Once the decision for surgery has been made, an operative plan needs to be discussed and implemented. Should one initially start with laparoscopic surgery for the “bad gallbladder”? If a laparoscopic approach is taken, when should bail-out maneuvers be attempted? Is converting to open operation still the standard next step? A 2016 study published by Ashfaq and colleagues sheds some light on our first question. They studied 2212 patients who underwent laparoscopic cholecystectomy, of which 351 were considered “difficult gallbladders.” A difficult gallbladder was considered one that was necrotic or gangrenous, involved Mirizzi syndrome, had extensive adhesions, was converted to open, lasted more than 120 minutes, had a prior tube cholecystostomy, or had known gallbladder perforation. Seventy of these 351 operations were converted to open. The indications for conversion included severe inflammation and adhesions around the gallbladder rendering dissection of triangle of Calot difficult (n 5 37 [11.1%]), altered anatomy (n 5 14 [4.2%]), and intraoperative bleeding that was difficult to control laparoscopically (n 5 6 [1.8%]). The remaining 13 patients (18.5%) included a combination of cholecystoenteric fistula, concern for malignancy, common bile duct exploration for stones, and inadvertent enterotomy requiring small bowel repair. Comparing the total laparoscopic cholecystectomy group and the conversion groups, operative time and length of hospital stay were significantly different; 147 +- 47 minutes versus 185 +- 71 minutes (P<.005) and 3+-2 days versus 5+-3 days (P 5 .011), respectively. There was no significant difference in postoperative hemorrhage, subhepatic collection, cystic duct leak, wound infection, reoperation, and 30-day mortality.2 From these findings, we can glean that most cholecystectomies should be started laparoscopically, because it is safe to do so. It is the authors’ practice to start laparoscopically in all cases.
Despite the best efforts of experienced surgeons, it is sometimes impossible to safely obtain the critical view of safety in a bad gallbladder with dense inflammation and even scarring in the hepatocystic triangle. Continued attempts to dissect in this hazardous region can lead to devastating injury, including transection of 1 or both hepatic ducts, the common bile duct, and/or a major vascular injury (usually the right hepatic artery). Therefore, it is imperative that any surgeon faced with a bad gallbladder have a toolkit of procedures to safely terminate the operation while obtaining maximum symptom and source control, rather than continue to plunge blindly into treacherous terrain. If the critical view of safety cannot be achieved owing to inflammation, and when further dissection in the hepatocystic triangle is dangerous, these authors default to laparoscopic subtotal cholecystectomy as our bail-out procedure of choice. The rationale for this approach is that it resolves symptoms by removing the majority of the gallbladder, leading to low (although not zero) rates of recurrent symptoms. It is safe, and can be easily completed laparoscopically, thus avoiding the longer hospital stay and morbidity of an open operation. There is now significant data supporting this approach. In a series of 168 patients (of whom 153 were laparoscopic) who underwent subtotal cholecystectomy for bad gallbladders, the mean operative time was 150 minutes (range, 70–315 minutes) and the average blood loss was 170 mL (range, 50–1500 mL). The median length of stay for these patients was 4 days (range, 1–68 days), and there were no common bile duct injuries.23 There were 12 postoperative collections (7.1%), 4 wound infections (2.4%), 1 bile leak (0.6%), and 7 retained stones (4.2%), but the 30-day mortality was similar to those who underwent a total laparoscopic cholecystectomy. A systematic review and meta-analysis by Elshaer and colleagues showed that subtotal cholecystectomy achieves comparable morbidity rates compared with total cholecystectomy. These data support the idea that we should move away from the idea that the only acceptable outcome for a cholecystectomy is the complete removal of a gallbladder, especially when it is not safe to do so. This shift toward subtotal cholecystectomy has been appropriately referred to as the safety first, total cholecystectomy second approach.
At a minimum, cessation of exogenous hormones is recommended, followed by serial imaging, as these lesions will shrink when the inciting hormone has been removed. In general, to obtain either CT or MRI every 6 months for the first 2 years and then once annually for lesions that we are following. Intervention is dictated by the risk of hemorrhage and malignant transformation, which is directly correlated to size. Hepatocellular carcinoma is seen in 5% of patients with lesions exceeding 8 cm. The rate of rupture is strongly associated with size > 5 cm.
Surgical resection is recommended for lesions ≥ 5 cm, those that are enlarging, those for which malignancy cannot be excluded, and those that are symptomatic. Additionally, adenomas in men, regardless of size, and especially those that are associated with anabolic steroid use, those with glycogen storage disease, and those that harbor ß-catenin mutations should also be given serious consideration for surgical extirpation.
Pregnant women with HA pose a management challenge. Since adenomas respond to hormones, they can increase in size with pregnancy and thus put the patient at risk for rupturing and bleeding. For women who would like to become pregnant, close monitoring without discouraging the patient’s wish is
recommended for lesions < 5 cm. However, for those patients with lesions > 5 cm or those who had complications from the adenomas from previous pregnancies, we recommend surgical resection prior to proceeding with the pregnancy. In situations where HA is discovered during pregnancy, we recommend close monitoring for lesions < 5 cm. However, for lesions > 5 cm, surgical resection should be considered during the second trimester but delayed in the third trimester since surgical intervention during this trimester is fraught with complications.