Laparoscopic completion cholecystectomy: a retrospective study of 40 cases

Resection of the remnant gallbladder after subtotal cholecystectomy: An institutional experience

BACKGROUND

Laparoscopic subtotal cholecystectomy is an acceptable method of preventing bile duct injuries in "difficult" gallbladders. However, it is associated with postoperative bile leaks and retained gallstones that may necessitate resection of the gallbladder remnant. This study evaluates the outcomes of patients who underwent completion cholecystectomy for ongoing symptoms or complication after subtotal cholecystectomy.

METHODS

We performed a retrospective review of adults who underwent laparoscopic completion cholecystectomy after previous subtotal cholecystectomy at a single institution from 2009 to 2023. Indications for reoperation were collected and intraoperative findings, operative outcomes, and rates of postoperative morbidity were evaluated.

RESULTS

Over 14 years, 46 patients underwent completion cholecystectomy, with 40 (80%) in the last 5 years. Remnant cholecystitis was the most common reason for reoperation in 37 patients (80.4%). Choledocholithiasis was seen in 4 cases (8.7%). Bile leak, gallstone pancreatitis, and abdominal abscess were observed in 8 (17.4%), 4 (8.7%), and 5 (10.8%) patients, respectively. Four patients (8.7%) had intestinal fistulas intraoperatively. Laparoscopic completion cholecystectomy was attempted in all, with 2 (4.4%) converted to open laparotomy. The median operative time was 111 minutes (interquartile range, 83-140 minutes), and the median hospital stay was 1 day (interquartile range, 0-2 days). Minor complications occurred in 5 patients (10.9%), which were managed conservatively. Four patients had major complications requiring endoscopic retrograde cholangiopancreatography or percutaneous intervention. There were no bile duct injuries or reoperations, and 44 (95.6%) patients had complete symptom resolution at follow-up.

CONCLUSION

Laparoscopic completion cholecystectomy is feasible and safe but technically challenging. With the increased use of subtotal cholecystectomy, patients presenting with persistent postoperative pain require timely work-up and management of their symptoms.

Surgical Options for Retained Gallstones After Cholecystectomy

BACKGROUND

Retained gallstones are the most common cause of postcholecystectomy pain. They may be in a long remnant cystic duct (CD), the common bile duct (CBD), or within a remnant gallbladder (GB) post subtotal cholecystectomy. Although endoscopic management is often attempted, occasionally surgical clearance is required. Rates of preoperative surgery to remove stones in a remnant GB are rising due to the increased practice of subtotal cholecystectomy during a problematic laparoscopic cholecystectomy. This study aims to review the surgical management of symptomatic retained stones at a tertiary hepatobiliary referral center in Sydney, Australia.

PATIENTS AND METHODS

This retrospective analysis of prospectively collected data was performed on patients who underwent an operation for retained stones after a previous cholecystectomy over 18 years (2004-2022). All of the patients with residual CBD stones had failed endoscopic retrograde cholangiopancreatogram (ERCP) attempts or could not have an ERCP because of prior foregut surgery. All patients underwent a systematic preoperative workup confirming the biliary anatomy and pathology.

RESULTS

Fourteen patients had surgical intervention for retained stones. All cases were attempted laparoscopically and were successful in 11/14 patients (78%). Retained stones were found within a remnant GB (29%, n=4), a remnant CD (36%, n=5), or the CBD (36%, n=5). Conversion to an open procedure in 3 patients was for dense fibrosis associated with a long low-insertion of the CD, necessitating a hepatico-jejunostomy, failure to delineate the biliary anatomy, and inability to clear CBD stones, respectively. One patient developed a minor postoperative complication (superficial wound infection), and all patients were free of symptoms at a median follow-up of 33.5 months.

CONCLUSION

This study demonstrates favorable outcomes in patients undergoing laparoscopic intervention for retained gallstones. A systematic approach to the workup and surgical management of patients with retained stones is essential.

