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Perioperative Complications and Outcome of Laparoscopic

Cholecystectomy in 20 Dogs

Jacqueline Scott1, Ameet Singh1, Philipp D. Mayhew2, J. Brad Case3, Jeffrey J. Runge4,

Matthieu Gatineau5, and Jessica Kilkenny1

1Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada, 2Department of Surgical and

Radiological Sciences, University of California-Davis, Davis, California, 3Department of Small Animal Clinical Sciences, College of Veterinary

Medicine, University of Florida, Gainesville, Florida, 4Department of Clinical Studies, Matthew J. Ryan Veterinary Hospital at the University of

Pennsylvania, Philadelphia, Pennsylvania, and 5Centre V�et�erinaire DMV, Montreal, Quebec, Canada

Corresponding Author

Ameet Singh

Ontario Veterinary College

University of Guelph

Gordon Street

Guelph, Ontario, Canada

N1G 2W1

[email protected]

Submitted February 2016

Accepted May 2016

DOI:10.1111/vsu.12534

Objective: To report the complications and outcome of dogs undergoing

laparoscopic cholecystectomy for uncomplicated gall bladder disease.

Study Design: Multi-institutional case series.

Animals: Client-owned dogs (n520).

Methods: Medical records of dogs that underwent laparoscopic cholecystectomy

were reviewed and signalment, history, clinical and ultrasound examination findings,

surgical variables, and complications were collated. Laparoscopic cholecystectomy

was performed using a multiport approach. Data were compared between dogs with

successful laparoscopic cholecystectomy and dogs requiring conversion to open

cholecystectomy.

Results: Six dogs (30%) required conversion from laparoscopic to open

cholecystectomy due to inability to ligate the cystic duct (3), evidence of gall

bladder rupture (1), leakage from the cystic duct during dissection (1), and cardiac

arrest (1). Cystic duct dissection was performed in 19 dogs using an articulating

dissector (10), right angle forceps (7), and unrecorded (2). The cystic duct was

ligated in 15 dogs using surgical clips (5), suture (6), or a combination (4). All dogs

were discharged from the hospital and had resolution of clinical signs, although 1

dog developed pancreatitis and 1 dog required revision surgery for bile peritonitis.

There was no significant difference in preoperative blood analysis results, surgical

technique, or duration of hospitalization between dogs undergoing laparoscopic

cholecystectomy and cases converted to open cholecystectomy.

Conclusion: Laparoscopic cholecystectomy can be performed successfully for

uncomplicated gall bladder disease in dogs after careful case selection. The surgeon

considering laparoscopic cholecystectomy should be familiar with a variety

of methods for cystic duct dissection and ligation to avoid difficulties during the

procedure.

Laparoscopic surgery has become popular in veterinary med-

icine1 and is associated with faster return to function,

improved visualization, possible reduction in surgical site

infections, and reduced postoperative pain for selected surgi-

cal procedures in dogs.2–8

In people, laparoscopic cholecystectomy is performed

for symptomatic cholecystolithiasis and is associated with a

significantly shorter hospital stay and shorter convalescence

compared with open cholecystectomy.9–13 Recent reports

cite a conversion rate of 5–10% for multiport laparoscopic

cholecystectomy in people,9–11 most often due to adhesions

obscuring visualization, iatrogenic biliary duct injury, and

hemorrhage.10,13

Laparoscopic cholecystectomy has been described in a

clinical report of uncomplicated gall bladder mucoceles in 6

dogs without evidence of biliary tract rupture or obstruc-

tion.14 All dogs had successful laparoscopic cholecystectomy

without conversion to an open procedure, and all dogs

showed improvement or postoperative resolution of clinical

signs.14

For advanced laparoscopic procedures such as laparo-

scopic cholecystectomy, careful case selection is impor-

tant.14–17 Appropriate case selection for laparoscopic

cholecystectomy in dogs and factors that may indicate the

need for conversion to an open cholecystectomy are not

clearly identified. The objective of this study was to report

the complications and perioperative outcome of dogs under-

going laparoscopic cholecystectomy and describe details of

the laparoscopic procedure, including surgery duration and

conversion rate.

O49Veterinary Surgery 45 (2016) O49–O59VC Copyright 2016 by The American College of Veterinary Surgeons

MATERIALS AND METHODS

Case Selection

Medical records of dogs that underwent laparoscopic chole-

cystectomy for uncomplicated gall bladder disease at the

participating institutions from July 15, 2008 to July 15,

2015 were identified and reviewed. All dogs that underwent

laparoscopic cholecystectomy with or without conversion to

an open cholecystectomy were included. Candidates for lap-

aroscopic cholecystectomy were approximately based upon

previously published recommendations.14 Dogs with clinical

signs, persistent total serum bilirubin concentration eleva-

tions or evidence of gall bladder rupture, abdominal effu-

sion, or extra-hepatic biliary obstruction on ultrasound

examination were not considered candidates for laparo-

scopic cholecystectomy.14

Data retrieved from medical records included age, body

weight, sex, breed, clinical history, current medications, con-

current comorbidities, and physical examination findings.

Complete blood count, serum biochemistry analysis, coagu-

lation parameters, and urinalysis from the perioperative

period were recorded. Results of abdominal ultrasound

examination and results of any additional diagnostic imaging

was recorded and reviewed. Data for surgery included opera-

tive technique, intraoperative findings, surgery and general

anesthesia duration, results of bacterial culture, and histo-

logic findings of gall bladder and liver biopsies. Periopera-

tive complications, medications prescribed at hospital

discharge, recurrence of clinical signs, and duration of post-

operative hospitalization were noted.

