomy: for the difficult gallbladder in portal hypertension and cholecystitis. Surgery 1985;98: 1– 6. [48] Bradley KM, Dempsey DT. Laparoscopic tube cholecystostomy: still useful in the management of complicated acute cholecystitis. J Laparoendosc Adv Surg Tech A 2002;12:187–91. [49] Yang HK, Hodgson WJ. Laparoscopic cholecystostomy for acute acalculous cholecystitis. Surg Endosc 1996;10:673–5. [50] Beldi G, Glattli A. Laparoscopic subtotal cholecystectomy for severe cholecystitis. Surg Endosc. 2003;17:1437–9. [51] Palanivelu C, Rajan PS, Jani K, et al. Laparoscopic cholecystectomy in cirrhotic patients: the role of subtotal cholecystectomy and its variants. J Am Coll Surg 2006;203:145–51. [52] Michalowski K, Bornman PC, Krige JE, et al. Laparoscopic subtotal cholecystectomy in patients with complicated acute cholecystitis or fibrosis. Br J Surg 1998;85:904 – 6. [53] Livingston EH, Rege RV. Technical complications are rising as common duct exploration is becoming rare. J Am Coll Surg 2005; 201:426 –33. [54] Nathanson LK, O’Rourke NA, Martin IJ, et al. Postoperative ERCP versus laparoscopic choledochotomy for clearance of selected bile duct calculi: a randomized trial. Ann Surg 2005;242:188 –92. [55] Cuschieri A, Lezoche E, Morino M, et al. E.A.E.S. multicenter prospective randomized trial comparing two-stage vs single-stage management of patients with gallstone disease and ductal calculi. Surg Endosc 1999;13:952–7. [56] Neoptolemos JP, Carr-Locke DL, Fossard DP. Prospective randomised study of preoperative endoscopic sphincterotomy versus surgery alone for common bile duct stones. Br Med J (Clin Res Ed) 1987; 294:470 – 4. [57] Kapoor R, Kaushik SP, Saraswat VA, et al. Prospective randomized trial comparing endoscopic sphincterotomy followed by surgery with surgery alone in good risk patients with choledocholithiasis. HPG Surg 1996;9:145– 8. [58] Martin DJ, Vernon DR, Toouli J. Surgical versus endoscopic treatment of bile duct stones. Cochrane Database Syst Rev 2006: CD003327. [59] ACGME Web site. Available at: https://www.acgme.org/acWebsite/ RRC_440/440_info.asp #16. Accessed January 8, 2007.
114
B.C. Visser et al. / The American Journal of Surgery 195 (2008) 108 –114
[60] Widdison AL, Norton S, Armstrong CP. Open cholecystectomy in the age of the laparoscope. Ann R Coll Surg Engl 1995;77:256 – 8. [61] Boberg J. Surgical Operative Log Reports, Residency Review Committee for Surgery, Accreditation Council for Graduate Medical Education, Chicago, IL, 1992–1993. [62] Dunham R, Sackier JM. Is there a dilemma in adequately training surgeons in both open and laparoscopic biliary surgery? Surg Clin N Am 1994;74:913–21. [63] Birkmeyer JD, Stukel TA, Siewers AE, et al. Surgeon volume and operative mortality in the United States. N Engl J Med 2003;349:2117–27. [64] Stewart L, Way LW. Bile duct injuries during laparoscopic cholecystectomy. Factors that influence the results of treatment. Arch Surg 1995;130:1123– 8. [65] Sosa JA, Bowman HM, Gordon TA, et al. Importance of hospital volume in the overall management of pancreatic cancer. Ann Surg 1998;228:429 –38.
[66] Accreditation Council for Graduate Medical Education (ACGME). Developing a Competency-based Curriculum. Available at: http:// www.acgme.org/outcome/e-learn/e_powerpoint.asp. Accessed January 8, 2007. [67] Intercollegiate Surgical Curriculum Project. Available at: www. iscp.ac.uk. Accessed January 8, 2007. [68] Grober ED, Jewett MA. The concept and trajectory of “operative competence” in surgical training. Can J Surg 2006;49:238 – 40. [69] Aggarwal R, Moorthy K, Darzi A. Laparoscopic skills training and assessment. Br J Surg 2004;91:1549 –58. [70] Strasberg SM. Biliary injury in laparoscopic surgery: part 2. Changing the culture of cholecystectomy. J Am Coll Surg 2005; 201:604 –11. [71] Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995;180:101–25.
