This document compares open and laparoscopic cholecystectomy procedures. Open cholecystectomy is easier to perform and more cost effective, but results in a longer hospital stay and poorer cosmetic outcomes. Laparoscopic cholecystectomy is now the gold standard, providing shorter recovery time and fewer complications, but requires specialized equipment and training and carries a higher risk of duct injuries. Both approaches are appropriate depending on the patient's condition and surgeon's expertise.

1. Cholecystectomy: Open Versus
Laparoscopic Surgery.
Dr Imran Javed.
Associate Professor Surgery.
Fiji National University.

2. Indications
• Chronic Cholecystitis.
• Cholelethiasis.
• Acute on Chronic Cholecystitis.
• Acute Cholecystitis with complications.
• Empyema Gallbladder.
• Gangrenous Gallbladder.
• Perforated Gallbladder.
• Trauma to Gallbladder.
• Choledocholesthiasis.
• As a part of other procedure like Whipple Procedure.
• Carcinoma Gallbladder.
• Direct Invasion of Hepato-cellular carcinoma.
• Metastasis to gall bladder.
• Prophylactic Cholecystectomy in high risk patients.
• Parasitic Infestation of Gallbladder like in Ascariasis.

4. Open Procedure
• Preoperative Considerations:
• Consent
• Nill by mouth for 6 hrs.
• Intravenous Fluids.
• Prophylactic Broad Spectrum Antibiotics.
• Anesthesia fitness for General Anesthesia especially
with related to respiratory function.
• Control of Hypertension & DM in affected patients.
• Arrangement of 1-2 pints of cross-matched blood.
• Correction of Any bleeding or clotting disorder.

6. Operative Method
• Right Sub-costal Incision.
• Right Transverse upper abdominal Incision.
• Upper Midline Incision.
• Muscle Cutting variety of incision.
• Hemostasis.
• Division of Right Rectus Abdomenis Muscle
versus retraction.
• Ligation of Right Superior Epigastric Artery.
• Placement of Retractors and abdominal Sponges.

8. Dissection in Calot’s Triangle
• Use of Sponge Holder to hold fundus of gall
bladder.
• Dissection of Cystic Duct & Cyst Artery by gentle
pull on gallbladder after division of Peritoneal
reflection.
• Ligation and Division of Cystic Artery & Cystic
Duct with Lahey Forceps (Right Angle Forceps).
• Dissection of gallbladder from liver bed.
• Hemostasis.
• Drain Versus no Drain.

11. Closure of the Wound
• After adequate Hemostasis & removal of
abdominal packs closure of posterior rectus
sheath with absorbable sutures.
• Anterior Rectus Sheath is closed in continuous
fashion by Non-Absorbable sutures.
• Skin Closure by Interrupted Sutures.
• Sterile Dressing Techniques.
• Connecting Drain if placed with gravity
drainage container.

13. Postoperative Management
• Nill by mouth till bowl sounds are present.
• Continue Intravenous fluids till patient is oral free.
• Adequate Analgesia.
• Continue Intravenous Antibiotics for 72 hours and then
change to oral for one week.
• Change of dressing if soaked early otherwise after 72 hours.
• Removal of drain when drainage is minimal.
• Removal of Sutures when wound is healed.
• Anti-ulcer therapy if needed.
• DVT Prophylaxis.
• Send specimen for Histopathology and stones for chemical
Analysis if present.

16. Laparoscopic Approach
• Traditional approach is 4 port but SILS has become
available as well now a days.
• Has become a gold standard approach for gallbladder
removal.
• If fails then convert to Open Procedure.
• Difficult to perform in Patients with Previous open
Abdominal Surgeries.
• Carries some increased risk of extra-hepatic duct
injuries.
• Recovery is better and early than open surgery.
• Needs specialized equipment & training of personnel.
• Usually avoided in cases of suspected malignant
Disease.

18. Technical Considerations
• 4 ports (Umbilical, Epigastric & 2 subcostal).
• Umbilical is used for Camera.
• Subcostal (upper to hold gall bladder from neck & Lower
from fundus)
• Epigastric port is for Dissector, Cautery, Sucker, Clip
Placement & removal of Gall bladder.
• Varus Needle for Insufflation of CO2 into the peritoneal
cavity.
• Lower Subcostal port may be used for Drain if needed.
• After surgery Epigastric & Umbilical Port may need one
stich for closure other ports may be closed by sterri-strips
or simple dressing.
• Post Operative Course is early recovery with shorter
hospital stay.

22. Comparison
Open Approach
• Easy.
• Can be done in peripheral
centers.
• Cost effective.
• Less extra hepatic injuries.
• May have more post operative
respiratory complications.
• Cosmetically not good.
• Hospital Stay is longer.
• Usually Reserved for failed
laparoscopic cases &
malignant Disease.
Laparoscopic Approach
• Needs special equipment &
training of personnel.
• Learning Curve & Good Hand eye
coordination needed.
• Cost is higher.
• Extra-hepatic duct injuries are
more than open approach.
• Hospital stay is shorter.
• Lesser post operative
complications.
• Avoided in Malignant Disease.
• If fails then have to proceed
towards open approach.
• Has become Gold standard
treatment for Gall bladder
Surgery.