Clinical View Overview

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More detailed content about clinical aspects of the gallbladder...

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Further clinical discussions and case studies...

Gallstone disease

Gallstones are very common affecting around 1 in 12 patients. The presence of gallstones can lead to multiple complications which we will dive into below.

Introduction

• Gallstone disease refers to any symptoms or diseases caused by the presence of gallstones in the biliary system
• Gallstones are hard pebble like material, that develop in the gallbladder.
• Gallstone disease can have a wide variety of presentations and this varies according to the location of the stones in the biliary tract.

Aetiology of stone formation

Stone type	Composition	Prevalence	Cause
Cholesterol	High cholesterol, low electrolytes	80%	5Fs (see below)
Black Pigment	High calcium and bilirubin	15%	Altered bilirubin metabolism
Brown	Calcium and fatty acids	5%	Chronic biliary tract infections

Pathophysiology of gallstones disease

How do Cholesterol stones form?

Black Pigment Stones

Composition

Black pigment stones are primarily composed of calcium bilirubinate, resulting from increased bilirubin in bile.

Haemolytic Disorders

Conditions such as sickle cell disease and spherocytosis increase the risk of black pigment stone formation due to chronic haemolysis.

Cirrhosis

Liver cirrhosis is associated with an increased risk of black pigment stones due to altered bilirubin metabolism.

Bile Salt Loss

Conditions affecting the terminal ileum can lead to bile salt loss, increasing bilirubin reabsorption and stone risk.

Brown Stones:

Biliary Infection

Chronic biliary infections, often due to parasites or bacteria, create an environment conducive to brown stone formation.

Bile Stasis

Reduced bile flow, often due to biliary strictures or previous surgeries, promotes bacterial growth and stone formation.

Stone Composition

Brown stones are composed of calcium salts of fatty acids, resulting from bacterial action on bile components.

Risk factors

The risk factors for formation of cholesterol stones can be remembered by the mnemonic 5Fs.

Clinical Presentation

Summary of stone location vs presentation

Stone Location	Clinical Presentation	Key Features
Gallbladder	Biliary colic	Self limiting episodes of RUQ pain.
Gallbladder neck or Cystic duct	Biliary colic, Acute cholecystitis	RUQ pain, Murphy's sign, fevers, raised inflammatory markers.
Common bile duct	Obstructive jaundice, Cholangitis	Jaundice, fever, abdominal pain, raised billirubin
Ampulla of Vater	Pancreatitis	Epigastric pain, nausea, vomiting, raised amylase.

Diseases associated with gallstones

Biliary Colic

Definition

Biliary colic is a symptom, not a disease, characterised by right upper quadrant or epigastric pain due to contraction of a gallbladder against stones.

Trigger

Often precipitated by fatty meals, which stimulate cholecystokinin release and gallbladder contraction.

Duration

Pain typically lasts for several hours, distinguishing it from other abdominal pain syndromes.

Associated Symptoms

May be accompanied by nausea and vomiting, but notably without fever.

Acute Cholecystitis:

Initial Obstruction

A gallstone becomes lodged in the gallbladder neck, gallbladder neck or Cystic duct obstructing bile flow from the gallbladder.

Inflammation

Trapped bile irritates the gallbladder wall, leading to chemical inflammation.

Bacterial Infection

Stasis of bile creates an ideal environment for bacterial growth, often E. coli, leading to secondary infection.

Progression

Without treatment, inflammation can progress to empyema, gangrene, or perforation.

Clinical Features of Acute Cholecystitis

Pain Characteristics

Persistent right upper quadrant pain, more severe and prolonged than biliary colic. May radiate to the right shoulder or back.

Systemic Symptoms

Fever, chills, and general malaise indicate systemic inflammation. Nausea and vomiting are common.

Physical Examination

• Tenderness in the right upper quadrant, often with guarding. Murphy's sign is typically positive, indicating gallbladder inflammation.
• Murphy's sign:
  • Examiner places fingers gently on the right upper quadrant, just below the costal margin.
  • Patient is asked to take a deep breath, causing the gallbladder to descend and contact the examiner's fingers.
  • A positive Murphy's sign occurs when the patient abruptly halts inspiration due to pain.

