Clinical Challenges in Emergency General Surgery: Open Cholecystectomy - “A Lost Art”

When the gallbladder turns hostile, sometimes you must do more than just pause—you have to call in a senior partner for help. Join the Behind the Knife EGS team at Mizzou as we dive into the art and grit of open cholecystectomy. From fundus-first dissection to navigating the “barrier to happiness,” this episode is packed with surgical pearls, tough love, and the kind of wisdom only scars can teach.

Participants:

• Dr. Rushabh Dev FACS (Moderator, Surgical Attending) – Assistant Professor of Surgery, Associate PD ACS & SCCM Fellowship, SICU Medical Director, Lieutenant Commander United States Navy Reserve
• Dr. Jeffery Coughenour FACS (Surgical Attending) – Professor of Surgery and Emergency Medicine, Trauma Medical Director at the University of Missouri SOM
• Dr. Christopher Nelson FACS (Surgical Attending) – Associate Professor of Surgery, Medical Director of Emergency General Surgery at the University of Missouri SOM
• Dr. Micah Ancheta (ACS Fellow) – Major, United States Airforce
• Dr. Desra Fletcher (3rd year general surgery resident)

Learning Objectives:
· Recognize Indications for Conversion
Identify clinical and intraoperative factors that necessitate conversion from laparoscopic to open cholecystectomy.

· Apply Risk Stratification Tools
Utilize grading systems (e.g., Parkland, Tokyo, AAST) to assess cholecystitis severity and predict surgical difficulty.

· Implement Safe Cholecystectomy Techniques
Describe the six steps of the SAGES Safe Cholecystectomy Program to minimize bile duct injury.

· Understand Bailout Strategies
Differentiate between fenestrating and reconstituting subtotal cholecystectomy techniques and their respective risks.

· Master Key Operative Steps
Outline the essential components of open cholecystectomy: positioning, incision, exposure, and dissection.

· Navigate High-Risk Anatomy
Recognize “zones of danger” and use the B-SAFE mnemonic to reorient and ensure safe progression.

· Develop Intraoperative Judgment
Demonstrate when to proceed with subtotal techniques, convert to open, or call for assistance.

· Perform Technical Nuances Safely
Identify proper dissection planes, manage gallbladder bed inflammation, and secure cystic structures with confidence.

· Prevent and Manage Complications
Understand the risks of bile leaks, bilomas, and subcostal hernias—and how to mitigate them through technique and closure.

· Foster Surgical Maturity
Emphasize humility, collaboration, and mentorship in difficult operations—knowing when to ask for help is a skill.

References:
1. Dhanasekara, C. S., Shrestha, K., Grossman, H., Garcia, L. M., Maqbool, B., Luppens, C., ... & Dissanaike, S. (2024). A comparison of outcomes including bile duct injury of subtotal cholecystectomy versus open total cholecystectomy as bailout procedures for severe cholecystitis: A multicenter real-world study. Surgery, 176(5), 605–613. https://doi.org/10.1016/j.surg.2024.03.057
2. Motter, S. B., de Figueiredo, S. M. P., Marcolin, P., Trindade, B. O., Brandao, G. R., & Moffett, J. M. (2024). Fenestrating vs reconstituting laparoscopic subtotal cholecystectomy: A systematic review and meta-analysis. Surgical Endoscopy, 38, 7475–7485. https://doi.org/10.1007/s00464-024-11225-8
3. Brunt, L. M., Deziel, D. J., Telem, D. A., Strasberg, S. M., Aggarwal, R., Asbun, H., ... & Stefanidis, D. (2020). Safe cholecystectomy multi-society practice guideline and state of the art consensus conference on prevention of bile duct injury during cholecystectomy. Surgical Endoscopy.https://www.sages.org/publications/guidelines/safe-cholecystectomy-multi-society-practice-guideline/
4. Elshaer, M., Gravante, G., Thomas, K., Sorge, R., Al-Hamali, S., & Ebdewi, H. (2015). Subtotal cholecystectomy for “difficult gallbladders”: Systematic review and meta-analysis. JAMA Surgery, 150(2), 159–168. https://doi.org/10.1001/jamasurg.2014.1219
5. Koo, S. S. J., Krishnan, R. J., Ishikawa, K., Matsunaga, M., Ahn, H. J., Murayama, K. M., & Kitamura, R. K. (2024). Subtotal vs total cholecystectomy for difficult gallbladders: A systematic review and meta-analysis. The American Journal of Surgery, 229(1), 145–150. https://doi.org/10.1016/j.amjsurg.2023.12.022
6. Strasberg, S. M., Pucci, M. J., Brunt, L. M., & Deziel, D. J. (2016). Subtotal cholecystectomy—“Fenestrating” vs “reconstituting” subtypes and the prevention of bile duct injury: Definition of the optimal procedure in difficult operative conditions. Journal of the American College of Surgeons, 222(1), 89–96. https://doi.org/10.1016/j.jamcollsurg.2015.09.019
7. Ahmed, O., & Walsh, T. N. (2020). Surgical trainee experience with open cholecystectomy and the Dunning-Kruger effect. Journal of Surgical Education.https://doi.org/10.1016/j.jsurg.2020.03.025
8. Seshadri, A., & Peitzman, A. B. (2024). The difficult cholecystectomy: What you need to know. The Journal of Trauma and Acute Care Surgery, 97(3), 325–336. https://doi.org/10.1097/TA.0000000000004156
9. Invited commentary on “A comparison of outcomes including bile duct injury of subtotal cholecystectomy versus open total cholecystectomy as bailout procedures for severe cholecystitis: A multicenter real-world study”. (2024). Surgery, 176(5), 614–615. https://doi.org/10.1016/j.surg.2024.05.003

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