Ambe PC (2017) The Difficult Gallbladder. JSM Gen Surg Cases Images 2(2): 1023.

Laparoscopic cholecystectomy (LC) represents with over 1.4 millioncases per annum one of the most commonly performed surgical procedures world wide [1]. Although early LC has been unequivocally proven as the gold standard for management of benign gallbladder pathologies [2-4], high rates of morbidity and mortality have been reported in patients undergoing LC for acute cholecystitis (AC) [5, 6]. Thus percutaneous cholecystostomy (PC), i.e. an interventional placement of a percutaneous tube following computed tomographic or sonographic guidance has been sugested for the management of severe cases with cholecystitis [7-9]. This procedure so far has been widely used either as a bridge to surgery or as a definite management of severe cases of AC. Although thecurrent evidence of the efficacy of PCis weak [10-12], its safety the management of severe cholecystitis has been justified in many mostly retrospective studies [11,13,14].

Acute cholecystitis has a broad spectrum of clinical presentation; from amild self-limiting to a septic life-threatening condition. The clinical presentation and course of AC might be influenced by both patient-dependent and disease-specific features. Patient-dependent features including age, gender, body mass index (BMI) and preexisting medical condition have been shown to influence the outcome of AC [15,16]. The extent of gallbladder inflammation (gangrenous, empyematous and perforated cholecystitis), the duration of symptom onset, presence or absence of gallbladder stones constitute diseasespecific factors [17,18]. In addition to these factors, surgical expertise constitutes an important factor in patients undergoing surgical.

Currently, surgical experience with LC is comprehensively available and the advantages oft he minimal invasive approach (lesser pain, shorter hospital stay, better cosmesis, early return to work, etc) are unquestionable. Unfortunately, the high procedural volume and the presumed safety of LC obsure medical damagessuffered by patients and the socioeconomical burden imposedon the health system by perioperative complications. Amongst all perioperative morbidities, bile duct injury is the most feared complication in gallbladder surgery. The risk of bile duct injury has been estimated at below 0.2% in open cholecystectomy and close to 0.4% in elective LC [19]. The rate of bile duct injury in patients with AC has been shown to be some where between 0.5% an 4% depending on the extent of gallbladder inflammation [6].

Two aspects of perioperative morbidity, especially bile duct injury during elective gallbladder surgery are worth mentioning: On the patient´s perspective, bile duct injury might predispose to recurrent cholangitis and eventually lead to biliary cirrhosis with the need of liver transplantation. The surgeon on the other hand might have to deal with medicolegal issues. Although the medicolegal aspect are usually time consuming it becomes irrelevant compared to the devastating sequalae of a poorly managed bile duct injury .

Preventing bile duct injury during gallbladder surgery is of utmost importance. The critical view approach has been advocated as a safe means of preventing bile duct injury during gallbladder dissection [20]. Our clinical experience however suggests that the critical view is not always achievable. Many experienced laparoscopic surgeons probably have developed tricts for a safe gallbladder dissection in such situations.As the saying goes „Tutte le strade portano a Roma (“All roads lead to Rom“), there are probably many ways to perform a safe gallbladder dissection without risking a bile duct injury.

This special issue is dedicated to this crucial aspect of gallbladder surgery. Articles of all kinds including original research, review articles, case reports, How I do, technical notes, intraoperative images, etc on tips and tricks forthe difficult gallbladder dissection would be included in this issue. Every single gallbladder is a surgical challenge. We need to teach and learn from each other

1. Ambe P, Esfahani BJ, Tasci I, Christ H, Kohler L. Is laparoscopic cholecystectomy more challenging in male patients? Surg Endosc. 2011; 25: 2236-2240.

2. Gurusamy K, Samraj K, Gluud C, Wilson E, Davidson BR. Meta-analysis of randomized controlled trials on the safety and effectiveness of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Br J Surg. 2010; 97: 141-150.

3. Gurusamy KS, Davidson C, Gluud C, Davidson BR. Early versus delayed laparoscopic cholecystectomy for people with acute cholecystitis. The Cochrane database of systematic reviews 2013; 6.