Important differentials to consider when assessing Right Upper Quadrant Pain

Gastrointestinal

• Peptic ulcer disease
• Hepatic flexure tumour
• Irritable bowel syndrome

Hepatobiliary

• Acute hepatitis
• Liver abscess
• Budd-Chiari syndrome

Other Systems

• Renal colic
• Right lower lobe pneumonia
• Myocardial infarction (rare)

Investigations for Suspected Gallbladder Disease

Blood Tests

• Rise in inflammatory markers is seen (Raised WCC and raised CRP) due to infection.
• liver function tests
• A rise in ALP and GGT due to inflammation damaging cells in the biliary tract.
• AST and ALT can be mildly raised in uncomplicated cholecystitis, but the rise is to a much lesser extend.
• Bilirubin should be normal in cholecystitis as there is no biliary obstruction.
• Amylase:
• Checked to rule out acute pancreatitis, which can present similarly. This should be normal in uncomplicated cholecystitis.
• Troponin: a myocardial infarction can be an important differential to rule out in upper abdominal disease.
• Chest xray: to rule out right lower lobe pneumonia as a cause for RUQ pain.

Imaging

Abdominal ultrasound is the gold standard for initial imaging, offering high sensitivity for gallstones and signs of inflammation.

• Findings on Ultrasound in cholecsytitis:
• Appear as echogenic foci with acoustic shadowing, often mobile with patient positioning.
• Gallbladder wall >3mm suggests inflammation, characteristic of acute cholecystitis.
• Pericholecystic Fluid
• Indicates more severe inflammation or potential perforation.
• USS should show no evidence of CBD obstruction
• The CBD should be of normal caliber


image depicting an ultrasound of a gallbladder with gallstones. Note tha accousting shadowing formed the stone.

Complications of cholecystitis

Empyema

Accumulation of pus in the gallbladder.

Perforation

Gallbladder wall rupture leading to billiary peritonitis, leading to septic shock.

Mirizzi's Syndrome

Rare complication where a stone in the cystic duct compresses the common hepatic duct.

Gallbladder Cancer

Long-standing inflammation increases the risk of gallbladder malignancy.

Cholecystoduodenal fistula:

Multiple severe episodes of cholecsytitis can lead to a fistula to form between the gallbladder and the duodenum.

obstruction of the GI tract due to gallstones:

This is a rare complication of gallstone disease.

How does it occur?

The obvious way a stone can reach the GI tract from the gallbladder would be through the billiary tree. You may be asking yourself "How would a stone that could pass through a CBD that has a diameter less than 7mm obstruct the small bowel?

The answer is it can't!. Stones that cause obstruction reach the GI tract through a different route.

The steps for gallstone ileus to happen are typically as listed below:

Management of Acute Cholecystitis

Initial Management

IV fluids, analgesia, and nil by mouth. Broad-spectrum antibiotics are initiated to cover common biliary pathogens.

Antibiotic Choice

Typically a broad-spectrum antibiotic Tazocin or Co-Amoxiclav can provide cover against gram negative and anaerobes ((use your local guidelines!!)).

Laparoscopic cholecystectomy (see surgeon's view)

• Early laparoscopic cholecystectomy (within 72 hours) is preferred if the patient is fit for surgery.
• This is referred to as a "Hot laparoscopic Cholecystectomy”.
• Most guidance recommends not to attempt a lap chole after 72 hours from symptoms starting, as adhesions would have formed by this point, making the operation difficult and increasing risk of complications such as ductal injuries or bleeding.
• An operation is usually delayed for about 6 weeks as long as the patient has responded to antibiotic therapy.

Percutaneous cholecystostomy

A tube inserted into the gallbladder by interventional radiologists.

• This may be considered in high-risk patients unfit for immediate surgery to drain sepsis and control the source of infection.
• This tube is inserted into the gallbladder and is kept in place for a number of weeks (4-6) ((check local guidelines)).
• The tube is kept in until a tract forms between the skin and the gallbladder.
  • This prevents the defect caused by the tube insertion from causing bile to leak into the abdomen.
  • If a bile leak happens after tube removal, it will leak through the skin and a small drain bag can be attached to catch this until it resolves.
• The tube is sometimes left until the date a cholecystectomy is planned or kept indefinitely in patients with recurrent biliary sepsis who are not fit for an operation.

Ascending Cholangitis:

Definition

Ascending cholangitis is a severe infection of the biliary system, typically caused by bacterial colonisation of an obstructed bile duct.