Laparoscopic Cholecystectomy

Following induction of general anesthesia, dogs were posi-

tioned in dorsal recumbency and the ventral abdomen was

aseptically prepared. Abdominal access was obtained using a

Hasson or modified Hasson technique.15 A 5 mm incision

was made through the skin, subcutaneous tissues and linea

alba, 10 mm caudal to the umbilicus to allow introduction of

a 308 laparoscope (Karl Storz Endoscopy, Goleta, CA). A

stab incision was made into the linea alba and a 6 or 12 mm

smooth, trocar/cannula assembly (Karl Storz Endoscopy)

was introduced into the abdomen. The abdomen was insuf-

flated with CO2 to a maximum of 8–12 mmHg using a pres-

sure regulating mechanical insufflator (Karl Storz

Endoscopy). Three instrument portals (3.5–12 mm) were

established under laparoscopic guidance in locations

described by Mayhew et al.14 One portal was placed in the

left cranial quadrant, just caudal to the costal arch for the

introduction of a retraction device to elevate the gall bladder

and allow visualization of the cystic duct. Two portals were

placed in the right middle and cranial quadrant for the intro-

duction of dissection forceps, taking care to triangulate all

ports around the anticipated location of the gall bladder (Fig

1).14 Based on surgeon preference, a commercially available

multiple channel, single access port (SILSTM port, Covidien

Inc, Mansfield, MA) was used (Fig 2). The SILSTM port was

inserted into the abdomen as described.18 Briefly, a 25 mm

incision was created 10 mm caudal to the umbilicus through

the skin, subcutaneous tissues, and linea alba. Two apposing

stay sutures were placed into the rectus sheath at the incision

margins. Digital insertion through the incision was

Figure 1 Laparoscopic cholecystectomy multiport trocar arrangement using four 6 mm trocar-cannula assemblies.

Laparoscopic Cholecystectomy in Dogs Scott et al.

O50 Veterinary Surgery 45 (2016) O49–O59VC Copyright 2016 by The American College of Veterinary Surgeons

performed to liberate the falciform ligament. Two adjacently

placed Carmalt forceps were attached to the multichannel

single access port in a staggered manner allowing for its

insertion into the abdomen.18 When a single access port was

used, an additional 5 mm instrumental portal was placed in

the left cranial abdominal quadrant for insertion of a retrac-

tion device for gall bladder elevation.

Laparoscopic cholecystectomy was performed as

described.14 Briefly, following establishment of pneumoperi-

toneum and creation of instrument portals, the gall bladder

was elevated using either a blunt probe or a 5 or 10 mm fan

retractor placed in the left sided instrument portal. The cystic

duct was visualized, and, if present, adhesions were trans-

ected using a vessel-sealing device (LigasureTM, Covidien

Inc) through a right-sided instrument portal. Dissection of

the cystic duct was performed using a laparoscopic articulat-

ing dissector (Karl Storz Endoscopy) or 5 mm right-angled

forceps (Fig 3A). When using the articulating dissector for

cystic duct dissection, the instrument was placed through the

right-sided instrument portal and deflected to create a 908

angle in the shaft of the instrument to provide an optimal dis-

section angle behind the cystic duct (Fig 3B). The deflection

angle was alternated between right and left to allow for dis-

section from both sides of the cystic duct. Once dissection

was complete, the cystic duct was ligated using 10 mm

metallic clips (Endo ClipTM, Covidien Inc), extracorporeal

or intracorporeal ligation, pretied ligature loop (SurgitieTM,

Covidien Inc) or a combination of these methods (Fig 3C).

The cystic duct was transected using laparoscopic Metzen-

baum scissors (Karl Storz Endoscopy). Laparoscopic Bab-

cock forceps were used to grasp the cystic duct remnant on

the gall bladder and a combination of blunt dissection and

vessel-sealing devices were used to dissect the gall bladder

free from the hepatic fossa. The gall bladder was temporarily

deposited in the lateral aspect of the abdomen and the

hepatic fossa was inspected and lavaged (Suction wand with

trumpet valve, Karl Storz Endoscopy). In selected cases, a

pretied ligature loop was inserted through the left instrument

portal and laparoscopic Babcock forceps were inserted

through the right instrument portal through the loop and

grasped the cystic duct stump allowing for ligature place-

ment. Liver biopsy was obtained with laparoscopic cup

biopsy forceps inserted through an instrument portal. A spec-

imen retrieval bag (Endo CatchTM, Covidien Inc) was

inserted through a 10 mm portal to retrieve the gall bladder

in some dogs. In other dogs, the gall bladder was retrieved

through the subumbilical port site incision without the use of

a specimen retrieval bag. The gall bladder and liver biopsy

were submitted for histologic examination, and bacterial cul-

ture and susceptibility testing of gall bladder contents was

performed.

Open Cholecystectomy

Conversion to open laparotomy was performed if the cystic

duct was unable to be securely ligated or if there was evi-

dence of gall bladder rupture. Following ventral midline celi-

otomy, the gall bladder was dissected from the hepatic fossa

using a combination of sharp and blunt dissection.19 The

cystic duct was ligated using 2–0 polydioxanone circumfer-

ential ligatures. The celiotomy incision was then closed.