Open versus laparoscopic completion cholecystectomy in patients with previous open partial cholecystectomy: a retrospective comparative study

Background

Some patients report recurrence or persistence of their manifestations after cholecystectomy, and retained gallstones may be a relevant etiology for their complaint. Completion cholecystectomy is advised for these cases to alleviate their manifestations. No previous studies have compared the outcomes of open versus laparoscopic outcomes in these patients, especially in patients who had initial open partial procedures. That is why we performed this study to report the perioperative outcomes of the two approaches in such patients.

Methodology

This is a retrospective analysis of 80 patients who had a completion cholecystectomy in the authors' center (40 open and 40 laparoscopic cases) after initial open partial cholecystectomy.

Results

The duration elapsed since the primary procedure had an average of 18 months in the open group and 21 months in the laparoscopic group. Abdominal pain and dyspepsia were the most common presentations. Some patients had stump cholecystitis or jaundice. The intraoperative assessment revealed either the residual gallbladder or a long cystic duct stump. Laparoscopy yielded shorter operative time, earlier oral intake, and shorter hospitalization periods compared to the open approach (P<0.05). The latter was associated with a 20% wound infection rate that was never encountered after laparoscopy (P =0.003).

Conclusion

Previous open partial cholecystectomy does not hinder subsequent laparoscopic completion cholecystectomy. Additionally, laparoscopy is associated with better perioperative outcomes than the open approach.

The use of indocyanine green and near-infrared imaging in laparoscopic completion cholecystectomy for the management of stump cholecystitis: A case series

INTRODUCTION

Stump cholecystitis is managed by performing a completion cholecystectomy, which can be done either laparoscopically or by an open method. The use of indocyanine green (ICG) is known to improve the identification of the biliary tree anatomy, facilitating Calot's triangle dissection and shortening surgery, thereby reducing the risk of bile duct injuries and making laparoscopic cholecystectomy safer.

PATIENTS AND METHODS

A retrospective analysis was performed of prospectively collected data from 15 patients at our institution from March 2016 to March 2021. Magnetic resonance cholangiopancreatography was performed in all 15 cases, showing remnant gall bladder in all cases with calculi within. Four cases had a dilated common bile duct (CBD) with CBD calculi. Endoscopic retrograde cholangiopancreatography (ERCP) and stone removal followed by CBD stenting were performed in the four patients with CBD calculi. These four cases were scheduled for surgery 4 weeks post-ERCP. All 15 patients underwent laparoscopic completion cholecystectomy. The mean operating time was 80 min.

RESULTS

The post-operative period of all cases was uneventful, and the patients were discharged on post-operative day 2 or day 3. All patients remained asymptomatic during 1-5 years of follow-up.

CONCLUSION

Laparoscopic completion cholecystectomy was performed safely in cases of stump cholecystitis and resulted in symptom relief during short-term follow-up. The use of ICG and near-infrared imaging in such cases helps identify the biliary anatomy, may contribute to the safety of laparoscopic completion cholecystectomy and might reduce the duration of surgery.

Robotic-assisted completion cholecystectomy with repair of cholecystoduodenal fistula

Post-cholecystectomy syndrome (PCS) is a well-documented complication of incomplete cholecystectomy. The etiology is often post-surgical chronic inflammation from unresolved cholelithiasis, which is secondary to anatomical abnormalities, including a retained gallbladder or a large cystic duct remnant (CDR). An exceedingly rare consequence is retained gallstone fistulization into the gastrointestinal tract. We present a case of a 70-year-old female with multiple comorbidities 4 years status-post incomplete cholecystectomy, who developed PCS with cholecystoduodenal fistula secondary to retained gallstone in the remnant gallbladder, with CDR involvement, treated via robotic-assisted surgery. Reoperation in PCS has been traditionally performed via laparoscopic approach with recent advances made in robotic-assisted surgery. However, we report the first documented case of PCS complicated by bilioenteric fistula repaired with robotic-assisted surgery. This highlights the value of robotic-assisted surgery in complicated cases, where one must contend with post-surgical anatomic abnormalities and visualization difficulties. Subsequent investigation is necessary to objectively quantify the safety and reproducibility of our approach.

