Managing the Difficult Gallbladder in Acute Cholecystitis

Abstract

Minimally invasive, or laparoscopic, cholecystectomy is currently the most frequently performed general surgical operation performed within the abdomen, as well as by our surgical trainees. This seemingly straightforward operation takes on increased difficulty, complexity, and risk in the setting of acute inflammation (i.e., acute cholecystitis). While detailed knowledge of preoperative diagnostic tests and early nonsurgical therapies are crucial for all acute care surgeons, the risk of a life-altering bile duct injury makes the intraoperative techniques surrounding laparoscopic cholecystectomy absolutely critical. Enhanced techniques such as obtaining the critical view of safety (anterior and posterior), utilizing a gallbladder “time-out,” and defining regional anatomy (B.E. S.A.F.E.) prior to dividing any structure are absolutely essential. This chapter provides a comprehensive description of the diagnosis, management, and intraoperative technical safety maneuvers that are essential to a successful laparoscopic cholecystectomy.