Review
Open cholecystectomy in the laparoendoscopic era Brendan C. Visser, M.D.a,*, Rowan W. Parks, M.D., F.R.C.S.(Ire)b, O. James Garden, M.D., F.R.C.S.(Ed)b a
Department of Surgery, Stanford University School of Medicine, Palo Alto, CA, USA b Department of Surgery, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK Manuscript received February 20, 2007; revised manuscript April 3, 2007
Abstract Laparoscopic cholecystectomy has all but replaced the traditional open approach. Hence open cholecystectomy (OC) is principally reserved for cases in which laparoscopy fails, leaving fewer surgeons with experience in the procedure required for the most challenging cases. This review of OC includes discussion of the indications for a primary open approach, conversion from laparoscopy, technical aspects of OC, and alternatives (cholecystostomy and subtotal cholecystectomy). Strategies for safe OC must be formally addressed in residency programs. © 2008 Excerpta Medica Inc. All rights reserved. Keywords: Open cholecystectomy; Cholecystostomy; Conversion; Surgical training; Subtotal cholecystectomy; Open common bile duct exploration
Since its introduction in the late 1980s, laparoscopic cholecystectomy (LC) has all but replaced open cholecystectomy (OC). The laparoscopic approach, used in 75% to 95% of cases, is now referred to widely as the “gold standard” for management of symptomatic gallstone disease [1,2]. There is overwhelming evidence that LC offers patients less pain, shorter hospitalization, and faster recovery [3]. The decreasing frequency of OC in clinical practice is, of course, reflected in a reduction in training opportunities. Nonetheless, the procedure remains the fallback gold standard in the operating theater and the courtroom with respect to safety and success, particularly in complicated cases [4,5]. OC is thus reserved principally for cases where laparoscopic surgery fails with the resulting paradox that fewer surgeons have experience of the technique required for the most difficult cases. This review of OC includes discussion of the indications for a primary open approach, conversion from LC (which underpins any discussion of OC in the modern era), technical aspects of OC and its alternatives, and considerations in training young surgeons to perform safe OC in the laparoendoscopic era. Indications for OC After the initial introduction of LC, there were several “relative” contraindications to laparoscopy—previous upper abdominal surgery, pregnancy and cirrhosis. Subsequently, * Corresponding author. Tel.: ⫹1-650-849-1910; fax: ⫹1-650-852-3430. E-mail address: [email protected]
LC has been proven to be feasible and safe, if not superior in each of these settings [6 – 8]. The physiologic changes associated with pneumoperitoneum favor laparotomy very occasionally in patients with severe cardiopulmonary disease [9,10]; however, with careful anesthetic management, preoperative morbidity is not per se a contraindication to attempting LC [11,12]. Hence, after 15 years of evolving technique and experience with LC, there are very few strict indications for beginning a cholecystectomy as an open operation. The most common reason for OC is likely that the cholecystectomy is to be performed in conjunction with another procedure requiring laparotomy, whether the cholecystectomy is required for the operation (eg, during right hepatectomy) or because the patient suffers biliary colic in addition to the more pressing reason for laparotomy (eg, during colectomy). In this setting, the gallbladder is typically minimally diseased and the operation is straightforward. Only 2 specific gallbladder-related diseases demand OC. Suspected gallbladder cancer is widely considered as a strong indication for open cholecystectomy [13,14]. While not precluding further radical resection [15], LC prior to definitive management appears to worsen the prognosis of gallbladder cancer [14,16]. Hence, in cases where gallbladder cancer is suspected based on prior imaging, the patient should be referred to a surgeon prepared in the first instance to perform a “radical” cholecystectomy, including a partial segment IV/V liver resection and lymphadenectomy of the hepatoduodenal ligament [14]. However, it is worth noting
0002-9610/08/$ – see front matter © 2008 Excerpta Medica Inc. All rights reserved. doi:10.1016/j.amjsurg.2007.04.008
B.C. Visser et al. / The American Journal of Surgery 195 (2008) 108 –114
109
that the recommendation favoring OC in cases of preoperatively suspected gallbladder cancer remains somewhat problematic, given that as many as two thirds of gallbladder cancers are discovered incidentally at surgery or in the specimen [17,18]. The second indication for OC, Mirizzi syndrome, is similarly challenging to diagnose with certainty preoperatively [19]. Type I Mirizzi syndrome, with extrinsic compression of the hepatic duct, may be treated successfully by laparoscopic means in experienced hands [20,21]. However, whether diagnosed preoperatively or intraoperatively, type II Mirizzi syndrome (cholecystobiliary fistula) remains a clear indication for OC [19,22,23]. The management of the choledochal defect encountered with type II Mirizzi is often complex, requiring biliary-enteric bypass or occasionally more creative solutions [24,25]. Hence, both of the indications for primary OC should likely be referred to surgeons with significant experience in complex biliary surgery. Conversion During Laparoscopic Cholecystectomy Thus, while a small proportion of OC are performed open primarily, the majority of OC currently follow conversion from LC. The range of conversion rates reported in the literature is quite wide; however, in most series it is less than 10%, and in some closer to 1% to 2% [26,27]. Often conversion is reported as a “complication” of LC, and individual surgeons and institutional series trumpet low conversion rates. A number of important “risk factors” have been identified that predict conversion—male gender, extreme old age, obesity, previous surgery, severe disease, and emergency LC for acute cholecystitis [27]. Ultimately, however, the individual surgeon is left with their own subjective intraoperative assessment, weighing the severity of the inflammatory changes, clarity of the anatomy, and his or her own skill/comfort in proceeding. Yet our surgical culture subtly suggests that conversion to OC represents failure. In addition, many young surgeons, given little experience with OC, may be more comfortable continuing to struggle laparoscopically than to simply convert. In those cases that ultimately require conversion to safely remove the gallbladder, these factors may contribute to unnecessarily long operative times, or worse, avoidable bile duct injuries. Although the early surge seen in the 1990s has subsided, the incidence of bile duct injury during LC remains between 1 per 200 and 1 per 500 cases, twice that seen in the era of OC [28]. This iatrogenic catastrophe is associated with significant short- and long-term morbidity and even mortality, and almost uniformly results in costly litigation against the injuring surgeon [5]. Misinterpretation of the perceived anatomy rather than any fault in technical skill is the overwhelming cause of bile duct injury during LC [29]. A variety of operative dissection strategies have been described to minimize the risk of bile duct injury; the most reliable is likely the “critical view” technique described by Strasberg [30]. To achieve the “critical view,” the triangle of Calot is dissected free of all tissue except for the cystic duct and artery, and the base of the liver bed is exposed (Fig. 1). Thus, the 2 structures entering the gallbladder can only be the cystic duct and artery, and the common bile duct need not be exposed. Though more controversial, another
