Difficult Gallbladder – Part 1 Identify the difficult cases

21st October 2023.

Earlier this year, I was invited to speak at the 9th Biennial Congress of the Asian Pacific Hepato Pancreato Biliary Association on the topic of managing a difficult gallbladder.  Unfortunately, I had other commitments and had to decline the invite.  This article will share with you my thoughts and my personal experiences.

When we perform surgery, we do not like surprises. In other words, when we identify the difficult gallbladder beforehand, we are better prepared for the surgery.

Couple of factors below will give us a clue of identifying the difficult cases.

a) Patient factors – Immunocompromised patients such as those with diabetes, patients who are unwell in the intensive care settings, cancer patients on treatment and the elderly.  These patients usually present late.  The infection may have started much earlier before they present with  pain or fevers and signs of sepsis.

b) During the initial presentation. In simple terms, when patients present with pain for more then a week, the infected gallbladder surgery tends to be more challenging.  Cases that present within 24 to 48 hours will be easier to manage.

c) Radiological findings – Scans such as CT, MRI or ultrasound gives us signs of a challenging gallbladder.  When the report uses words such as perforated with lots of free fluid would suggest a difficult case.  I usually look for oedema in the surrounding structures such as the duodenum or colon.  Oedema means swelling.  When the adjacent organs swells up means that the infection has been going on for a period of time.

Another imaging finding I look out for is a contracted gallbladder with stones.  Patients are generally fasted when they go for scans.  In a fasted state, the gallbladder is usually distended.  A contracted gallbladder means that there may be multiple episodes of inflammation previously.  This will cause the  tissue around the bile duct and cystic duct to be thick and hardened, similar to scar tissue.

d) Taking a good history and examining the patient.  Able to assess the patient adequately comes from experience.  Something that can be taught but not easy to master.

Being able to identify the difficult cases will allow better planning.  This would include getting a more experienced surgical assistant, doing the case in a proper hospital instead of a day surgery centre, doing the case during daylight hours in case help is required etc.  Primary objective is to have a safe operation by an experienced surgeon and minimise the risk.

Stay tune for part II.

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