Surgical management of cystic duct stump calculi causing post-cholecystectomy syndrome: A prospective study

Aim

Remnant cystic duct stump calculi are an uncommon but important cause of 'post-cholecystectomy syndrome'. High index of suspicion is needed to diagnose this condition in a symptomatic post-cholecystectomy patient. We present our experience with the surgical management of this condition.

Patients and Methods

This prospective study included 19 patients with residual gallstone disease who underwent completion cholecystectomy between August 2016 and October 2021. Investigations included abdominal ultrasound and magnetic resonance cholangiopancreatography. The demographic, clinical, surgical and early post-operative variables of these patients were prospectively maintained and analysed.

Results

The study included 14 women and 5 men. The mean age was 42.1 years (range, 14-80 years). The median duration between index surgery and completion cholecystectomy was 36 months (range, 2-178 months) (interquartile range, 105 months). The follow-up duration was 2 months. The initial surgery was open cholecystectomy in 17 and laparoscopic cholecystectomy in 2 patients. All patients with residual stump stone presented with pain, while 10 out of 19 patients complained of dyspepsia. Completion cholecystectomy could be performed laparoscopically in 16 cases, whereas 3 patients underwent open surgery. The mean operative time was 80 min (range, 55-140 min), and the mean blood loss was 100 ml (range, 50-160 ml). The mean hospital stay was 3 days (range, 2-10 days). No post-operative mortality or major morbidity was recorded in any of our patients.

Conclusion

Laparoscopic excision of the cystic duct stump is feasible and safe even after previous open cholecystectomy. It is increasingly becoming the treatment of choice where expertise is available.

The second 'gallbladder operation'

Background:

Subtotal cholecystectomy has been reported in 8% and 3.3% of patients undergoing open and laparoscopic cholecystectomy, respectively. According to a recent nationwide survey, the utilisation of subtotal cholecystectomy in the treatment of acute cholecystitis is on the rise. In 1.8% of subtotal cholecystectomies, a reoperation is required. Reoperations for residual gallbladder (GB), gallstones, and related complications accounted for half of the reoperations described in the literature after subtotal cholecystectomy. The purpose of this study was to evaluate the clinical profile, risk of complications, and feasibility of laparoscopic approaches and surgical procedures in patients with recurrent symptoms from a residual GB that necessitated a completion cholecystectomy.

Methods:

Patients who underwent surgery for residual GB with stones and/or complications between January 2007 and January 2020 were included in the study group. A prospectively maintained database was used to review patient information retrospectively. The demographic profile, operation details of the index surgery, current presentation, investigations performed, surgery details, morbidity and mortality were all included in the clinical information.

Results:

There were 13 patients who underwent completion cholecystectomy. The median age was 55 years (22–63 years). Prior operative notes mentioned subtotal cholecystectomy in only seven patients. The average time between the index surgery and the onset of symptoms was 30 months (2–175 months). A final diagnosis of residual GB with or without calculi was made by ultrasound (USG) in 11 patients and by magnetic resonance cholangiopancreatography (MRCP) in two others. Choledocholithiasis (n = 4, 30.7%), acute cholecystitis (n = 2, one with empyema and GB perforation) and Mirizzi syndrome (n = 1) were seen as complications of residual gallstones in seven patients. All 13 patients underwent successful laparoscopic procedures. A fifth port was used in all. A critical view of safety was achieved in 12 patients. Two patients required laparoscopic common bile duct (CBD) exploration for CBD stones. Intraoperative cholangiograms were done in eight patients (61.5%). There were no conversions, injuries to the bile duct or deaths. Morbidity was seen in one. The patient required therapeutic endoscopic retrograde cholangiography for cholangitis and CBD clearance on the fifth post-operative day. The median hospital stay was 4 days (3–7 days). At a median follow-up of 99 months, symptom resolution was seen in all 13 patients.