Fig. 1. Strasberg’s “critical view.” The triangle of Calot is dissected free of all tissue except for cystic duct and artery, and the base of the liver bed is exposed. Reprinted from [71], with permission from The American College of Surgeons.
key strategy for avoiding bile duct injuries is routine (or at least very liberal) cholangiography [28]. Cholangiography likely reduces the risk of bile duct injury, and certainly results in more prompt recognition if an injury does occur [31,32]. Neither of these strategies will allow safe removal of the gallbladder in all situations. In difficult cases, be it due anatomic confusion, fusion of dissection planes, failure to progress, or poor visualization, the prudent maneuver remains conversion to OC. Conversion to conventional OC does translate clearly into longer operative times, longer hospitalization, and higher morbidity compared to successful LC [26]. However, given the predictors for conversion, most morbidity associated with conversion to OC may be ascribed to the patients’ comorbidities and severity of gallbladder disease, rather than the conventional incision itself. The results of routine OC in the pre-laparoscopic era [33,34] and the few randomized trials available [3] demonstrate that LC offers shorter hospital stay and a quicker convalescence but no noteworthy difference in significant complications or mortality. Furthermore, the morbidity related to conversion to a safe OC is clearly much less than that of iatrogenic bile duct injury. Open Cholecystectomy: Technical Aspects OC can be performed by 2 basic techniques: “antegrade” (beginning the dissection medially in the hepatoduodenal ligament) or “retrograde” (from the fundus downward). As in LC, the former technique commences with dissection of the peritoneum overlying the triangle of Calot to allow identification of the cystic artery and duct, achieving the same “critical view” as during LC. Once the artery and duct are ligated and divided (and cholangiogram performed if appropriate), the gallbladder is freed from the cystic plate in the subserosal plane. This can be accomplished either from the infundibulum up (in the manner of LC) or from the fundus down (more common in OC). The advantages of
110
B.C. Visser et al. / The American Journal of Surgery 195 (2008) 108 –114
early dissection of the cystic duct/artery are that their identification may be easier in a bloodless field, and that freeing the gallbladder from the liver bed may be less bloody. The more traditional method of OC is the retrograde (“topdown”) technique, in which the dissection begins at the fundus and proceeds toward the hepatoduodenal ligament. This strategy allows sure identification of the cystic duct and artery, as they remain the sole attachments once the gallbladder is freed from the cystic plate. In cases where the gallbladder is normal or minimally inflamed, the antegrade technique may be convenient, bloodless, and particularly appropriate for teaching anatomy to junior trainees. Interestingly, in a recent audit of cholecystectomy at the Royal Infirmary of Edinburgh, almost half of OCs since 2000 were performed in antegrade fashion, possibly because the younger surgeons responsible for much of the emergency general surgery are more comfortable with this technique (unpublished data). However, the retrograde technique for OC may have advantage in certain settings. In acute cholecystitis, acute inflammation and induration render the initial dissection within the triangle of Calot less safe, particularly given that most OCs have been converted from LCs for just this reason. However, even the traditional retrograde technique will not avoid trouble in all cases. Occasionally, as a result of severe acute on chronic inflammation, the medial aspect of the infundibulum is fused to the common bile duct, obliterating the triangle of Calot. Persistence in these cases may not only result in bile duct injury, but occasionally in life-threatening injuries to the vascular structures of the hepatoduodenal ligament. For the general surgeon faced with a difficult OC, the first and perhaps best option is an intraoperative consultation with a colleague more experienced in hepatobiliary surgery. This may serve to reduce the chance of misadventure, and mitigates the consequences of litigation if an injury does occur. If this option is not available, the best tactic may be retreat. Although taught traditionally to come away with a prize, the surgeon must appreciate that the benefit to the patient of completing the cholecystectomy is never as important as avoiding injury. Occasionally, cholecystostomy represents the best approach, but most often, subtotal cholecystectomy provides a definitive but safe solution. Alternatives: Cholecystostomy and Subtotal Cholecystectomy In particularly difficult cases, 2 alternatives to OC may be employed that have received little attention in recent years, cholecystostomy and subtotal cholecystectomy. OC was historically performed under local anesthesia for elderly patients suffering from acute cholecystitis who were deemed to be too high-risk for general anesthesia [35,36]. Percutaneous cholecystostomy has largely supplanted its open counterpart in critically ill patients, because it can be performed at the bedside under ultrasound guidance and avoids the morbidity of the (albeit small) incision [37,38], though perhaps at a cost of a higher rate of local complications [39,40]. Hence, few young surgeons have performed an open cholecystectomy. Nonetheless, cholecystostomy remains a “bail out” option in cases where severe inflammatory changes, difficult anatomy, or bleeding make the in-
Fig. 2. Open cholecystostomy. The Malecot drain is secured into the fundus with a purse-string suture. Reprinted with permission from [35].