Charcot's Triad

The classic presentation includes right upper quadrant pain, fever, and jaundice, though not all symptoms may be present.

Aetiology

Most commonly the obstruction is caused by gallstones, but can also result from strictures, tumours, or iatrogenic causes like ERCP.

Urgency

Considered a medical emergency due to the risk of rapid progression to sepsis and multi-organ failure.

Diagnosis of ascending cholangitis

Bloods

• WCC and CRP are raised due to presence of an infection.
• LFTs:
  • ALP and GGT are raised.
  • Bilirubin is raised.
  • Small rise in ALT and AST can be seen (less in comparison to ALP and GGT).

Imaging

Ultrasound:

• Can show a widened CBD (over 7mm).
• Can confirm presence of stones or gallbladder inflammation

MRCP (MR cholangiopancreatography):

• The most sensitive radiological investigation to assess presence of CBD stones/ assess the cause of CBD obstruction causing this inflammation.

ERCP: A Crucial Tool in management of biliary disease

What is an ERCP

• ERCP stands for endoscopic-retrograde-cholangiopancreatography-
• Can be used as a diagnostic tool to assess the cause of biliary obstruction, and to obtain brushings (biopsies) of any abnormalities in the biliary tract.
• Can also be used to treat biliary obstruction causing ascending cholangitis.

Description

A procedure combining endoscopic and fluoroscopic techniques.

Post-ERCP Complications

The most common complication, occurring in 3-5% of cases. Risk factors include young age, female gender, and difficult cannulation.

There is an argument that younger females should not have an ERCP as first-line for biliary tract decompression due to the significantly increased risk of pancreatitis, and that they should be considered for CBD exploration instead.

Bleeding

Can occur after sphincterotomy, especially in patients with coagulopathy. Usually self-limiting but may require endoscopic intervention.

Perforation

Rare but serious complication. Can occur due to guidewire manipulation or excessive sphincterotomy. May require surgical intervention.

Cholangitis

Can occur if biliary drainage is incomplete. Prophylactic antibiotics are often given to high-risk patients.

A septic shower phenomenon can be seen in patients post decompression of biliary should be tract obstruction, especially in patients with significant ongoing cholangitis.

Gallbladder Polyps (GPs)

what is a gallbladder polyp

• polypoid lesions that project from the gallbladder wall into the gallbladder interior are called gallbladder polyps (GPs).
• Polyps are found incidentally in around 5% of all abdominal ultrasounds
• The majority of GPs are benign but some may be cancerous. Cancers of the gallbladder generally have very poor prognoses, which means it is important to differentiate benign and malignant polyps.

Presentation of gallbladder poylps:

• The majority of patients with Gallbladder polyps are completely asymptomatic. The polyps are incidentally noted on ultrasound
• The difficulty is the malignant potential of polyps cannot be assessed on imaging.

Mangement of gallbladder polyps:

The management of gallbladder polyps in the UK is based on joint guidelines published by the European Society of Gastrointestinal and Abdominal Radiology (ESGAR), European Association for Endoscopic Surgery and other Interventional Techniques (EAES), International Society of Digestive Surgery—European Federation (EFISDS) and European Society of Gastrointestinal Endoscopy (ESGE)

Other diseases of the gallbladder (including carcinoma)

Adenomyomatosis of the gallbladder

• it is a chronic benign condition of the gallbladder wall.
• The consition is characterised by epithelial proliferation with muscular atrophy and mural diverticulae (Rokitasnky-Ashchoff sinuses).
• Those changes can be seen on US, CT and MRI.
• The presence of the sinuses differentiate adenomyomatosis from other cause of gallbladder wall thickening such as cholecystitis or gallbladder malignancy.
• Adenomyomatosis can cause ongoing chronic pain (similar to pain from biliary colic).
• The main treatment to this is laparoscopic cholecystectomy.

Porelain gallbladder

• A rare condition characterised by widespread calcification of the gallbladder wall.
• This calcification can be seen on imaging such as CT or abdominal films.
• There is an increased risk of gallbladder carcinoma with porcelain gallbladder.

Gallbladder carcinoma

• A rare malignancy accounting to almost 50% of all biliary tract malignancies.
• Most tumours are adenocarcinomas, with squamous, adenosquamous and neuroendocrine tumours being less common.
• Early symptoms may be similar to biliary colic or cholecystitis.
• Gallbladder carcinoma presentations vary from incidentally detected neoplasms in gallbladders removed for other indications to full blown metastatic cancer with distant mets.

