Cholecystectomy is predominantly performed for (chronic) cholecystitis and gall stones. Other lesions include adenomyoma and adenocarcinoma.
Elements to note: stones and their location, wall thickness, gangrene or perforation, and mass or nodule.
Measure the specimen (length and diameter) and note its overall shape (pyriform = pear-shaped, globular, elongate).
Describe the outer surface (color, texture, hemorrhage, perforation, adhesions). One aspect represents the free surface and the other aspect represents the hepatic surface. Note whether there is attached liver tissue. Mention whether the gallbladder has been surgically opened and if there are any stones free in the container.
Look for lymph nodes along the cystic duct.
Open the gallbladder longitudinally with a pair of scissors. Note whether stones impact the cystic duct.
Estimate the volume of bile and describe it (color, viscosity). Count or estimate the number of stones present, give an aggregate measurement, and the diameter of the smallest and largest stones (express as a range).
Describe the stones (e.g., cholesterol, black stones) by cracking a stone and examining the inside.
Describe the mucosa (color, velvety, ulcerated, granular, yellow flecks = cholesterolosis) and any masses/nodules (color, dimensions, location and distance from margin, polypoid, friable, invasive). Measure the wall thickness (express as a range if significantly different in areas) and describe any abnormalities.
Received without fixative/in formalin, labeled _____ and “_____”, is a _____ (shape) gallbladder measuring __ cm in length and __ cm in maximum diameter and __ (number) separate stones. The specimen has been surgically opened/is intact. The free external surface is _____ (color, texture) and the hepatic surface is _____ (color, texture) with __ x __ x __ cm of attached _____ (color) liver parenchyma. No/perforations are noted in the _____ region. A __ x __ x __ cm _____ (color, soft vs. firm) lymph node is identified near the proximal margin, in the cystic duct region. The cystic duct is patent/a __ cm stone impacts the cystic duct, which is dilated/not dilated. The gallbladder lumen contains approximately __ cc of _____ (color, viscosity) bile fluid and approximately __ (number) _____ (shape, color) stones (__ x __ x __ cm in aggregate), ranging from __ to __ cm in diameter. The mucosa is _____ (color, texture, ulcerated), with/without cholesterolosis. The wall is __ cm in average thickness. Representatively submitted in #__ (gallbladder) and #__ (lymph node).