tended cholecystectomy unsafe. Cholecystostomy may be performed both laparoscopically or after conversion to laparotomy. In order to perform an OC, a purse-string suture is first placed in the fundus and a small incision made to allow evacuation of bile and removal of any accessible stones. A large Malecot or mushroom catheter is introduced into the gallbladder, secured with the purse-string, and brought out a separate stab wound in the abdominal wall (Fig. 2). Placing the omentum around the tube facilitates tract formation and may reduce the risk of bile leakage into the peritoneal cavity. Finally, a separate subhepatic drain should be placed. Although an important alternative to OC, cholecystostomy does suffer several drawbacks. This technique cannot be readily performed for true gangrenous cholecystitis or following significant surgical trauma to the gallbladder during dissection aimed at cholecystectomy. Furthermore, even after resolution of the acute process, the local complications and morbidity associated with the tube are significant (including tube dislodgement or obstruction, biliary fistula, abscess, bile leak/peritonitis). The management of cholecystostomy tubes after resolution of the acute episode can be controversial, especially given that they are often utilized in patients with significant comorbidities or very severe illness. In cases of true acalculous cholecystitis, once the physiologic stress has resolved and hence inflammation resolved, cholecystectomy is not mandatory [41]. However, if the patient is deemed appropriate for interval cholecystectomy, the tube should be left in place until the time of surgery. An adequate delay, approximately 3 months, is desirable to allow resolution of the inflammation and results in a lower rate of conversion at subsequent LC [42]. For those patients deemed poor candidates for interval cholecystectomy, a cholecystogram is performed after 10 to 14 days. If contrast passes freely into the bile duct and duodenum, and a fistulogram from the skin confirms a well-formed tract (without leakage of contrast into the peritoneal cavity), the tube may be withdrawn safely. The bile fistula will close over the course of a few days. Finally, though occasionally reported, endoscopic cholecystolithotripsy is rarely indicated [43]. Overall, while cholecystostomy may be definitive in selected patients [38,44], the majority of patients do require subsequent interval cholecystectomy [45]. The preferred alternative to OC in difficult cases is therefore subtotal cholecystectomy. This operation was de-
B.C. Visser et al. / The American Journal of Surgery 195 (2008) 108 –114
111
wall of the gallbladder abutting the cystic plate may be left in place to avoid inadvertent injury to the tributaries of the middle hepatic vein in the gallbladder bed. Diathermy is applied to the exposed mucosa to reduce the theoretical risk of mucocele, and a drain should be left in place. Routine and determined efforts to suture the orifice of the cystic duct cannot be recommended, given that the cystic duct is almost uniformly obstructed and the significant risk of misadventure in the context of anatomic distortion caused by severe inflammation. If a postoperative biliary fistula occurs, it can be managed safely later by endoscopic stenting. Subtotal cholecystectomy often provides a definitive but safe solution and avoids the potential complications associated with cholecystostomy. Both of the above alternatives to cholecystectomy can, of course, be performed laparoscopically. Laparoscopic cholecystostomy has been offered as an alternative to conversion to open surgery when inflammation precludes safe LC [48,49]. The technique is similar to that of its traditional open counterpart but uses a 16-F Foley catheter (through the midclavicular 5 mm port site) rather than a Malecot [48]. Although this strategy can prove successful, it should likely be reserved for very rare cases. For most patients, it is preferable to convert to OC and complete the cholecystectomy at the first anesthetic (keeping in mind that despite the above description of alternatives to OC, in the great majority of LC cases that require to conversion, the gallbladder can be safely removed via laparotomy). Similarly, laparoscopic subtotal cholecystectomy has been offered as an alternative to conversion [50]. The advantages of this approach are most striking in patients with cirrhosis [51]. Experienced laparoscopic surgeons do employ this strategy with safety and acceptable morbidity (bile leaks, spilled/lost stones, recurrent problems with stones in the remnant) in cases of severe acute cholecystitis [8,52]. However, although no meaningful direct comparison of subtotal LC versus conversion to OC (completing the cholecystectomy in most cases) will ever be possible, the latter should likely remain the default choice for most general surgeons. Again, for most patients the drawbacks of OC do not merit the potential risks and morbidity of subtotal LC in less experienced hands. In particular, the use of the endoscopic linear stapler (eg, Endo-GIA; Tyco/US Surgical, Norwalk, CT) to divide and close the infundibulum during attempted subtotal LC may result in very serious common duct injuries. Fig. 3. Subtotal cholecystectomy as classically described by Bornman and Terblanche. They recommended over-sewing the cut edge for hemostasis (B), and tying or purse-stringing the cystic duct where possible (B, inset). Reprinted from [47], with permission from Mosby.
