CALOTCholecystectomy Anatomy, Learning & Operative Technique Exam zone
The operation

Open cholecystectomy and conversion

Opening the abdomen changes your access, not the anatomy. Convert for a problem that open surgery solves, and keep the same rules once you are in.

Latest source: de'Angelis et al., WSES 2021 · about 5 min read · how evidence is marked

Reviewed against its sources on 3 November 2026.

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Three things to remember
  1. Convert for bleeding, an injury, impassable adhesions or intolerance of pneumoperitoneum, not to see a frozen triangle better.
  2. Once open, the Critical View still applies; fundus-first stops at the infundibulum in a badly inflamed gallbladder.
  3. When the triangle will not clear, do an open subtotal and drain.

01When to convert

Know this
  • Convert for a problem that the open approach solves. A triangle you cannot dissect with a laparoscope is no easier with a hand in it.
  • Strasberg’s “extreme” vasculobiliary injuries happened mostly after conversion, during fundus-down dissection of a badly inflamed gallbladder.
  • Conversion is not a failure, and it is not automatically safe. The same rules apply after the wound is open.

Good reasons

Bleeding not controlled by pressure, suction and a second surgeon. A recognised duct injury that a competent surgeon will repair or drain open. Adhesions that prevent any safe access. A fistula that needs bowel repair. A patient who cannot tolerate the pneumoperitoneum.

Poor reasons

“To see better” in a frozen triangle. Running out of time. Pressure from the list. In these, a laparoscopic subtotal cholecystectomy or a drain and a referral is often safer. See subtotal cholecystectomy.

When

Convert early, when the field is still clean, not after an hour of bleeding and blind dissection. Expert opinion

Convert when open access helps you regain safe control; reassess before continuing

Sources

Extreme injuries: Strasberg and Gouma, HPB 2012. Case series Conversion and bail-out: Brunt et al., Ann Surg 2020; de’Angelis et al., WSES 2021. Guideline The 2020 consensus made no recommendation on conversion specifically to reduce BDI. WSES allows conversion when safe laparoscopic management is not possible, and its acute-cholecystitis guideline recommends it for specified difficult circumstances. See conversion: recommendations and evidence for the distinctions.

02Converting safely

  1. Say it out loud. Tell the anaesthetist, the scrub team and the theatre coordinator. Ask for an open set, a self-retaining retractor and a good light.
  2. Call for help. A second consultant, or a hepatobiliary surgeon if a duct injury is possible. Help is better before the wound than after it.
  3. Record the laparoscopic view. Photograph or record what you have seen and what you have divided. It will matter later. Expert opinion
  4. Hold what you have. Leave a grasper on a bleeding point or a pack in place until the wound is open; do not desufflate onto an uncontrolled bleed. Expert opinion
  5. Choose the incision for what you need to do next (see below), not by habit.
  6. Start again from the landmarks: Rouvière’s sulcus, the base of segment IV, the duodenum. The rules of identification do not change.

Steps in this section and the next are common practice, not trial evidence. Author practice

03The open operation, step by step

  1. Incision. A right subcostal (Kocher) incision, two finger-breadths below the costal margin, is the usual choice. An upper midline incision suits an uncertain diagnosis, a previous midline scar or a narrow costal angle.
  2. Exposure. Self-retaining retractor on the costal margin. Packs push the hepatic flexure and duodenum down and the stomach to the left. The assistant lifts the liver.
  3. Decompress. Aspirate a tense gallbladder through a purse-string so that it can be held. Send bile for culture if it is infected.
  4. Grip and orient. A clamp on the fundus lifts the liver; a second on Hartmann’s pouch pulls down and out to open the triangle. Feel the common duct between finger and thumb in the free edge of the lesser omentum.
  5. Dissect the triangle. Stay on the gallbladder, high and lateral. Clear the hepatocystic triangle and separate the lower third of the gallbladder from the liver bed: the same Critical View of Safety as in the laparoscopic operation. See the Critical View of Safety.
  6. Ligate and divide. Tie or transfix the cystic artery, then the cystic duct, only after the critical view. Cholangiogram through the cystic duct if the anatomy or the duct is in doubt.
  7. Fundus-first, if you choose it, stays on the gallbladder wall. In a severely inflamed gallbladder the plane leads behind the cystic plate onto the right portal structures. Stop at the infundibulum and do a subtotal rather than chase the neck. Expert opinion
  8. Haemostasis and close. Diathermy and pressure on the liver bed. A drain if there was bile, a leak risk or a subtotal. Close in layers.

04Open subtotal cholecystectomy

Know this
  • When the triangle will not clear, open subtotal cholecystectomy follows the same principles as the laparoscopic one: remove the free wall and the stones, leave the back wall on the liver if needed, and never dissect the triangle.
  • Reconstituting: close the lower gallbladder to leave a small pouch. Fewer early leaks, but a pouch that can form stones later.
  • Fenestrating: leave the remnant open over a drain and close the cystic duct orifice from inside if you can see it. No pouch, but more early leaks.
Do
  • Empty every stone from the remnant and Hartmann’s pouch; feel for the one in the neck.
  • Close the internal cystic duct orifice with a purse-string from inside when it is visible.
  • Leave a drain to the remnant.
Don’t
  • Dissect into the triangle “to finish the job”.
  • Leave a large cuff of gallbladder that will form stones.
  • Forget to tell the patient and the GP what was done, and what a later bile leak or recurrent pain may mean.
Sources

Definitions: Strasberg et al., J Am Coll Surg 2016. Consensus The trade-off between the two techniques and the evidence behind it are on the bail-out page: subtotal cholecystectomy.

05After a conversion

  • Write the note at once: why you converted and when, what you had identified and divided before, what you found, what you did, and the drain.
  • Tell the patient the same day, in plain words, and say what to watch for.
  • Plan the recovery for an open operation: pain relief (a wound catheter, a regional block or an epidural), chest physiotherapy, thromboprophylaxis and a longer stay. Expert opinion
  • Bile in the drain or a rising bilirubin follows the same pathway as after a laparoscopic operation. See bile leak and bile duct injury after the operation.
  • Bring it to audit. A conversion rate means little without the subtotal and injury rates beside it. See open cholecystectomy as a skill.
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06What examiners ask

  1. When would you convert a laparoscopic cholecystectomy to open, and when would you not?
  2. Describe the steps of an open cholecystectomy, starting with the incision.
  3. You have converted and the triangle is still frozen. What now?
  4. Why is fundus-first dissection dangerous in a severely inflamed gallbladder?
Most recent sources on this page: de’Angelis et al., WSES 2021; Brunt et al., Ann Surg 2020; Strasberg et al., J Am Coll Surg 2016.

Test yourself further: Practise questions on Open and conversion in the Exam zone.