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Gallbladder surgery

1. Fatima alzahraa Jadalla. 14/3/2025
Gallbladder

2. •The gallbladder is a hollow,
pear-like-shaped (piriform)
organ that lies on the cystic
plate (gallbladder bed) under
the liver segments IVB and V.
The cystic plate is a
fibroareolar tissue that
attaches the superior surface
of the gallbladder to the liver
Anatomy and physiology of
gallbladder

4. Of gallbladder
•Location: intraperitoneal organ
•Size and volume
•Length: 7–10 cm
•Width: 2.5 cm (at its widest point)
•Volume
•30–35 mL under normal conditions
•Can hold up to 300 mL if the cystic
duct is obstructed
Anatomy

5. Gallbladder disease
Cholelithiasis
Acute cholecystitis
Ascending cholangitis

6. Cholelithiasis
•Cholelithiasis refers to the presence of abnormal gallstones
in the gallbladder. About 10–20% of American adults have
gallstones. Gallstones most commonly consist of
cholesterol.
•Cholelithiasis can manifest with biliary colic (postprandial
RUQ pain) but is most commonly an incidental finding in
asymptomatic individuals.
• The diagnosis is confirmed by ultrasound.

7. Imbalance in bile salts, lecithin (stabilizer), cholesterol, calcium carbonate, and bilirubin
Biliary stasis is a key component in gallstone formation.
Impaired gallbladder emptying (e.g., pregnancy ) → biliary sludge → bile stasis (cholestasis)
Why ?

8. Risk factor to
cholesterol stones
6F
Fat
Female
Forty
Fair skinned
Fertile
Family history

9. Clinical features
Most gallstones are asymptomatic.
Biliary colic: constant, dull RUQ pain lasting < 6 hours
Especially postprandial: vagal stimulation (e.g.,
cholecystokinin release following a fatty meal) → gallbladder
contraction → attempts to force the stone into the cystic duct
May radiate to the epigastrium, right shoulder, and back
(referred pain)
Nonspecific symptoms
Nausea, vomiting, early satiety
Bloating, dyspepsia
Only a minority of patients with gallstones are
sympathetic

10. Diagnosis & treatment

12. Acute cholecystitis refers to the
acute inflammation of the
gallbladder, which is typically
due to cystic duct obstruction by
a gallstone (acute calculous
cholecystitis )

13. Acute acalculous cholecystitis
Type of cholecystitis
Description: an acute life-threatening necroinflammatory disorder of the gallbladder, usually
seen in critically ill patients, that is not associated with gallstones
Incidence: 5–10% of acute cholecystitis
Etiology: conditions predisposing to bile stasis and reduced perfusion of the gallbladder
Risk factors
Multiorgan failure (critically ill patients)
Severe trauma, burns
Surgery
Sepsis, septic shock
Total parenteral nutrition
Prolonged fasting
Immunodeficiency
Clinical features: similar to acute calculous cholecystitis

14. Diagnostics
Laboratory studies and findings: similar to acute calculous cholecystitis
Imaging
Abdominal ultrasound: preferred initial imaging modality
Supportive findings
Signs of gallbladder inflammation: gallbladder wall thickening (> 3–5 mm), pericholecystic fluid
No evidence of cholelithiasis (sludge may be present)
HIDA scan: preferred confirmatory imaging modality if ultrasound is inconclusive
findings: similar to acute calculous cholecystitis
Treatment
Initial supportive management: NPO, IV fluids, analgesics
IV antibiotics: see “Empiric antibiotic therapy for acute biliary infection”
Source control
Low surgical risk: emergency laparoscopic cholecystectomy
High surgical risk: percutaneous cholecystostomy
If patients do not improve within 2–3 days, cholecystectomy should be performed

15. Emphysematous cholecystitis
Type of cholecystitis
Description: a rare but life-threatening form of acute cholecystitis characterized by air within the gallbladder
wall that is caused by gas-forming bacteria (e.g., Clostridium spp., E.coli)
Epidemiology: rare; most commonly seen in older men with diabetes (esp. 50–70 years of age)
Most common pathogens : Clostridium species, Escherichia coli
Risk factors
Hyperglycemia (e.g., diabetes mellitus)
Immunosuppression
Vascular disease (e.g., atherosclerosis, arterial embolism, vasculitis)
Abdominal surgery, and trauma
Clinical features
Similar to acute calculous cholecystitis: fever, RUQ pain, referred pain
Symptoms progress rapidly.
Associated with early gangrene and gallbladder perforation

16. Diagnostics
Laboratory studies and findings: similar to those of acute calculous cholecystitis
Imaging: The characteristic feature of EC on imaging is air within the gallbladder wall or lumen.
RUQ ultrasound
Noncontrast CT abdomen
Treatment
Initial supportive management: NPO, IV fluids, analgesics
Broad-spectrum IV antibiotics with anaerobic coverage
Surgery
Low surgical risk: emergency laparoscopic cholecystectomy
High surgical risk: gallbladder drainage

17. Complications
Gallbladder empyema
Gallbladder perforation
Gangrenous cholecystitis

18. Acute cholabgitis

19. Acute cholangitis (ascending cholangitis) refers to a bacterial infection of the biliary tract,
typically secondary to biliary obstruction and stasis
.
Charcot cholangitis triad (25–70% of patients present with all three
features)
Abdominal pain (most commonly RUQ)
High fever
Jaundice (least common feature)
Reynolds pentad: Charcot cholangitis triad PLUS hypotension and
mental status changes
Features of sepsis, septic shock, and multiorgan dysfunction may be
present, depending on the severity of disease at presentation.

20. Diagnosis

21. Diagnostic criteria
Charcot triad is not included in the diagnostic criteria because,
although specific, it is not a sensitive criterion and may even be
absent in patients with acute cholangitis.
Then lab tests and imaging