scribed initially in classical operative texts [46], and more recently championed by Bornman and Terblanche (Fig. 3) [47]. During retrograde OC, when it becomes apparent that further dissection toward the hepatoduodenal ligament is unsafe, the gallbladder is transected to leave a 1- to 2-cm rim of the infundibulum/Hartmann’s pouch, avoiding the dangerous dissection into the thickened cystic plate that fuses the posterior wall of the gallbladder to the at-risk right hepatic and common hepatic ducts. In cases of very severe inflammation or any bleeding diathesis, the entire posterior
Open Common Bile Duct Exploration To a greater degree than even OC, open common bile duct exploration (CDE) has become rare in clinical practice— declining almost 85% since the popularization of endoscopic retrograde cholangiopancreatography (ERCP) in the 1980s [53]. The bulk of choledocholithiasis is managed by ERCP, and much of the recent literature centers on the relative merits of ERCP versus the emerging technology of laparoscopic bile duct exploration [54,55]. Laparoscopic duct exploration during LC requires fewer procedures overall, shortens hospitalization, and is less expensive. However, this technique has not gained widespread popularity because of both the technical expertise required, and the time and equipment demands in the operating theatre. In the era of
112
B.C. Visser et al. / The American Journal of Surgery 195 (2008) 108 –114
OC, open CDE was demonstrated superior to ERCP in successfully clearing the bile duct and was associated with many fewer procedures [55–57]. If choledocholithiasis is discovered during LC on intraoperative cholangiogram and laparoscopic CDE fails or is not available, conversion to laparotomy for open CDE remains is not routinely recommended. However, if OC is required for other reasons, common duct stones should be ideally removed at the same time [58]. Furthermore, if choledocholithiasis is diagnosed preoperatively and preoperative ERCP fails to clear the duct, conversion is certainly preferable to further attempts at endoscopic duct clearance. As open CDE becomes exceptional in many operating theaters, a surgeon’s request for a T-tube is met with blank stares, and the stone forceps may have been prematurely sent to a museum. Efforts should be made to hold on to these basic tools and retain the skill set to perform open CDE. Alarmingly, as experience in open CDE diminishes, the rate of complications has risen quite markedly—approximately 5-fold since the popularization of ERCP in a recent analysis of US national hospital discharge data [53]. Given this concerning trend, open CDE, like its newer laparoscopic counterpart, is progressively becoming “specialized” biliary surgery. Cases where open CDE is anticipated preoperatively should be referred appropriately. Surgeons with little training in open CDE should enlist a more experienced colleague whenever possible. However, if during OC unanticipated choledocholithiasis is found and a surgeon experienced in open CDE is not available, it might be prudent to forego open exploration in favor of postoperative ERCP. Training Surgeons in Open Biliary Surgery The ascendancy of LC and ERCP in clinical practice has left relatively few training opportunities in open biliary surgery. In the United States, the average general surgical resident completing training in 2004 had performed just 12.6 OCs (declining further from 15.5 in 2000), in contrast to more than 90 LCs [59]. Trainees in the United Kingdom face a similar paucity of open cases [60]. Open CDEs are even more scarce— down from an average of just 7.3 for 1993 US trainees [61], to 1.7 for those graduating in 2005 (with a mode of 1) [59]. Furthermore, very few of these cases are straight-forward, often making them less appropriate as “teaching cases.” The potential for this problem in training adequately surgeons in open biliary surgery was recognized early in the evolution of LC. In 1994, in an invited commentary on the issue, Jonathan Sackier stated that “there is no dilemma,” because the means to ensure adequate training remain “a thorough knowledge of the basic sciences, requisite technical skills, sufficient clinical experience, and the integrity and humility to make sound judgment calls” [62]. He compares the evolution from OC to LC to the transition to arthroscopy in orthopedics and transurethral prostatectomy in urology. While this comparison has some merit, it is clear that there remains a need for open gallbladder surgery. Furthermore, there is widespread pressure in surgery to move towards increasing centralization of complex operations given the growing recognition of the relationship between volume and outcome for many procedures [63], including specifically