Complications

Complications were defined as major if they necessitated

conversion to open cholecystectomy or required revision

Figure 2 Laparoscopic cholecystectomy using a single incision, multichannel (SILSTM) port placed on ventral midline and a single 6 mm trocar-

cannula assembly placed in the left cranial abdominal region.

Scott et al. Laparoscopic Cholecystectomy in Dogs


surgery and minor if they were transient with no intervention

required.

Outcome

Follow-up phone conversations and/or clinical examination

with owners determined short-term (<14 days postoperative)

and long-term (>30 days) outcomes. If the dog had died or

was euthanatized, the cause of death was recorded.

Statistical Analysis

Age, body weight, serum total bilirubin concentration,

serum alkaline phosphatase, alanine transaminase, and

Figure 3 Intraoperative images from a 10-year-old, castrated male, Shetland Sheepdog undergoing laparoscopic cholecystectomy. (A) A fan

retractor is used to elevate the gall bladder for visualization of the cystic duct. (B) The cystic duct is dissected with an articulating dissector.

(C) Placement of surgical clips prior to transection.



gamma-glutamyl transferase activities, white blood cell count,

platelet count, surgical technique, surgery duration, anesthe-

sia duration, hospitalization duration, and postoperative stay

were categorized by conversion status (laparoscopic chole-

cystectomy vs. conversion to open cholecystectomy). Surgi-

cal technique was described by the total number of ports

placed, the use of SILSTM port compared to multiple single

ports, method of cystic duct dissection (right-angled forceps

and articulating forceps), method of cystic duct ligation

(suture, metallic clips, and combination), and the method of

gall bladder dissection (blunt probe, vessel-sealing device,

and combination). Normality of continuous variables was

confirmed using a Shapiro–Wilk test. Categorical variables

were compared with a Fisher's exact test, and continuous

variables were compared with a Student's t-test for normally

distributed data. Nonparametric data were tested with a Wil-

coxon rank-sum test. P�.05 was considered statistically

significant.

RESULTS

Cases

Twenty dogs were identified in the study period and

included. Breeds included Shetland Sheepdog (8), Mixed-

breed (3), Dachshund (2) and 1 each of a Jack Russell, Pom-

eranian, Cocker Spaniel, Cairn Terrier, West Highland White

Terrier, Bichon Frise, and an Italian Greyhound. The age at

diagnosis ranged from 5 months to 14.7 years (median 10.4).

The body weight ranged from 3.8 to 16.3 kg (median 9.4).

There were 10 spayed females (50%), 9 castrated males

(45%), and 1 intact male (5%). There was no significant dif-

ference in sex (P5.55), age (P5.27), or body weight

(P5.48) between dogs undergoing laparoscopic cholecystec-

tomy vs. cases requiring conversion to open cholecystec-

tomy. Comorbidities included valvular heart disease (7),

hypothyroidism (3), diabetes mellitus (2), hyperadrenocorti-

cism (2), cardiac arrhythmia (1), tracheal collapse (1),

immune-mediated thrombocytopenia (1), immune-mediated

hemolytic anemia (1), seizures (1), and oral melanoma (1).

Preoperative Findings

Fourteen dogs (70%) presented with clinical signs (Table 1).

Six dogs (30%) had evidence of gall bladder disease on

abdominal ultrasound examination that was an unexpected

finding. There was no significant difference in preoperative

serum total bilirubin concentration, serum alkaline phospha-

tase, alanine transaminase and gamma-glutamyl transferase

activities, white blood cell count, or platelet count between

dogs undergoing laparoscopic vs. cases requiring conversion

to open cholecystectomy (Table 2). Coagulation parameters

(prothrombin time, partial thromboplastin time) were

assessed in 6 dogs and were within reference intervals.

Three-view thoracic radiographs were obtained prior to

surgery in 10 dogs and were considered normal, except in 1

dog with mild left atrial enlargement. Abdominal ultrasound

examination was performed for all dogs. There was evidence

of mucocele development with echogenic bile sludge and

stellate bile patterns in 18 dogs.20 Cholelithiasis was present

in 3 dogs but choledocholithiasis was not observed in any

dog. A well circumscribed echogenic mass was seen in the

lumen of the gall bladder in 2 dogs and gall bladder neopla-

sia was suspected.

The gall bladder length and width were reported in the

ultrasound examination for 12 dogs and ranged from 72 3

37 mm to 16 3 14 mm (Table 3). Subjective assessment of

size was reported for 10 dogs and considered severely dis-

tended (1), prominent (1), moderately distended (4), mildly

distended (3), and not dilated (1). Cystic duct diameter was

recorded for 6 dogs, ranging from 3 to 7 mm (median 6).