4. Gutt CN, Encke J, Köninger J, Harnoss JC, Weigand K, Kipfmüller K, et al. Acute cholecystitis: Early versus delayed cholecystectomy, a multicenter randomized trial (ACDC Study, NCT00447304). Ann Surg. 2013; 258: 385-391.

5. Ambe PC, Jansen S, Macher-Heidrich S, Zirngibl H. Surgical management of empyematous cholecystitis: a register study of over 12,000 cases from a regional quality control database in Germany. Surg Endosc. 2016. 30: 5319-5324.

6. Jansen S, Doerner J, Macher-Heidrich S, Zirngibl H, Ambe PC. Outcome of acute perforated cholecystitis: a register study of over 5000 cases from a quality control database in Germany. Surg Endosc. 2017; 31: 1896-1900.

7. Ambe PC, Kaptanis S, Papadakis M, Weber SA, Zirngibl H. Cholecystectomy vs. percutaneous cholecystostomy for the management of critically ill patients with acute cholecystitis: a protocol for a systematic review. Syst Rev. 2015; 4: 77.

8. Cherng N, Witkowski ET, Sneider EB, Wiseman JT, Lewis J, Litwin DEM, et al. Use of cholecystostomy tubes in the management of patients with primary diagnosis of acute cholecystitis. J Am Coll Surg. 2012; 214: 196-201.

9. Gurusamy KS, Koti R, Davidson BR. T-tube drainage versus primary closure after laparoscopic common bile duct exploration. Cochrane Database Syst Rev. 2013; 21.

10. Ambe PC, Kaptanis S, Papadakis M, Weber SA, Jansen S, Zirngibl H. The Treatment of Critically Ill Patients With Acute Cholecystitis. Dtsch Arztebl Int. 2016; 113: 545-551.

11. Gurusamy KS, Rossi M, Davidson BR. Percutaneous cholecystostomy for high-risk surgical patients with acute calculous cholecystitis. Cochrane Database Syst Rev. 2013; 12.

12. Winbladh A, Gullstrand P, Svanvik J, Sandstrom P. Systematic review of cholecystostomy as a treatment option in acute cholecystitis. HPB (Oxford). 2009; 11: 183-193.

13. Baron TH, Grimm IS, Swanstrom LL. Interventional Approaches to Gallbladder Disease. N Engl J Med. 2015; 373: 357-365.

14. de Mestral C, Gomez D, Haas B, Zagorski B, Rotstein OD, Nathens AB. Cholecystostomy: a bridge to hospital discharge but not delayed cholecystectomy. J Trauma Acute Care Surg. 2013; 74: 175-179.

15. Ambe PC, Kohler L. Is the male gender an independent risk factor for complication in patients undergoing laparoscopic cholecystectomy for acute cholecystitis? Int Surg. 2015; 100: 854-859.

16. Ambe PC, Weber SA, Wassenberg D. Is gallbladder inflammation more severe in male patients presenting with acute cholecystitis? BMC surg. 2015; 15: 48.

17. Ambe PC, Christ H, Wassenberg D. Does the Tokyo guidelines predict the extent of gallbladder inflammation in patients with acute cholecystitis? A single center retrospective analysis. BMC Gastroenterol. 2015; 15: 142.

18. Papadakis M, Ambe PC, Zirngibl H. Critically ill patients with acute cholecystitis are at increased risk for extensive gallbladder inflammation. World J Emerg Surg. WJES. 2015; 10: 59.

19. Gentileschi P, Di Paola M, Catarci M, Santoro E, Montemurro L, Carlini M, et al. Bile duct injuries during laparoscopic cholecystectomy: a 1994-2001 audit on 13,718 operations in the area of Rome. Surg Endosc. 2004; 18: 232-236.

20. Vettoretto N, Saronni C, Harbi A, Balestra L, Taglietti L, Giovanetti M. Critical view of safety during laparoscopic cholecystectomy. JSLS. 2011; 15: 322-325