Biliary disease: Surgery view

The primary treatment for gallstone disease is a laparoscopic cholecystectomy. This aims to relieve symptoms of biliary colic and to reduce risk of complications of gallstones including cholecystitis, ascending cholangitis and pancreatitis.

Should everyone with gallstones get a lap chole?

NICE guideline [CG188] discusses the management of gall stones. It recommends the following

• Reassure people with asymptomatic gallbladder stones found in a normal gallbladder and normal biliary tree that they do not need treatment unless they develop symptoms.
  • asymptomatic gallstones are defined as stones found incidentally on imaging which was requested for an indication not relating to gallstones.
• Offer a laparoscopic cholecystectomy to patients diagnosed with symptomatic gallbladder stones.

The decision to operate should be made a “shared decision” between the patient and the medical team. This decision should be made after careful consideration of risks vs benefits.

What does a laparoscopic cholecystectomy involve

Day case:

• NICE recommends lap choles to be offered as a day case to fit and well patients.
• Patients with significant comorbidities or social issues can be offered overnight stay.
• Patients requiring drain insertion or who have had significant intraoperative complications will require a prolonged stay.

Pre-operative Preparation and Patient Selection

• Medical History and Imaging: Detailed patient history, focusing on symptoms and previous abdominal surgeries. Ultrasound is essential for confirming gallstones.
• Risk Assessment: Evaluate for risk factors like acute cholecystitis, gallstone pancreatitis, and choledocholithiasis. Consider MRCP or EUS if bile duct stones are suspected.

Informed consent

Discuss risks and benefits of undertaking a laparoscopic cholecystectomy. It is pertinent to ensure the patient is aware of the intervention and its alternative (conservative management).

Benefits of the operation:

• Reduction in pain associated with biliary colic
• Reduction in risk of complications associated with gallstones (cholecystitis, ascending cholangitis and pancreatitis.

Risks of the operation

Bleeding

Could happen due to any of the following:

• Injury to hepatic vessels.
• bleeding from the gallbladder fossa.
• bleeding from the clipped cystic artery.

Infection

The gallbladder contains bile. Any instrumentation involving it means the operation is inherently non-sterile.

The infection can be to any of the following:

• skin infection
• deeper wound infection
• collection post op

Injury to bowel, major vessels:

• This can be recognised during the procedure. Rarely it is missed intra-operatively and recognised post-op when patients become unwell.
• Can happen due to a multitude of reasons, but commonest is due to port insertion or division of adhesions between colon/bowel and gallbladder after severe cholecystitis episodes.

Bile leak

• Different risks quoted in literature, author uses a figure of less than 1 in 20 in his consent forms. This risk is probably on the higher end.
• Risk increased if there is blockage in the CBD due to retained stones. This is because bile can’t drain through the CBD and will create pressure on the clipped Cystic duct.
• This complication requires a return to theatre for washout, drain insertion and repair of the leak.

Ductal injury:

• This is a major complication of laparoscopic cholecystectomies.
• It is associated with very major morbidity and mortality.
• Management of this is through biliary reconstruction done by hepaticopancreaticobiliary specialists.

Types of ductal injuries

Type	Description
A	Cystic duct leak or leak from small ducts in the liver bed
B	Occlusion of an aberrant right hepatic duct
C	Transection without ligation of an aberrant right hepatic duct
D	Lateral injury to a major bile duct
E	Circumferential injury to a major bile duct:
E1	Transection or stricture >2 cm from the hilum
E2	Transection or stricture <2 cm from the hilum
E3	Transection at the level of the bifurcation, without loss of contact between the left and right hepatic duct
E4	Transection at the level of the bifurcation with loss of communication between the left and right hepatic duct
E5	An injury of a right segmental duct combined with an E3 or E4 injury

Port-site hernia:

• increased risk in patients who heavy lift early post-op.
• patients to be advised not to heavy lift for at least 4 weeks post-op. (I tell patients nothing heavier than a full tea kettle for 4 weeks).

