The Difficult Cholecystectomy

A number of conditions can be associated with increased difficulty of cholecystectomy. These include acute cholecystitis, severe chronic cholecystitis, Mirizzi syndrome, cirrhosis, and other non-gallbladder-related factors such as morbid obesity and extensive previous upper abdominal surgery. Preoperative recognition and awareness as well as modifications of technical strategies are important to a successful outcome and avoiding major complications in these patients. Percutaneous cholecystostomy tube drainage is an important option in patients with severe acute cholecystitis who are too high risk to undergo surgery. At operation, if it is not possible to obtain the critical view of safety, an operative bailout strategy should be considered such as surgical tube cholecystostomy, laparoscopic subtotal cholecystostomy, conversion to an open operation, or aborting the procedure. This chapter will review conditions that increase the difficulty of cholecystectomy and will highlight technical modifications one can employ to enhance the safety of cholecystectomy in these patients.