pancreaticobiliary surgery [64,65]. Among Sackier’s principles of training, 2 of the 4 are potentially problematic: “requisite technical skills” and “sufficient clinical experience.” These cannot be taught exclusively in a classroom and they may not be entirely transferable between minimally invasive and traditional techniques. Nevertheless, there are some solutions. In completing 5 or more years of clinical training, surgical residents have participated in a large number of emergency gastrointestinal and trauma operations. The principles learned and experience gained from these cases are applicable to urgent biliary surgery. Furthermore, strategies to deal with rare but challenging situations (eg, Ladd’s procedure for midgut volvulus) are taught throughout residency. Given the relative paucity of these cases, greater attention to training in open biliary surgery should be given in formal and informal teaching. Elective operations for pancreaticobiliary tumors, chronic pancreatitis, and biliary-enteric bypass also provide valuable occasions to teach principles of open biliary surgery. However, these solutions are rooted in the traditional “apprenticeship” model of surgical training. In recent years, surgical educators in North America and the United Kingdom are placing greater emphasis on structured curriculums that stress objective assessment of competence [66 – 68] and, particularly in laparoscopic surgery, laboratory-based skills training [69]. It is unclear whether this trend could impact training in open biliary surgery. Perhaps if an appropriate simulation model for laparoscopic CDE is developed and manufactured, such a model could be used to acquaint trainees with the techniques and tools of open CDE. Fundamentally, however, the “requisite technical skills” and “sufficient clinical experience” must still be taught in the operating theater, but during fewer and fewer discrete opportunities. Conclusions In the era of LC and ERCP, OC and open CDE grow increasingly rare in training and clinical practice. We must therefore, as Strasberg suggests, “change the culture of cholecystectomy” [70]. Efforts to improve formal training in LC, aimed particularly at avoidance of bile duct injury, must continue. OC and open CDE can no longer be regarded as routine general surgery operations. Hence the acquisition of these skills during general surgery training must not be taken for granted, and strategies for safe OC must be formally addressed in residency programs. Surgeons who are inexperienced in these procedures should have a low threshold for recruiting assistance or referring to colleagues with greater expertise in biliary surgery. References [1] Sain AH. Laparoscopic cholecystectomy is the current “gold standard” for the treatment of gallstone disease. Ann Surg 1996;224:689 –90. [2] Begos DG, Modlin IM. Laparoscopic cholecystectomy: from gimmick to gold standard. J Clin Gastroenterol 1994;19:325–30. [3] Keus F, de Jong JA, Gooszen HG, van Laarhoven CJ. Laparoscopic versus open cholecystectomy for patients with symptomatic cholecystolithiasis. Cochrane Database Syst Rev 2006:CD006231. [4] McSherry CK. Cholecystectomy: the gold standard. Am J Surg 1989; 158:174 – 8.
B.C. Visser et al. / The American Journal of Surgery 195 (2008) 108 –114 [5] McLean TR. Risk management observations from litigation involving laparoscopic cholecystectomy. Arch Surg 2006;141:643– 8. [6] Karayiannakis AJ, Polychronidis A, Perente S, et al. Laparoscopic cholecystectomy in patients with previous upper or lower abdominal surgery. Surg Endosc 2004;18:97–101. [7] Glasgow RE, Visser BC, Harris HW, et al. Changing management of gallstone disease during pregnancy. Surg Endosc 1998;12:241– 6. [8] Ji W, Li LT, Wang ZM, et al. A randomized controlled trial of laparoscopic versus open cholecystectomy in patients with cirrhotic portal hypertension. World J Gastroenterol 2005;11:2513–7. [9] Kraut EJ, Anderson JT, Safwat A, et al. Impairment of cardiac performance by laparoscopy in patients receiving positive end-expiratory pressure. Arch Surg 1999;134:76 – 80. [10] Gebhardt H, Bautz A, Ross M, et al. Pathophysiological and clinical aspects of the CO2 pneumoperitoneum (CO2-PP). Surg Endosc 1997; 11:864 –7. [11] Stuttmann R, Paul A, Kirschnik M, et al. Preoperative morbidity and anaesthesia-related negative events