Empyema of the gallbladder is a life-threatening complication of acute cholecystitis in which the gallbladder becomes distended with pus due to cystic duct obstruction and secondary bacterial infection. It is associated with severe inflammation, systemic toxicity, and a high risk of sepsis. Prompt surgical management is the standard of care, and laparoscopic cholecystectomy has emerged as a safe and effective approach for treating this condition when performed by experienced surgeons. However, empyema gallbladder poses unique challenges due to difficult anatomy, dense adhesions, and friable tissues.

Pathophysiology and Clinical Presentation

Empyema results from untreated or complicated acute calculous cholecystitis. The cystic duct obstruction, usually by an impacted gallstone, leads to stasis, bacterial infection, and accumulation of pus inside the gallbladder. Common pathogens include Escherichia coli, Klebsiella, Streptococcus, and Enterococcus.

Patients typically present with high-grade fever, right upper quadrant pain, tenderness, and signs of systemic toxicity such as tachycardia, leukocytosis, and occasionally hypotension. On examination, a palpable, tender mass may be felt in the right hypochondrium. If untreated, empyema may lead to perforation, peritonitis, or septic shock, making urgent surgical intervention necessary.

Role of Laparoscopic Cholecystectomy

Traditionally, empyema of the gallbladder was considered a relative contraindication to laparoscopic surgery due to the high risk of bile duct injury, bleeding, and conversion to open surgery. However, with improved laparoscopic instruments, energy sources, and refined surgical techniques, laparoscopic cholecystectomy has become the preferred method in many centers, provided it is carried out by skilled surgeons.

The laparoscopic approach offers advantages such as reduced postoperative pain, shorter hospital stay, early mobilization, and lower incidence of wound infection compared to open cholecystectomy. Nevertheless, surgeons must be prepared for technical difficulties and the possibility of conversion to open surgery in complicated cases.

Surgical Technique

Preoperative Preparation
Patients are optimized with intravenous fluids, antibiotics, and correction of electrolyte imbalance. Imaging, typically ultrasound or CT scan, confirms the diagnosis and helps rule out complications such as perforation or abscess formation.

Anesthesia and Positioning
The surgery is performed under general anesthesia. The patient is placed in the supine position with reverse Trendelenburg and left tilt to allow better exposure of the gallbladder region.

Port Placement
Standard four-port technique is commonly used. Pneumoperitoneum is created, and careful entry is essential because adhesions may involve the anterior abdominal wall and omentum.

Adhesiolysis and Exposure
Dense adhesions around the gallbladder are meticulously dissected using blunt and sharp techniques. In empyema, the gallbladder is often grossly distended, and initial decompression by needle aspiration or trocar puncture is recommended to reduce tension and allow better handling.

Dissection of Calot’s Triangle
The most critical step is identifying the cystic duct and cystic artery safely. Due to intense inflammation and distorted anatomy, the “critical view of safety” must be obtained before clipping or dividing any structures. If this is not possible, alternative strategies are used.

Alternative Techniques

Subtotal Cholecystectomy may be performed when dissection of Calot’s triangle is unsafe. The anterior wall is excised, stones are removed, and the mucosa is cauterized.

Fundus-First Approach (Retrograde Dissection) is useful when Calot’s triangle is inaccessible. Dissection begins at the gallbladder fundus and proceeds downward.

Conversion to Open Surgery should not be considered a failure but rather a safety measure when laparoscopic dissection is too hazardous.

Hemostasis and Drainage
Adequate hemostasis is secured, and a drain is often placed in the subhepatic space due to the risk of bile leak or infection.

Postoperative Care

Postoperatively, patients are monitored for signs of sepsis, bile leak, or bleeding. Intravenous antibiotics are continued until clinical improvement, followed by oral therapy. Early ambulation, pain management, and resumption of diet are encouraged. Most patients recover quickly after laparoscopic cholecystectomy compared to open surgery.

Challenges and Complications

The main challenges during laparoscopic management of empyema gallbladder include:

Difficult identification of anatomy due to inflammation.

Risk of common bile duct injury.

Dense adhesions leading to prolonged operative time.

Increased risk of bleeding from friable tissues.

Potential complications include bile duct injury, postoperative bile leak, intra-abdominal abscess, and wound infection. The conversion rate to open cholecystectomy may be higher than in elective cases, ranging from 10–30% in different series.

Conclusion

Laparoscopic cholecystectomy for empyema gallbladder, though technically demanding, is a safe and effective treatment option in experienced hands. Early intervention before the development of complications, meticulous dissection, and adherence to the principle of obtaining a critical view of safety are essential to avoid biliary injury. When anatomy is unclear, alternative strategies such as subtotal cholecystectomy or conversion to open surgery should be employed without hesitation. With proper surgical expertise and perioperative care, laparoscopic cholecystectomy offers excellent outcomes and remains the gold standard for managing empyema gallbladder.