Post cholecystectomy syndrome:

Post-cholecystectomy syndrome (PCS) is a poorly understood condition characterised by ongoing pain post cholecystectomy. It is thought to be caused by bile leaking into areas such as the stomach, or by gallstones being left in the bile ducts. In most cases symptoms are mild and short-lived, but they can persist for many months requiring prolonged use of pain relief.

Risks of general Anaethetic:

• Usually discussed by anaesthetist pre-op.

Performing a laparoscopic Cholecystectomy

Equipment List

• Primary Instruments: High-definition laparoscopic camera, trocars (2x 10mm 2x5mm), laparoscopic grasper, scissors, hook electrocautery, and clip applier.
• Specialized Instruments: Intraoperative cholangiogram equipment, ultrasonic dissectors, or advanced energy devices if needed.

Port setup:

Label	position	size	use of port	notes
T1	infraumbilical port	10mm	camera	inserted using modified Hasson Cutdown technique.
T2	Right lateral subcostal (right axillary line)	5mm	grasper for retraction of gallbladder superiorly to allow disection of Calot’s	inserted using a sharp trocar under direct vision
T3	Right subcostal midclavicular port	5mm	For the left hand instrument	ensure triangulation with epigastric and infraumbilical port
T4	epigastric port	5-10mm	for the right hand instrument	useful if 10mm, allows use of camera in the port to visualise retrieval of gall bladder in bag from umbilical port.

Positioning of surgeon/patient

Patient position

Patient will be positioned supine, reverse Trendelenberg and right side up will be useful during the operation to move small bowel away from the gallbladder for ease of operating.

Surgeon’s position

The operating surgeon will be to the patient's left, as well as the camera operator. A third surgeon may be on the patient's right for retraction.

Pro-tip:

• During a laparoscopic cholecystectomy, retraction is relatively passive since significant repositioning of the gallbladder is usually unnecessary during the dissection of Calot’s triangle. A laparoscopic grasper can be used to retract the gallbladder.
• To free the camera operator’s hand, two towel clips can secure the gallbladder retractor, eliminating the need for the first assistant to provide passive retraction, which can be effectively replaced by towel clips.
• Later, during the dissection of the gallbladder off the liver bed, active retraction should be utilised to help this process.

Exploration:

• Assess the abdominal content for any concurrent pathology.

Adhesiolysis:

• Carefully perform adhesiolysis using hook diathermy.
• Adhesions can be fairly extensive with duodenum, colon and or omentum in patients who have had severe cholecystitis previously.
• The aim of this dissection is to remove any adhesions to expose Calot’s triangle.

• The dissection should remain about Rouviere’s sulcus

  • This is a 2-5cm fissure between the right lobe and caudate provess of the liver.
  • Appearance: Usually appears as a deep groove that's open at the medial end
  • Significance: The cystic duct and artery are located above the sulcus, while the common bile duct is below it.
  • Remaining about Rouvier’s sulcus ensures you reduce risk of CBD injury.
  • Prevalence: Present in 82% of livers

  • Reliability: A relatively constant anatomical structure that can be reliably identified in most patients

    

    Diagram depicting the position of Rouvier's sulcus in relation to disected cystic duct and artery

Achieving the critical view of safety

• The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) have introduced a programme to reduce the rate of bile duct injuries.
• This programme aimed to reduce the number of CBD injuries which can be life altering leading to significant morbidity and cost.
• The critical view of safety is a method introduced as part of this programme.

The Critical view of Safety (CVS):

Three criteria are needed to achieve the CVS:

1. The hepatocystic triangle needs to be cleared of fat and fibrous tissue.

   The hepatocystic triangle is defined as the triangle formed by the cystic duct, the common hepatic duct, and inferior edge of the liver.

   The common bile duct and common hepatic duct do not have to be exposed.

   gamma hepatocystic triangle image

2. The lower one third of the gallbladder is separated from the liver to expose the cystic plate.

   The cystic plate is also known as the liver bed of the gallbladder and lies in the gallbladder fossa.

3. Two and only 2 structures should be seen entering the gall bladder

   That pertains to the cystic artery and cystic duct.

Image showing the critical view of safety. Note the lower third of the gallbladder is off the cystic plate, note the hepatocystic triangle is cleared off fat and only 2 structures entering the gallbladder (cystic duct and cystic artery).

Management of the cystic duct and artery

Dividing the cystic artery:

The cystic artery is clipped (2 clips proximally and 1 clip distally). It is then divided using lap scissors.