Conclusion:

Gallstones in the residual GB are associated with more complications than conventional gallstones. The diagnosis requires a high level of suspicion. MRCP is more accurate in establishing the diagnosis and identifying the associated complications, even if the diagnosis is made on USG in most patients. A pre-operative roadmap is provided by the MRCP. For patients with residual GB, laparoscopic completion cholecystectomy is a feasible and safe option.

Robotic-assisted completion cholecystectomy: A safe and effective approach to a challenging surgical scenario - A single center retrospective cohort study

BACKGROUND

Reoperation following a previous subtotal or aborted cholecystectomy presents a challenging surgical scenario that has traditionally required an open completion cholecystectomy. The aim of this study was to describe an institutional experience with a robotic-assisted approach to completion cholecystectomy.

METHODS

A database was retrospectively audited to identify all patients who underwent robotic-assisted cholecystectomy performed by two hepatopancreatobiliary surgeons at a single centre from 2010 to 2019.

RESULTS

Twenty six patients who underwent a robotic-assisted completion cholecystectomy were identified. Median operative time was 142 min (48-247 min) with a blood loss of 50 cc (0-500 cc). Minor complications (Clavien-Dindo ≤ II 90 days) occurred in three patients (11.5%) with no major complication or mortality reported. Median hospital length of stay was 1 day (0-6 days) with one patient readmitted.

CONCLUSION

This study represents to our knowledge the largest series of robotic-assisted completion cholecystectomies to date. The robotic approach appears to be a safe and effective procedure associated with a low morbidity and high success rate.

Laparoscopic Completion Cholecystectomy: An Audit from the Americas Hepato-Pancreato-Biliary Association (AHPBA) Caribbean Chapter

Objective

Removal of a gallbladder remnant occasionally becomes necessary when retained stones become symptomatic. Although the laparoscopic approach has been described, it is not yet considered the standard of care. We sought to determine the outcomes after completion cholecystectomies in the resource-poor setting within the Caribbean. 

Methods

We carried out an audit of the databases from all hepatobiliary surgeons in the Anglophone Caribbean. We identified all patients who had completion cholecystectomy over the five-year period from July 1, 2012 to June 30, 2018. Retrospective chart review was performed to extract the following data: patient demographics, diagnoses, presenting complaints, operative details, morbidity, mortality, and clinical outcomes. Descriptive statistics were generated using Statistical Packaging for Social Sciences (SPSS), version 12.0 (SPSS Inc., Chicago IL)

Results

There were 12 patients who were subjected to laparoscopic completion cholecystectomy for acute cholecystitis (7), severe biliary pancreatitis (3), and chronic cholecystitis (2) secondary to stones in a gallbladder remnant. There were 10 women and two men at a mean age of 47.4 years (range 32-60; standard deviation (SD) +/-7.81; median 48; mode 52) and a mean body mass index (BMI) of 30.8 Kg/M² (SD +/-3.81; range 26-38; median 29.5). The mean interval between the index operation and the completion operation was 14.8 months (SD +/- 12.3; range 1-48; median 13; mode 18). Five (42%) patients had their original cholecystectomy using the open approach. Five (42%) index operations were done on an emergent basis and the gallbladder remnant was deliberately left behind in three (25%) index operations. The completion cholecystectomies were all completed laparoscopically in 130.5 minutes (SD +/- 30.5; range 90-180, median 125; mode 125) without any conversions or mortality. There were two minor bile leaks that resolved without intervention through an indwelling drain. 

Discussion

Completions cholecystectomy can be completed via the laparoscopic approach with good outcomes and acceptable morbidity and mortality rates. The patients derive the same advantages as elective cholecystectomies. Therefore, the laparoscopic approach, when performed by hepatobiliary surgeons with advanced laparoscopic expertise in specialized centers, should be the new standard of care. 