One dog had multifocal small intestinal muscularis and

Table 1 Number of dogs (%) with clinical signs at presentation in

dogs undergoing laparoscopic cholecystectomy or conversion to open

cholecystectomy

Number of dogs

Clinical

signs

Laparoscopic

n514

Open

n56

Total

n520

None 4 (31%) 2 (29%) 6 (30%)

Vomiting 6 (46%) 4 (57%) 10 (50%)

Anorexia 6 (46%) 3 (43%) 9 (45%)

Lethargy 5 (38%) 2 (29%) 7 (35%)

Polyuria/

polydipsia

1 (8%) 1 (14%) 2 (10%)

Diarrhea 2 (15%) 0 2 (10%)

Abdominal pain 3 (23%) 2 (29%) 5 (25%)

Depression 1 (8%) 1 (14%) 2 (10%)

Panting 1 (8%) 0 1 (5%)

Table 2 Comparison of preoperative serum biochemistry and hematology for dogs undergoing laparoscopic cholecystectomy or conversion

to open cholecystectomy

Parameter (reference interval)

Laparoscopic Median

(range) n516

Converted cases

Mean (range) n56 P-value

Total bilirubin (0–0.2 mg/dL) 0.3 (0.06–1.9) 0.7 (0.06–3.7) 0.79

ALP (23–143 U/L) 357.6 (56–738) 607.6 (128–1095) 0.51

ALT (19–107 U/L) 277.2 (37–1464) 236 (37–788) 0.97

GGT (0–7 U/L) 20.4 (0–125) 18.6 (6–31) 0.22

White blood cell count (4.9–15.4 3 109/L) 10.4 (5.7–19.5) 14.3 (5.5–35.6) 0.32

Platelet count (117–4183 109/L) 411.5 (215–784) 404.7 (231–530) 0.91

ALP, alkaline phosphatase; ALT, alanine transaminase; GGT gamma-glutamyl transferase.



submucosal thickening. Four dogs had course hepatic paren-

chyma and 2 dogs had mild bilateral adrenomegaly. Two

dogs had mild bilateral chronic renal degenerative changes

and 1 dog had hypoechoic nodules within the spleen.

Laparoscopic Cholecystectomy

Various surgical approaches and instrumentation was used,

according to surgeon preference. All procedures used a multi-

port technique. Procedures used 4 portals14,19 (11), 3 portals

(1), 2 portals (1), and SILSTM port (7). The subumbilical cam-

era port was a 12 mm port (11), 6 mm port (1), or 3.5 mm port

(1). The left instrument port was a 12 mm port (6) or 6 mm

port (14). The right instrument port used a 6 mm port (18) or

3.5 mm port (1). A second instrument portal was placed in the

left cranial quadrant rather than the right cranial quadrant in 1

dog. A 3 port technique, omitting the second right sided

instrument portal, was used in 1 dog and 2 ports were placed

with a 12 mm port as the subumbilical camera port and a

12 mm port as the left instrument port in 1 dog. The most

common port placement combined with the SILSTM port in 6/

7 dogs was to place the SILSTM port in the subumbilical loca-

tion, with the placement of two 6 mm instrument portals para-

median in the right and left cranial abdominal quadrants. In 1/

7 SILSTM port applications, there was only 1 additional instru-

ment port in the left cranial quadrant for placement of the fan

retractor for gall bladder elevation. The use of multiple, single

ports compared to the multi-channel single access port device

did not significantly affect the conversion rate (P51.0), nor

did the total number of ports placed (P5.4).

The gall bladder was elevated towards the ventral body

wall with an instrument placed in the left cranial abdominal

instrument portal in all dogs. Elevation was performed using

a 5 mm fan retractor (13), a 10 mm fan retractor (6), or a

blunt probe (1).

Surgery was converted to open cholecystectomy in 1 dog

after initial exploratory revealed bile leakage and gall bladder

rupture. Cystic duct dissection prior to dissection of the gall

bladder from the hepatic fossa was performed in 18 dogs. In 1

dog, the gall bladder was dissected from the hepatic fossa

prior to cystic duct dissection, which resulted in moderate

hemorrhage and a dependent gall bladder. This obscured visu-

alization of the cystic duct and required conversion to open

cholecystectomy. The method of cystic duct dissection was

not recorded (1), by articulating forceps (10) or 5 mm right-

angled forceps (7). Conversion was required during cystic

duct dissection due to mild iatrogenic biliary leakage or an

inability to safely ligate the cystic duct in 3 dogs. The cystic

duct spread to a width >10 mm, precluding the use of the sur-

gical clips and requiring conversion in 2/3 dogs. Sudden car-

diac arrest necessitating open chest compressions through the

diaphragm required conversion in 1 dog. This dog was suc-

cessfully resuscitated and the cholecystectomy was completed

as an open procedure. The method of cystic duct dissection

was not significantly different between the laparoscopic and

converted cases (P51.0).

Cystic duct ligation during laparoscopic cholecystec-

tomy was successfully performed in the remaining 15 dogs

using metallic clips (9) of which 4 were augmented with

extracorporeal techniques (Roeder knot) or suture alone

(6) with either intracorporeal or extracorporeal techniques

(modified 4S Roeder knot). Two or more ligatures remained

on the proximal end of the duct following transection in all

dogs. There was no significant association between the mate-

rial or method of ligation used between laparoscopic and

converted cases (P51.0).