in patients undergoing conventional or laparoscopic cholecystectomy. Endosc Surg Allied Technol 1995;3:156 – 61. [12] Gerges FJ, Kanazi GE, Jabbour-Khoury SI. Anesthesia for laparoscopy: a review. J Clin Anesth 2006;18:67–78. [13] Steinert R, Nestler G, Sagynaliev E, et al. Laparoscopic cholecystectomy and gallbladder cancer. J Surg Oncol 2006;93:682–9. [14] Weiland ST, Mahvi DM, Niederhuber JE, et al. Should suspected early gallbladder cancer be treated laparoscopically? J Gastrointest Surg 2002;6:50 – 6. [15] Fong Y, Jarnagin W, Blumgart LH. Gallbladder cancer: comparison of patients presenting initially for definitive operation with those presenting after prior noncurative intervention. Ann Surg 2000;232:557– 69. [16] Gall FP, Kockerling F, Scheele J, et al. Radical operations for carcinoma of the gallbladder: present status in Germany. World J Surg 1991;15:328 –36. [17] Wullstein C, Woeste G, Barkhausen S, et al. Do complications related to laparoscopic cholecystectomy influence the prognosis of gallbladder cancer? Surg Endosc 2002;16:828 –32. [18] Varshney S, Buttirini G, Gupta R. Incidental carcinoma of the gallbladder. Eur J Surg Oncol 2002;28:4 –10. [19] Lai EC, Lau WY. Mirizzi syndrome: history, present and future development. Aust NZ J Surg 2006;76:251–7. [20] Yeh CN, Jan YY, Chen MF. Laparoscopic treatment for Mirizzi syndrome. Surg Endosc 2003;17:1573– 8. [21] Rohatgi A, Singh KK. Mirizzi syndrome: laparoscopic management by subtotal cholecystectomy. Surg Endosc 2006;20:1477– 81. [22] Schafer M, Schneiter R, Krahenbuhl L. Incidence and management of Mirizzi syndrome during laparoscopic cholecystectomy. Surg Endosc 2003;17:1186 –90. [23] Tan KY, Chng HC, Chen CY, et al. Mirizzi syndrome: noteworthy aspects of a retrospective study in one centre. Aust NZ J Surg 2004;74:833–7. [24] Baer HU, Matthews JB, Schweizer WP, et al. Management of the Mirizzi syndrome and the surgical implications of cholecystcholedochal fistula. Br J Surg 1990;77:743–5. [25] Bower TC, Nagorney DM. Mirizzi syndrome. HPG Surg 1988;1:67– 74. [26] Livingston EH, Rege RV. A nationwide study of conversion from laparoscopic to open cholecystectomy. Am J Surg 2004;188:205–11. [27] Tang B, Cuschieri A. Conversions during laparoscopic cholecystectomy: risk factors and effects on patient outcome. J Gastrointest Surg 2006;10:1081–91. [28] Connor S, Garden OJ. Bile duct injury in the era of laparoscopic cholecystectomy. Br J Surg 2006;93:158 – 68. [29] Way LW, Stewart L, Gantert W, et al. Causes and prevention of laparoscopic bile duct injuries: analysis of 252 cases from a human factors and cognitive psychology perspective. Ann Surg 2003;237: 460 –9. [30] Strasberg SM. Avoidance of biliary injury during laparoscopic cholecystectomy. J Hepatobiliary Pancreat Surg 2002;9:543–7. [31] Archer SB, Brown DW, Smith CD, et al. Bile duct injury during laparoscopic cholecystectomy: results of a national survey. Ann Surg 2001;234:549 –58. [32] Gigot J, Etienne J, Aerts R, et al. The dramatic reality of biliary tract injury during laparoscopic cholecystectomy. An anonymous multicenter Belgian survey of 65 patients. Surg Endosc 1997;11:1171– 8.
113
[33] Moreaux J. Prospective study of open cholecystectomy for calculous biliary disease. Br J Surg 1994;81:116 –9. [34] Roslyn JJ, Binns GS, Hughes EF, et al. Open cholecystectomy. A contemporary analysis of 42,474 patients. Ann Surg 1993;218:129 –37. [35] Glenn F. Cholecystostomy in the high risk patient with biliary tract disease. Ann Surg 1977;185:185–91. [36] Skillings JC, Kumai C, Hinshaw JR. Cholecystostomy: a place in modern biliary surgery? Am J Surg 1980;139:865–9. [37] Patel M, Miedema BW, James MA, et al. Percutaneous cholecystostomy is an effective treatment for high-risk patients with acute cholecystitis. Am Surg 2000;66:33–7. [38] Sugiyama M, Tokuhara M, Atomi Y. Is percutaneous cholecystostomy the optimal treatment for acute cholecystitis in the very elderly? World J Surg 1998;22:459 – 63. [39] Spain DA, Bibbo C, Ecker T, et al. Operative tube versus percutaneous cholecystostomy for acute cholecystitis. Am J Surg 1993;166:28 –31. [40] Ghahreman A, McCall JL, Windsor JA. Cholecystostomy: a review of recent experience. Aust NZ J Surg 1999;69:837– 40. [41] Patterson EJ, McLoughlin RF, Mathieson JR, et al. An alternative approach to acute cholecystitis. Percutaneous cholecystostomy and interval laparoscopic cholecystectomy. Surg Endosc 1996;10:1185– 8. [42] Berber E, Engle KL, String A, et al. Selective use of tube cholecystostomy with interval laparoscopic