Review of the literature showed that the majority of surgeons who have favored nondrainage routinely close the gallbladder bed, presumably believing such a proce- dure will decrease the amount of drainage fluid [8,11,13,18,19]. In our study, such a theoretic advantage of closure was not confirmed since no significant differ- ence in the amount of postcholecystectomy discharge was found between the two groups of patients studied.

The drainage fluid obtained from all patients was serosanguinous in character, and the bilirubin level did not exceed that normally found in plasma; therefore, bile leakage, if present, was insignificant. As Luschka’s ducts communicate freely with the intrahepatic biliary system, alternative pathway for drainage must be present; there- fore, postoperative leakage of bile from these ducts usual- ly stops spontaneously without clinical significance.

Reperitonealization of the raw surface occurs rapidly. Healing is complete within 7 days [20]. Indeed, attempts to suture a wide gallbladder bed often lead to further liver denudation and hemorrhage. In such a situation, good hemostasis by cautery and local application of hemostatic agents is simpler, quicker, and safer than repeated futile attempts to approximate the edges of a wide gap in a fragile organ. The process of reperitonealization can safe- ly be left to nature itself.

Suturing of the gallbladder bed is also believed to reduce the likelihood of adhesions in the subhepatic re- gion [3]. This concept is incorrect because postoperative fibrous adhesions are now regarded as vascular grafts to ischemic areas 1201. A lack of serosal integrity is not an important factor in the genesis of adhesions. Obliteration of the gallbladder bed by suture may in fact create local ischemia and promote more adhesions, making subse- quent reexploration difficult and tedious.

In conclusion, all patients had an uneventful recovery. Drainage from the gallbladder bed was found to be inde- pendent of reperitonealization of the liver surface after uncomplicated cholecystectomy. Suturing of the gall- bladder bed is often carried out on the basis of traditional indoctrination rather than as part of a good surgical tech- nique. Routine closure of the gallbladder bed does not necessarily reduce the amount of drainage and can be safely omitted provided good hemostasis of the gallblad- der bed has been achieved.

EDITORIAL COMMENT

Hiram C. Polk, Jr., MD, Editor in Chief

Acknowledgment: We thank Sheila S.H. Ng for typ- ing the manuscript.

REFERENCES 1. Farquharson EL, Rintoul RF. Textbook of operative surgery. 6th ed. Edinburgh: Churchill Livingstone, 1978; 591-6. 2. Bailey H, Love M. Short practice of surgery. 19th ed. London: HK Lewis, 1984; 888-9. 3. Davidson CM. The biliary system. In: Keen G. Operative surgery and management. Bristol, England: John Wright, 1981: 21 l-5. 4. Glenn F. Complications of biliary tract surgery. Surg Gynecol Obstet 1960; 110: 141-56. 5. Maingot R. Abdominal operations. 7th ed. New York Appleton- Century-Crofts, 1980: 1051-3. 6. Deaver JB. Trauma to liver. Philadelphia: WB Saunders, 1964: 69. 7. Spivack JL. The surgical technique of abdominal operations. 4th ed. Springfield, IL: Charles C Thomas, 1964: 463. 8. Kambouris AA, Carpenter WS, Allaben RD. Cholecystectomy without drainage. Surg Gynecol Obstet 1973; 177: 613-7. 9. Truedson H, Elmros T, Holm S. Elective cholecystectomy with intraperitoneal drain. Acta Chir Stand 1983; 149: 315-21. 10. Kassum DA, Gagic NM, Menon GT. Cholecystectomy with and without drainage. Can J Surg 1979; 22: 358-60. 11. Goldberg IM, Goldberg JP, Liechty RD, Buerk C, Eiseman B, Norton L. Cholecystectomy with and without surgical drainage. Am J Surg 1975; 130: 29-32. 12. Lewis RT. Allan CM. Goodall RG. et al. The conduct of cholecystectomy: incision, drainage, bacteriology and post-opera- tive comolications. Can J Sure 1982: 25: 304-7.

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13. Edlund G, Gedda S, Van der Linden W. Intraperitoneal drains and nasogastric tubes in elective cholecystectomy. Am J Surg 1977; 137: 775-9. 14. Missen AJB. Aberrations of the biliary passages on the surface of the liver and gallbladder and in the gallbladder wall. Br J Surg 1969; 56: 427-31. 15. Johnson G, Gilsdorf R. Routine versus selective drainage of the gallbladder bed after cholecystectomy. Am J Surg 198 1; 142: 65 l- 3. 16. Truedson H. Cholecystectomy with and without intraperitone- al drain. Acta Chir Stand 1983; 149: 393-9. 17. Van der Linden W, Kempi V, Gedda S. A radionuclide study on the effectiveness of drainage after elective cholecystectomy. Ann Surg 1981; 193: 155-60. 18. Trowbridge PE. A randomized study of cholecystectomy with and without drainage. Surg Gynecol Obstet 1982; 155: 171-6. 19. Baraldi U, Macellari G, David P. Cholecystectomy without drainage: a dilemma? Am J Surg 1980; 140: 658-9. 20. Ellis H. The aetiology of post-operative abdominal adhesions. Br J Surg 1962; 50: 10-6.

It has always seemed to me that the energy and effort developing flaps in the gallbladder bed, which can then be closed, was poorly spent and that, further- more, it made some of the more difficult cholecystectomies even more difficult. Accordingly, for all of my surgical life, I have excised the gallbladder flush with the liver bed and, of course, have cheated to some degree by using suction drainage for cholecystectomy in a consistent fashion over all of that time.

The preceding report by Drs. Mok and Li does not represent a great surgical advance, but instead, a little refinement of thought and ideas that can be helpful for stimulating some of the surgical traditionalists.

From the Department of Surgery, Unviversity of Louisville, Louisville, Kentucky.

314 THE AMERICAN JOURNAL OF SURGERY VOLUME 157 MARCH 1989