Table 3 Preoperative appearance and dimensions of the gall bladder and bile ducts on ultrasound examination of dogs undergoing laparoscopic

cholecystectomy or conversion to open cholecystectomy

Gall bladder size Cystic duct size Common bile duct size

Group Descriptive Width 3 length (cm) Wall thickness (cm) Width (cm) Width (cm)

Converted to Open

Cholecystectomy

1 0.6

2 Prominent 0.9

3 Severe distension

4 4.4 3 2.9 0.2 0.3 0.4

5

6 7.2 3 3.7 0.6 2

Laparoscopic 1 Mild distension

2 Mild distension

3 Mild distension 4.1 3 2.5 < 0.7

4 Rounded 6.4 3 3.5 0.3

5 53 3

6 Moderate distension 3.6 3 2 0.2

7 Moderate distension 3.4 3 7.5

8 3.3 3 2.5 Normal

9 Moderate distension 2.6 3 3.3

10 1.6 3 1.4 0.3 0.6 0.2

11 1.3 3 3.7

12 Moderate distension

13 Not dilated

14 4.2 3 3.1 0.6



The gall bladder was dissected free from the hepatic

fossa during laparoscopic cholecystectomy in 15 dogs using

a bipolar vessel-sealing device (7), harmonic scalpel (4) or

blunt dissection alone (4). The method of gallbladder dissec-

tion was not significantly different between laparoscopic and

converted cases (P51.0). Intraoperative bleeding was con-

sidered mild (14) and moderate (1) during dissection.

A specimen retrieval bag inserted through the 10 mm

subumbilical port was used in 8 dogs, and not used in 6, with

only mild spillage of bile during extraction in 1/6.

Laparoscopic cholecystectomy was successfully com-

pleted in 14 dogs (70%) and conversion to open cholecystec-

tomy was required in 6 dogs (30%) due to cystic duct

anatomy precluding secure ligation (2), evidence of gall blad-

der rupture (1), leakage from cystic duct during dissection (1),

cardiac arrest (1), and dissection of the gall bladder initially

prior to cystic duct dissection, which obscured visualization of

the cystic duct (1). The anesthesia and surgery duration for

laparoscopic cholecystectomy ranged from 120 to 285

minutes (median 175) and 72 to 180 minutes (median 108),

respectively. There were significantly more intraoperative

complications (yes/no) in the cases converted to open chole-

cystectomy (P5.023). The anesthesia and surgery duration

for the converted open cholecystectomy cases was 135–285

minutes (median 205) and 75–175 minutes (median 103),

respectively. There was no significant difference in anesthesia

or surgery duration between laparoscopic cholecystectomy

and cases requiring conversion to open cholecystectomy.

Histologic and Microbiologic Findings

Histologic examination of the gall bladder was performed in

all dogs and showed evidence of mucosal cystic hyperplasia,

cholecystitis or mucocele formation in 18 dogs with 3/18 hav-

ing concurrent cholelithiasis. The remaining 2 dogs had a pap-

illary adenoma in the gall bladder (1) and mural hemorrhage

and fibrosis consistent with previous rupture or infarction (1).

Both these dogs had successful laparoscopic cholecystectomy.

Liver biopsy was performed in 18 dogs with cholestasis with

biliary hyperplasia, portal hepatitis, and cholangitis (17) and

no abnormalities (1). Bacterial culture of the gall bladder con-

tents resulted in no growth (8), Enterococcus sp. (2), Esche-

richia coli (2), Lactobacillus acidophilus (1), or Clostridium

sp. (1).

Postoperative Complications

One minor and 2 major complications were noted postopera-

tively and there was no significant difference in the frequency

of postoperative complications between the laparoscopic and

converted cases (P51.0). One dog undergoing laparoscopic

cholecystectomy had marked bruising of the ventral abdomen

4 days postoperative, despite normal coagulation parameters

at the time of presentation. No intervention was required and

the bruising resolved by 10 days postoperative. One dog

undergoing open cholecystectomy developed pancreatitis and

ketosis, which resolved with medical management. The third

dog had undergone laparoscopic cholecystectomy and

required surgical revision due to hepatic duct leakage and bile

peritonitis 6 days postoperative. There had been no intraopera-

tive complications noted during the initial procedure in this

dog except for mild bleeding from the quadrate lobe which

resolved without intervention. Two modified Roeder extracor-

poreal knots were used to ligate the cystic duct, prior to trans-

ection between them. An additional ligature was placed on the

cystic duct following transection using a pretied ligature loop

(SurgitieTM). At revision, a partial quadrate liver lobectomy

was performed to resolve a leaking hepatic duct. This dog

recovered without further complication and, at 446 days post-

operative, was clinically normal despite persistent elevations

in serum alanine transaminase activity.

Outcome

Hospitalization duration ranged from 2 to 7 days (median 2)

and all dogs were discharged from hospital. The hospitaliza-

tion duration was not significantly different for dogs under-

going laparoscopic cholecystectomy vs cases requiring

conversion to open cholecystectomy (laparoscopic: range

24–96 hours, median 27 hours, open: range 24–49 hours,

median 27 hours; P5.3). All dogs were discharged with

analgesics (tramadol, buprenorphine and/or meloxicam), and

continued on ursodeoxycholic acid and s-adenosylmethio-

nine/silybin supplements, if previously prescribed. Antibiot-

ics were continued or started in 11 dogs (clindamycin,

amoxicillin/clavulonic acid, enrofloxacin, metronidazole,

and chloramphenicol).

