Chronic Cholecystitis

Chronic cholecystitis is chronic inflammatory and fibrotic remodelling of the gallbladder, usually caused by repeated episodes of gallstone related cystic duct obstruction.

The gallbladder becomes thickened, fibrotic and poorly contractile. Advanced disease may produce a small contracted gallbladder densely adherent to surrounding structures.

Chronic cholecystitis is usually the pathological substrate behind recurrent symptomatic gallstone disease rather than a distinct acute inflammatory syndrome.

The major surgical importance is that longstanding fibrosis can make identification of biliary anatomy difficult and increase bile duct injury risk.

Patients commonly report recurrent episodes of right upper quadrant or epigastric pain compatible with biliary colic.

Symptoms may be provoked by meals and associated with nausea.

Unlike acute cholecystitis, fever and persistent inflammatory signs are absent between episodes.

Chronic vague dyspepsia alone is poorly specific for gallbladder disease and should not automatically be attributed to gallstones.

Right upper quadrant ultrasound: usually demonstrates gallstones with a fibrotic or contracted gallbladder; the decisive finding is gallstone disease corresponding to the patient\'s recurrent biliary symptoms.

Laboratory tests are often normal between attacks.

Abnormal bilirubin or cholestatic liver enzymes should prompt evaluation for common bile duct stones rather than being attributed to chronic cholecystitis.

A markedly irregular or mass like gallbladder wall requires evaluation for gallbladder malignancy before routine elective surgery.

Symptomatic chronic cholecystitis is treated with elective laparoscopic cholecystectomy.

Antibiotics are unnecessary in the absence of acute infection.

The operation can be technically difficult when the gallbladder is shrunken and densely fibrotic.

Dissection should be directed toward a safe critical view rather than toward completing a conventional cholecystectomy at any cost.

If the cystic duct and artery cannot be confidently defined:

• Stop dissection within the dangerous hepatocystic triangle
• Use intraoperative imaging when it will clarify biliary anatomy
• Perform subtotal cholecystectomy when necessary
• Convert to open surgery when exposure or control will genuinely improve

A subtotal cholecystectomy is a deliberate bailout operation, not a failure, when complete removal would expose the common bile duct or hepatic ducts to unacceptable risk.

If the gallbladder is unexpectedly indurated, mass like or inseparable from adjacent liver, avoid opening or fragmenting a possible malignancy. Obtain appropriate oncological assessment and modify the operation according to the findings.

After uncomplicated elective laparoscopic cholecystectomy, routine postoperative antibiotics are not indicated.