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 Sur