Short-term outcome was available for 19 dogs (14 lapa-

roscopic, 5 open) and long-term outcome for 16 dogs (12

laparoscopic, 4 open) with follow-up ranging from 10 to 900

days (median 268). All dogs with clinical signs attributable

to gall bladder disease had resolution of these signs in 1–14

days, except for the dog that represented 6 days after laparo-

scopic cholecystectomy for acute abdominal pain due to bile

peritonitis. The duration until resolution of clinical signs was

significantly shorter for dogs undergoing laparoscopic chole-

cystectomy vs cases requiring conversion to open cholecys-

tectomy (laparoscopic median 1 days, open median 7 days,

P5.047). Follow-up serum biochemistry at 2 days to 3

months showed persistent elevation of liver enzyme activity

in 12 dogs. Long-term outcomes were reported for 19 dogs

with survival to follow-up in 14 dogs (74%), euthanasia or

death for unrelated disease in 5 dogs (hemoabdomen, urinary

bladder transitional cell carcinoma, renal failure, progressive

endocrine disease, and thrombocytopenia). There was no sig-

nificant difference in survival time for dogs undergoing lapa-

roscopic cholecystectomy vs cases requiring conversion to

open cholecystectomy (P5.37).

DISCUSSION

Laparoscopic cholecystectomy was performed successfully

in 70% of dogs in this cohort using a multi-port technique

and 95% of dogs that were discharged from hospital had

resolution of clinical signs. Only 1 dog required revision



surgery, in this case for hepatic biliary duct leakage. Previ-

ously described criteria for case selection for laparoscopic

cholecystectomy recommended dogs have no evidence of

biliary obstruction on abdominal ultrasound examination or

on serum total bilirubin concentration.14 The current recom-

mendation for open cholecystectomy is to ensure patency of

the common bile duct with an enterotomy over the major

duodenal papilla and the introduction of a catheter to flush

the common bile duct.19 During laparoscopic cholecystec-

tomy, the patency of the common bile duct cannot be

assessed, although this is done during laparoscopic cholecys-

tectomy in people.34 Thus, it is important for surgeons con-

sidering laparoscopic cholecystectomy in dogs, to be

confident that there is no obstruction of the common bile

duct. Malek et al reported no significant association on sur-

vival for dogs undergoing open cholecystectomy for gall

bladder mucocele where the common bile duct was catheter-

ized to ensure patency compared to those dogs where com-

mon bile duct patency was not assessed.25 However, these

results may be biased based on intraoperative findings.25 In

our study, 6 dogs had elevated serum total bilirubin concen-

tration; however, postoperative complications related to bili-

ary obstruction were not observed. There was no difference

in the serum total bilirubin concentration for dogs under-

going laparoscopic cholecystectomy vs. dogs requiring con-

version to open cholecystectomy. Multiple studies have

failed to find significant differences in serum total bilirubin

concentration, and serum alkaline phosphatase, alanine trans-

aminase and gamma-glutamyl transferase activities, in dogs

undergoing open cholecystectomy, regardless of out-

come.25,46 The findings of previous studies along with the

results of our study suggest that dogs with mild elevations in

serum total bilirubin concentrations may be acceptable can-

didates for laparoscopic cholecystectomy.

Shetland Sheepdogs were overrepresented (8/20) in our

study and the most common clinical signs at presentation for

all dogs was vomiting, lethargy, and reduced food intake, all

findings consistent with previous reports.21,23–26 Comorbid-

ities were noted in the majority of dogs, including hyperadre-

nocorticism, hypothyroidism, and diabetes mellitus. There is

a known association of gall bladder mucoceles with endocri-

nopathies although the pathogenesis remains unclear.24–26

The reports on findings of the abdominal ultrasound

examination were inconsistent, prohibiting clear assessment

of gall bladder size as selection criteria for laparoscopic cho-

lecystectomy. Only 3/6 dogs that were converted to open

cholecystectomy had gall bladder size recorded, all of which

were marked enlarged. In comparison, most dogs undergoing

successful laparoscopic cholecystectomy had mild enlarge-

ment of the gall bladder. Besso et al reported the average

gall bladder volume of dogs with mucoceles was enlarged at

87 mL, compared to the approximated normal gall bladder

volume in a medium sized dog of 15 mL.20 We did not docu-

ment gall bladder volume. Gall bladder wall thickness is not

a good indicator of mucosal hyperplasia or cholecystitis in

dogs,20,26 although in people, gall bladder wall thickness can

be predictive of laparoscopic operability.27,28 Two dogs that

required open cholecystectomy had a gall bladder wall thick-

ness greater than normal (2–3 mm).21,29

Preoperative abdominal ultrasound examination showed

evidence of localized inflammation around the cystic duct in

1 dog. Initial laparoscopic exploration showed this dog had a

gall bladder rupture and required immediate conversion to

open cholecystectomy. Evidence of bile leakage during open

cholecystectomy has no impact on survival and is usually a

localized nonseptic bile peritonitis21,25,30 but correct identifi-

cation preoperatively is important to determine appropriate

laparoscopic cholecystectomy candidates.14 In people, the

presence of pericholecystic fluid and acute cholecystitis is

not a contraindication for laparoscopic cholecystectomy but

is associated with higher conversion rates.9,13 This dog could

have been ruled out as a candidate based on the preoperative

ultrasound findings; however, another dog with evidence of

hyperechoic fat and localized inflammation around the gall

bladder on abdominal ultrasound examination did not have

any evidence of gall bladder rupture or peritonitis and was dis-

charged after laparoscopic cholecystectomy <32 hours post-

operative. These dogs did, however, have different clinical

signs on presentation; the former with vomiting and lethargy

and moderate elevations in serum biochemistry parameters,

the latter without clinical signs and minimal serum biochemis-

try changes. Ultrasound examination is considered a sensitive

and specific tool in detecting bile peritonitis at 85.7 and

100%, respectively,24 but the outcomes of these 2 dogs with

similar findings on ultrasound examination highlight the com-

plexity of case selection for laparoscopic cholecystectomy.