cholecystectomy in acute cholecystitis. Arch Surg 2000;135:341– 6. [43] Wong SK, Yu SC, Lam YH, Chung SS. Percutaneous cholecystostomy and endoscopic cholecystolithotripsy in the management of acute cholecystitis. Surg Endosc 1999;13:48 –52. [44] Davis CA, Landercasper J, Gundersen LH, et al. Effective use of percutaneous cholecystostomy in high-risk surgical patients: techniques, tube management, and results. Arch Surg 1999;134:727–31. [45] Weigelt JA, Norcross JF, Aurbakken CM. Cholecystectomy after tube cholecystostomy. Am J Surg 1983;146:723– 6. [46] Maingot R. Abdominal Operations. East Norwalk, CT: AppeltonCentury-Crofts; 1940. [47] Bornman PC, Terblanche J. Subtotal cholecystectomy: for the difficult gallbladder in portal hypertension and cholecystitis. Surgery 1985;98: 1– 6. [48] Bradley KM, Dempsey DT. Laparoscopic tube cholecystostomy: still useful in the management of complicated acute cholecystitis. J Laparoendosc Adv Surg Tech A 2002;12:187–91. [49] Yang HK, Hodgson WJ. Laparoscopic cholecystostomy for acute acalculous cholecystitis. Surg Endosc 1996;10:673–5. [50] Beldi G, Glattli A. Laparoscopic subtotal cholecystectomy for severe cholecystitis. Surg Endosc. 2003;17:1437–9. [51] Palanivelu C, Rajan PS, Jani K, et al. Laparoscopic cholecystectomy in cirrhotic patients: the role of subtotal cholecystectomy and its variants. J Am Coll Surg 2006;203:145–51. [52] Michalowski K, Bornman PC, Krige JE, et al. Laparoscopic subtotal cholecystectomy in patients with complicated acute cholecystitis or fibrosis. Br J Surg 1998;85:904 – 6. [53] Livingston EH, Rege RV. Technical complications are rising as common duct exploration is becoming rare. J Am Coll Surg 2005; 201:426 –33. [54] Nathanson LK, O’Rourke NA, Martin IJ, et al. Postoperative ERCP versus laparoscopic choledochotomy for clearance of selected bile duct calculi: a randomized trial. Ann Surg 2005;242:188 –92. [55] Cuschieri A, Lezoche E, Morino M, et al. E.A.E.S. multicenter prospective randomized trial comparing two-stage vs single-stage management of patients with gallstone disease and ductal calculi. Surg Endosc 1999;13:952–7. [56] Neoptolemos JP, Carr-Locke DL, Fossard DP. Prospective randomised study of preoperative endoscopic sphincterotomy versus surgery alone for common bile duct stones. Br Med J (Clin Res Ed) 1987; 294:470 – 4. [57] Kapoor R, Kaushik SP, Saraswat VA, et al. Prospective randomized trial comparing endoscopic sphincterotomy followed by surgery with surgery alone in good risk patients with choledocholithiasis. HPG Surg 1996;9:145– 8. [58] Martin DJ, Vernon DR, Toouli J. Surgical versus endoscopic treatment of bile duct stones. Cochrane Database Syst Rev 2006: CD003327. [59] ACGME Web site. Available at: https://www.acgme.org/acWebsite/ RRC_440/440_info.asp #16. Accessed January 8, 2007.
114
B.C. Visser et al. / The American Journal of Surgery 195 (2008) 108 –114
[60] Widdison AL, Norton S, Armstrong CP. Open cholecystectomy in the age of the laparoscope. Ann R Coll Surg Engl 1995;77:256 – 8. [61] Boberg J. Surgical Operative Log Reports, Residency Review Committee for Surgery, Accreditation Council for Graduate Medical Education, Chicago, IL, 1992–1993. [62] Dunham R, Sackier JM. Is there a dilemma in adequately training surgeons in both open and laparoscopic biliary surgery? Surg Clin N Am 1994;74:913–21. [63] Birkmeyer JD, Stukel TA, Siewers AE, et al. Surgeon volume and operative mortality in the United States. N Engl J Med 2003;349:2117–27. [64] Stewart L, Way LW. Bile duct injuries during laparoscopic cholecystectomy. Factors that influence the results of treatment. Arch Surg 1995;130:1123– 8. [65] Sosa JA, Bowman HM, Gordon TA, et al. Importance of hospital volume in the overall management of pancreatic cancer. Ann Surg 1998;228:429 –38.
[66] Accreditation Council for Graduate Medical Education (ACGME). Developing a Competency-based Curriculum. Available at: http:// www.acgme.org/outcome/e-learn/e_powerpoint.asp. Accessed January 8, 2007. [67] Intercollegiate Surgical Curriculum Project. Available at: www. iscp.ac.uk. Accessed January 8, 2007. [68] Grober ED, Jewett MA. The concept and trajectory of “operative competence” in surgical training. Can J Surg 2006;49:238 – 40. [69] Aggarwal R, Moorthy K, Darzi A. Laparoscopic skills training and assessment. Br J Surg 2004;91:1549 –58. [70] Strasberg SM. Biliary injury in laparoscopic surgery: part 2. Changing the culture of cholecystectomy. J Am Coll Surg 2005; 201:604 –11. [71] Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995;180:101–25.