Gallstone disease is one of the most common gastrointestinal disorders encountered in surgical practice. While standard laparoscopic cholecystectomy is widely performed for typical cases of cholelithiasis, contracted gallbladder with a solitary large stone presents unique surgical challenges. The gallbladder may be fibrosed and shrunken due to chronic inflammation, making dissection difficult and increasing the risk of bile duct injury. However, with careful planning, precise technique, and experience in advanced laparoscopic surgery, safe and effective removal of the gallbladder is achievable.

Understanding Contracted Gallbladder

A contracted gallbladder is a small, fibrotic organ that may result from repeated episodes of chronic cholecystitis. The walls of the gallbladder become thickened, and the lumen is often obliterated or reduced to a tiny cavity. In many cases, a solitary large gallstone occupies the entire lumen, sometimes measuring more than 2–3 centimeters in diameter.

Patients with a contracted gallbladder often present with:

Recurrent right upper quadrant pain.

Dyspepsia or postprandial fullness.

Occasional jaundice if the stone compresses the cystic duct.

Ultrasound, CT scan, or MRCP can confirm the diagnosis, revealing a shrunken gallbladder with a single large stone and thickened walls.

Challenges in Laparoscopic Surgery

Laparoscopic cholecystectomy in contracted gallbladder cases is technically demanding due to several factors:

Distorted anatomy: Chronic inflammation leads to adhesions and obliteration of normal planes around Calot’s triangle.

Dense adhesions: The gallbladder may adhere to the liver, duodenum, colon, or omentum.

Limited space: The contracted gallbladder offers minimal room for grasping or manipulation.

Risk of bile duct injury: Identification of cystic duct and artery is difficult in fibrotic tissue.

Stone size: Large stones may make extraction through standard ports challenging, sometimes requiring bagging or fragmentation.

Preoperative Preparation

Successful outcomes depend on meticulous preoperative assessment:

Imaging studies: Ultrasound confirms stone size and gallbladder contraction. MRCP is advised if bile duct stones or anatomy distortion is suspected.

Laboratory tests: Liver function tests, complete blood count, and coagulation profile help assess operative risk.

Patient counseling: Patients should be informed about the increased complexity, potential need for conversion to open surgery, and risks of bile duct injury.

Surgical Technique
Patient Positioning

The patient is placed in the supine position with reverse Trendelenburg and right tilt, facilitating exposure of the gallbladder.

Port Placement

Standard four-port laparoscopic technique is used:

Umbilical port for the camera.

Epigastric port for main instruments.

Two right subcostal ports for retraction and assistance.

Adhesiolysis

Adhesions between the gallbladder and surrounding structures are carefully dissected. Blunt and sharp dissection with minimal energy use reduces the risk of injury.

Gallbladder Retraction

Given the limited size of the contracted gallbladder, retraction can be challenging. Techniques include:

Grasping the fundus or infundibulum.

Fundus-first (top-down) approach when Calot’s triangle is obscured.

Critical View of Safety

Achieving the Critical View of Safety (CVS) is essential to prevent bile duct injury. In contracted gallbladder cases, this may require:

Careful dissection of fibrotic tissue.

Use of intraoperative cholangiography to delineate biliary anatomy.

Division of Cystic Structures

The cystic duct and artery are clipped or ligated. Large stones may require decompression or extraction through a retrieval bag.

Gallbladder Extraction

The contracted gallbladder with the large stone is usually placed in an endoscopic retrieval bag.

If necessary, the umbilical incision is slightly extended to allow safe removal of the intact gallbladder.

Completion

Hemostasis is ensured, irrigation is performed, and ports are removed. Skin incisions are closed with absorbable sutures or surgical glue.

Postoperative Care

Patients typically recover rapidly despite the challenging procedure:

Early ambulation and oral intake are encouraged.

Analgesics are prescribed for mild postoperative pain.

Patients are monitored for complications such as bile leak, bleeding, or infection.

Advantages of Laparoscopic Approach

Despite the technical difficulty, laparoscopic cholecystectomy offers significant advantages over open surgery:

Minimally invasive with reduced postoperative pain.

Faster recovery and shorter hospital stay.

Superior cosmetic results.

Ability to manage unexpected findings, such as accessory ducts or adhesions, under magnified vision.

Risks and Complications

Potential complications include:

Bile duct injury due to distorted anatomy.

Bleeding from liver bed or cystic artery.

Stone spillage, which may cause abscess formation.

Conversion to open cholecystectomy in difficult cases.

Conclusion

Laparoscopic cholecystectomy for contracted gallbladder with a solitary large stone is a complex but feasible procedure in experienced hands. Thorough preoperative evaluation, careful dissection, adherence to the Critical View of Safety, and use of adjuncts such as intraoperative cholangiography ensure patient safety and excellent outcomes. This approach provides all the benefits of minimally invasive surgery, allowing patients with challenging gallbladder pathology to experience faster recovery, reduced morbidity, and superior long-term results.