Several international consensus conferences have defined laparoscopic cholecystectomy as the gold standard in symptomatic cholecystolithiasis. Currently, most surgeons explore all patients this way, leaving themselves the option of converting to open surgery.
The current meta-analysis of randomized trials comparing both techniques demonstrates identical complication rates for laparoscopic cholecystectomy, with a mean shortening of the hospital stay of 3 days and the recovery of 3 weeks. This is also reflected by cost analyses which saw 18% lower inpatient costs for laparoscopic cholecystectomy compared with open cholecystectomy. And the comparison of the current complication rates with historic figures favors laparoscopic over open cholecystectomy as well (biliary leakage 0.4 – 1.5%, wound infection 1.3 – 1.8%, pancreatitis 0.3%, bleeding 0.2 – 1.4%).
While in 1996 an extensive meta-analysis still saw a tendency toward higher rates of bile duct injuries, today the rate of bile duct injuries in cholecystectomy is low (0.2 – 0.4%), irrespective of the surgical technique.
In manifest portal hypertension and cirrhosis of the liver Child A/B, laparoscopic cholecystectomy may be superior to the open procedure, while for Child C patients – but possibly also for patients with a MELD score of 8 – the complication rate in cholecystectomy is rather high.
In case of strongly suspected (advanced) gallbladder cancer, the primary procedure of choice should be open cholecystectomy.
If the presence of a Mirizzi syndrome has been confirmed preoperatively, this does not constitute a contraindication for the laparoscopic procedure; however, particularly when dealing with Mirizzi II (fistula between gallbladder and hepatic duct), the surgeon should readily convert to open surgery.
The randomized trials comparing laparoscopic cholecystectomy and minilaparotomy cholecystectomy (laparotomy incision < 8 cm) did not find any differences between both techniques regarding complication rate, length of hospital stay and length of recovery. Access in open cholecystectomy is via the standard right oblique subcostal (Kocher) incision or right upper transverse incision.
In patients with very wide thoracic aperture, i.e., particularly in men, a somewhat superiorly convex transverse incision is recommended.
The upper transverse incision offers the following benefits compared with the right oblique subcostal access: Nerves remain (almost) completely untouched; the incision may be extended to the left at any time.
Sometimes the gallbladder is so heavily adherent to the liver bed because of chronic inflammation, that complete resection cannot avoid injury to the hepatic parenchyma. In these cases, it is recommended to leave the posterior wall in the liver bed and coagulate the remaining mucosa with the electrocautery.
Once the anatomical situation in Calot’s triangle has been clarified completely, subserous retrograde resection of the gallbladder from the liver bed is recommended. Antegrade resection toward the infundibulum should be reserved for special cases, since this technique increases the intraoperative complication rate.
It is not necessary to suture the liver bed.