Description

Empyema of the gallbladder is a severe and potentially life-threatening complication of acute cholecystitis, characterized by suppurative infection and pus-filled distension of the gallbladder. Prompt surgical intervention is the treatment of choice, and laparoscopic cholecystectomy has emerged as the gold standard in most cases. However, the procedure is technically demanding due to distorted anatomy, dense adhesions, and high risk of complications. Pathophysiology and Clinical Presentation Empyema gallbladder occurs when acute calculous cholecystitis progresses unchecked, leading to obstruction of the cystic duct and superimposed bacterial infection. Patients typically present with: Severe right upper quadrant pain High-grade fever with chills and rigors Leukocytosis Signs of sepsis in advanced cases Early diagnosis and urgent management are essential to prevent perforation, peritonitis, and septic shock. Role of Laparoscopic Cholecystectomy Traditionally, open cholecystectomy was preferred for empyema due to fear of complications during laparoscopy. However, with advances in laparoscopic techniques, improved instrumentation, and better surgeon experience, laparoscopic cholecystectomy is now considered safe and effective. Advantages of laparoscopic approach: Reduced postoperative pain Shorter hospital stay Faster recovery Better cosmesis Lower risk of wound infection Technical Considerations Performing laparoscopic cholecystectomy in empyema gallbladder requires caution and expertise. Important steps include: Initial Decompression The gallbladder is often tense and distended with pus. Aspiration of purulent content using a laparoscopic needle or trocar helps reduce tension and facilitates handling. Careful Adhesiolysis Dense adhesions between the gallbladder, omentum, and surrounding structures must be meticulously dissected to expose Calot’s triangle. Identification of Anatomy The critical view of safety (CVS) is paramount. In difficult cases, a fundus-first or subtotal cholecystectomy may be required. Bail-out Procedures If safe dissection is not possible, conversion to open cholecystectomy should be considered without hesitation. Drain Placement A drain is often placed to monitor for bile leak or residual infection. Challenges and Risks Increased risk of bile duct injury due to distorted anatomy Difficulty in identifying cystic duct and artery Higher conversion rates compared to elective cholecystectomy Potential for postoperative collections or abscesses Postoperative Care Intravenous antibiotics to control infection Monitoring for complications like bile leak, abscess, or sepsis Early ambulation and resumption of diet as tolerated Conclusion Laparoscopic cholecystectomy for empyema gallbladder, though technically challenging, is feasible and safe in experienced hands. Early surgical intervention not only prevents life-threatening complications but also provides the benefits of minimally invasive surgery. Proper case selection, meticulous surgical technique, and readiness to convert to open procedure when required remain the cornerstones of successful management.