Clinical presentation must be considered in conjunction with

findings on ultrasound examination (gall bladder size, gall

bladder wall thickness, gall bladder wall integrity, and cystic

duct size).

A case series of laparoscopic cholecystectomy in 6 dogs

first described a surgical technique for laparoscopic chole-

cystectomy.14 Variations of this technique were used by dif-

ferent surgeons in our study but no method of approach,

dissection or ligation was associated with conversion to open

cholecystectomy. Single incision laparoscopic cholecystec-

tomy in people is purported to improve cosmesis, reduce

morbidity, and minimize hospital stay.31,32 Gonzalez-Gasch

and Monnet reported on the SILSTM port system for elective

laparoscopic procedures in dogs, citing reduced surgery

duration and complication rate compared to a multi-port

technique.33 Port placement, number and size was not associ-

ated with conversion; however, a 12 mm subumbilical cam-

era portal and 12 mm instrument portal in the left cranial

quadrant appeared beneficial for successful laparoscopic

cholecystectomy. The 12 mm subumbilical portal allows

insertion of a 5 mm laparoscope, an instrument for dissection

if the angle is advantageous and a specimen retrieval bag for

gall bladder extraction through incisional enlargement on

ventral midline. The introduction of a 10 mm fan retractor in

the left paramedian portal for gall bladder elevation subjec-

tively appeared to improve visualization of the cystic duct.

The shift from using a 5 to a 10 mm fan retractor was made

as we gained experience, and this assisted in elevation of

moderately distended gall bladders, without damage to



adjacent liver parenchyma. The larger width of the 10 mm

fan blades may create less pressure and tearing of hepatic

parenchyma than the 5 mm blades. The use of a SILSTM port

may minimize surgery duration and morbidity through a

reduction in portal incisions33 while allowing for extraction

of the gall bladder without further extension of an instrument

portal. The SILSTM port was used with a left paramedian

portal in 7 dogs, which the authors believe is essential for

gall bladder elevation.

We believe the use of articulating forceps, initially

designed for use in the SILSTM port to reduce instrument

clashing during cystic duct dissection, improved the angle

for cystic duct dissection compared with straight 5/10 mm

right angle forceps. By deflecting the forceps to 70–908, a

safe angle for dissection around the cranial aspect of the

cystic duct was created and allowed the entire width of the

duct to be encompassed, especially in dogs where the duct

was >5 mm. While the articulating forceps are helpful,

straight right-angled forceps can also be used for safe dissec-

tion of the cystic duct.

Iatrogenic injury of a biliary duct during dissection is

reported in 0.3–2.7% of people undergoing laparoscopic cho-

lecystectomy.10,34 Risk factors include aberrant anatomy,

inflammation, and surgeon inexperience.34 Multiple imaging

modalities are proposed to facilitate dissection including

intraoperative cholangiography, intraoperative laparoscopic

ultrasound examination, and near-infrared fluoroscopic chol-

angiography.10,35 None of these imaging modalities were

used in this study but may be examined in the future.

If biliary duct injury is identified intraoperative, it should

be addressed immediately, which in people involves direct

laparoscopic repair.34 Cystic duct leakage was observed in 1

dog during cystic duct dissection. This leak was mild, identi-

fied quickly and well contained. Although not required, this

could have been addressed during laparoscopy with the place-

ment of ligatures or endoscopic clips.

The occurrence of intraoperative complications was sig-

nificantly more frequent in dogs undergoing open cholecys-

tectomy. This is not unexpected since the reason for open

conversion was a complication during laparoscopy. To deter-

mine an unbiased frequency of complication for laparoscopic

vs. open cholecystectomy, a prospective, randomized trial,

controlling for case complexity, would be required. We had

a 30% conversion rate to open cholecystectomy but believe

this rate could be further reduced with careful case selection

and familiarity with multiple techniques for laparoscopic

cystic duct ligation. We used metallic clips or suture material

to occlude the cystic duct. In people, the use of a self-

locking polymer clip (Hem-O-Lok clipTM, Weck, Research

Triangle Park, NC) is preferred over concern for migration

or dislodgement of the metallic clips.36–38 The polymer clip

has not been evaluated in laparoscopic cholecystectomy in

dogs, but clinical reports have been favourable.39 The use of

a bioabsorbable polymer clip (Laparo clipTM, Covidien Inc)

has also been investigated,36 which may be preferential to

avoid potential nidus stone formation in the cystic duct.40

The best method of cystic duct ligation cannot be discerned

from our study or others due to the lack of randomized

control trials.41 Bile peritonitis did develop 6 days postopera-

tive in 1 dog undergoing laparoscopic cholecystectomy but

was due to inadvertent hepatic duct trauma rather than suture

slippage from the transected cystic duct. While suture or sur-

gical clips appears appropriate for ligation of the cystic duct

during laparoscopic cholecystectomy in dogs, the laparo-

scopic surgeon should be capable of performing other meth-

ods of cystic duct ligation, especially for very dilated cystic

ducts. It is imperative that whatever method of cystic duct

ligation is performed results in complete occlusion of the

entire width of the duct, which is not always possible with

laparoscopic surgical clips.42 Conversion to open cholecys-

tectomy was required in 2 dogs due to spreading of the cystic

duct beyond the capacity of a 10 mm surgical clip. Had intra-

corporeal or extracorporeal suture techniques or a self-

locking polymer clip been used, conversion may have been

avoided. The use of a vessel-sealing device on the ligation

and transection of cystic ducts in healthy canine cadavers is

comparable to 10 mm metallic surgical clips.42 The vessel-

sealing device is a rapid and effective way to ligate and tran-

sect the cystic duct but in vivo investigation is required.