• It’s crucial to clip and cut the cystic artery before dividing the cystic duct.
  • The cystic artery is a delicate and weak structure that is susceptible to tearing (avulsion) if it is pulled or subjected to traction after being divided.
  • If the cystic duct is divided first, any manipulation or pulling of the gallbladder to access the cystic artery can cause the artery to avulse. This can lead to uncontrolled bleeding and complicate the surgery.
  • By securing the cystic artery with clips and cutting it before addressing the cystic duct, you minimise the risk of avulsion because the artery is dealt with while it’s still intact and stable, reducing the need for additional manipulation that could cause damage.

Dividing the Cystic Duct:

• The cystic duct is then clipped and cut in a similar fashion.

Gallbladder Dissection from Liver Bed:

Use a combination of blunt dissection and electrocautery, starting at the fundus and moving towards the neck.

It’s critical to dissect along the correct anatomical plane between the gallbladder and the liver to avoid complications:

Avoid Dissecting Too Deep into the Liver:

• Risks: Cutting too deeply into the liver tissue can cause significant bleeding from the liver parenchyma. Additionally, it may lead to leakage of bile from the small bile ducts within the liver (bile canaliculi) into the surgical field.
• Consequences: Excessive bleeding can obscure the surgical field, making the procedure more challenging and increasing the risk of injury to other structures. Bile leakage can lead to bile collections or bilomas, which may cause inflammation or infection postoperatively.

Avoid Dissecting Too Close to the Gallbladder:

• Risks: Dissecting too close to the gallbladder wall increases the chance of perforating it.
• Consequences:
  • Bile Leakage: Perforation allows bile to spill into the abdominal cavity, contaminating the surgical field and increasing the risk of peritonitis or postoperative infections.
  • Spillage of Gallstones: Gallstones may escape into the abdomen if the gallbladder is perforated. Should this happen, it’s imperative to meticulously search for and remove any spilled stones during the surgery.
• Potential Complications if Stones Are Missed:
  • Formation of intra-abdominal abscesses around the retained stones.
  • Development of adhesions or fistulas.
  • The patient may require additional surgical interventions to address these complications, such as abscess drainage or even re-operation to remove the retained stones.

Bail-out procedures in difficult laparoscopic Cholecystectomies:

A laparoscopic cholecystectomy can be particularly challenging in patients who have experienced multiple episodes of cholecystitis. Recurrent inflammation leads to adhesions and fibrosis, complicating the surgical field. In such cases, accurately delineating the biliary anatomy becomes difficult, increasing the risk of ductal injuries.

If you are unable to achieve the critical view of safety due to excessive adhesions and fibrosis, it is crucial to recognize this issue and stop before causing a ductal injury. In these circumstances, employing a bail-out technique is advisable.

Bail-Out Techniques in Laparoscopic Cholecystectomy

Subtotal Cholecystectomy

Principle: “The best way to avoid a ductal injury is to not cut any ducts.”

• If you are uncertain about the identity of a duct, avoid transecting it.
• A subtotal cholecystectomy involves removing most of the gallbladder body while leaving a small cuff of the fundus. This approach minimizes dissection in the hepatocystic triangle and reduces the risk of ductal injuries.
• The remaining gallbladder fundus should be dissected off the liver bed and securely closed.
• Closure can be achieved using an endoloop or endoscopic suturing techniques.
• This is an effective operation that removes the majority of the gallbladder, reducing the risk of future stone formation while avoiding injury to the bile ducts.

Conversion to Open Surgery

• Converting to an open cholecystectomy can sometimes improve the handling of the gallbladder and facilitate safer dissection.
• However, many laparoscopic surgeons prefer the enhanced visualization provided by laparoscopy compared to the top-down view in open surgery. Therefore, conversion is not always the optimal solution in a difficult laparoscopic cholecystectomy.

Cholecystostomy and Closure

• If you are not confident in safely performing a laparoscopic cholecystectomy, it is prudent not to proceed.
• Patients generally prefer a conservative approach—such as drainage of sepsis via a cholecystostomy and subsequent closure—over the risk of a common bile duct (CBD) injury. A CBD injury may necessitate biliary reconstruction and can lead to infections, strictures, and increased mortality risk.
• There is no shame in aborting the procedure and referring the patient to a specialist if the critical view of safety cannot be safely achieved.