The gall bladder was dissected free from the hepatic

fossa prior to cystic duct isolation and dissection in 1 dog

during laparoscopy. This fundus-first technique is usually

performed in open cholecystectomy19 and is used in people

during laparoscopy where excessive adhesions make access

to the cystic duct difficult.43,44 Differences in the pathology

of gall bladder disease in dogs19,22 compared to people9–12

make this less viable since most dogs present for cholecys-

tectomy of gall bladder mucocele, where the gall bladder is

engorged and heavy with inspissated bile. The weight of the

free gall bladder after dissection, combined with the diffi-

culty of retracting the heavy gall bladder ventrally and the

presence of hemorrhage from the hepatic fossa, make access

to the cystic duct difficult. We recommend a blunt instru-

ment (fan retractor, blunt probe and Cuschieri retractor) be

used for gall bladder elevation when dissecting the cystic

duct because of the fragile gall bladder wall, especially for

gall bladder mucoceles. This is in contrast to the approach in

people where the gall bladder is suspended with a transabdo-

minal suture or grasping instrument.10,32,34

One dog had a cardiac arrest during cystic duct ligation.

This dog was stable preoperative with clinical signs of abdom-

inal pain and mild changes on preoperative serum chemistry

analysis. Some dogs with hepatobiliary disease are poor anes-

thetic candidates due to hypotension associated with vagal

response during gall bladder manipulation, and endotoxemia

secondary to extra-hepatic biliary obstruction.45,46 Subjects

with postoperative hypotension are reported with poorer out-

comes25,30,46 but a recent retrospective study did not find

anesthetic complications in dogs undergoing cholecystectomy

to be any different from dogs undergoing other hepatic sur-

gery.45 Whether the dog in our study had a vagal-induced bra-

dycardic event or an anesthetic-related event is unknown.

The specimen retrieval bag was used in only 8 dogs,

although it is recommended for the extraction of the gall

bladder to minimize spillage of bile, and allow aspiration

of bile contents once partially exteriorized to collapse the



gall bladder and allow it to be removed through a smaller

incision.14

Extended surgery duration is referenced as a disadvant-

age of some laparoscopic procedures.2,3,5,8 Expertise impacts

surgery duration in laparoscopic cholecystectomy in peo-

ple47,48 but duration is also related to severity of disease.

Duration of surgery in our study was comparable to previous

reports for laparoscopic14 and open cholecystectomy.25

People have a faster convalescence and shorter hospital

stay after laparoscopic cholecystectomy.11,49 The duration of

hospitalization in our study was not different for dogs under-

going laparoscopic cholecystectomy compared to cases that

were converted, although resolution of clinical signs was

shorter for dogs undergoing laparoscopic cholecystectomy.

Interpretation of these results is inconclusive as results may

varying according to disease severity.24,50

Predictive factors for conversion to open cholecystec-

tomy in people include increased white blood cell count,

ultrasound findings of pericholecystic fluid, low serum albu-

min, elevated serum total bilirubin, right cranial abdominal

pain during ultrasound, being male, obesity, comorbidities,

and the presence of a thickened gall bladder wall.13,28,31,49

Since the pathogenesis of disease differs in canines,9–12,19,22

extrapolation of risk factors from people is not possible;

however, careful consideration of preoperative imaging and

the clinical status of the dog is imperative for successful lap-

aroscopic cholecystectomy. We did not find any factors

related to conversion to open cholecystecomy in our study.

Four of 6 conversions in our study were related to techni-

cal issues, lack of confidence performing intracorporeal or

extracorporeal suture techniques when the cystic duct was too

wide for metallic clips, dissection of the gall bladder prior to

the cystic duct impeding visualization, and early conversion

due to biliary leakage. These situations potentially represent a

learning curve in the procedure and it is expected lower con-

version rates for laparoscopic cholecystectomy can be

expected as experience and technical aptitude improve.

This study is limited by possible bias introduced by sur-

geon preferences in case selection and surgical technique.

Laparoscopic cholecystectomy is a relatively new procedure

in veterinary medicine and various centers are developing

and personalizing the technique. As such, we were only able

to examine a small sample size which limits the power of

comparisons.

We had good success with laparoscopic cholecystec-

tomy in a small cohort of dogs. Our results demonstrate that

laparoscopic cholecystectomy can be performed in dogs with

uncomplicated gall bladder disease, with a low complication

rate and an acceptable conversion rate. We expect conver-

sion rates will decrease with gains in clinical experience and

advances in training, as noted in human surgery.10,34 Appro-

priate case selection is imperative to ensure there is no evi-

dence of extra-hepatic biliary obstruction or gall bladder

leakage to limit the risk of conversion. The surgeon consider-

ing laparoscopic cholecystectomy should be familiar with a

variety of methods for cystic duct dissection and ligation to

avoid complications and reduce the rate of conversions.

DISCLOSURE

The authors declare no conflicts of interest related to this

report.

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