Residual gall bladder: An emerging disease after safe cholecystectomy

Backgrounds/Aims

Residual gallbladder mucosa left after subtotal/partial cholecystectomy is prone to develop recurrent lithiasis and become symptomatic, which mandates surgical removal.

Methods

We retrospectively evaluated the patients with residual gallbladder referred to us from January 2011 to December 2017. Based on MRCP we classified calot's anatomy to – type I where cystic duct was seen and type II where sessile GB stump was seen.

Results

21 patients with median age 38 years and M:F::1:9.5, had undergone cholecystectomy (3 months-20 years) prior, presented with recurrent biliary pain. 3 had jaundice (CBD stone, Mirizzi and biliary stricture), 1 had pancreatitis and one had malignancy of the GB. Imaging revealed type I anatomy in 14 (67%) and type II in 7 (33%). All underwent completion cholecystectomy – open in 18 and laparoscopic in 3 (one converted to open). Additional procedure was required in 5 patients – CBD exploration in 2 (10%) and one each Hepatico-jejunostomy, extended cholecystectomy and splenectomy. Median hospital stay was 1 day. There was no mortality and 10% morbidity. One patient with malignancy died at 2 years, two died of unrelated cause, one developed incisional hernia and the remaining were well at a median follow up of 29 months.

Conclusions

Residual GB lithiasis should be suspected if there are recurrent symptoms after cholecystectomy. MRCP based proposed classification can guide the management strategy. Completion cholecystectomy is curative.

How to Successfully Manage Residual Gallbladders Laparoscopically Following Open Techniques?

PURPOSE

This study aimed to explore the feasibility and safety of laparoscopic retreatment for residual gallbladders following open techniques, and outline strategies for successful reintervention.

PATIENTS AND METHODS

From January 2008 to December 2015, the clinical and follow-up data of 32 patients who underwent laparoscopic reintervention for residual gallbladders following open techniques were retrospectively analyzed and summarized.

RESULTS

Of all patients, 4 underwent 2 laparotomic surgeries; 6 had choledocholithiasis and underwent endoscopic retrograde cholangiopancreatography. All procedures for residual gallbladders, except 1, were successfully completed by laparoscopy using 3 to 6 trocars. The mean operative time, mean blood loss, and duration of hospital stay were 51.9±14.6 minutes, 30 mL, and 3 to 8 days, respectively. One patient had bilious drainage, lasting up to day 8. All patients remained symptom free, and no mortality and major morbidity were observed on a mean follow-up of at least 6 months.

CONCLUSIONS

Laparoscopic management is feasible and safe for residual gallbladders following open techniques, subject to availability of expertise with well-defined strategies.

Should We Perform Routine Upper Gastrointestinal Endoscopy Before Cholecystectomy?

In some patients, there is not any symptomatic relief after cholecystectomy due to the overlap of the symptoms of biliary and gastroduodenal pathologies known as postcholecystectomy syndrome. The aim of this study was to assess the effectiveness of upper gastrointestinal (UGI) endoscopy in reducing the possibility of postcholecystectomy syndrome. This retrospective study was conducted in 194 cases. In patients sampled for histopathologic examination, screening for Helicobacter pylori and intestinal metaplasia was carried out with Giemsa stain and PAS–Alcian stain. Patients who did not undergo UGI endoscopy before operation were designated as Group A (n = 100) and those who underwent routine UGI endoscopy before operation were called Group B (n = 94). Symptomatic relief after cholecystectomy and endoscopic findings were evaluated. Thirty-one of the 39 patients diagnosed with H. pylori, underwent eradication treatment. Seven of the 31 patients undergoing H. pylori eradication during the preoperative period had ongoing symptoms at the postoperative period. On the other hand, only 2 of 8 patients who did not undergo H. pylori eradication during the preoperative period had unremitting symptoms during the postoperative period. Only three of 100 patients who did not receive a UGI endoscopy during the preoperative period had unremitting symptoms during the postoperative period. The main outcome of the study is to evaluate the necessity of performing routine UGI endoscopy before cholecystectomy. Our results show that it is not necessary, because if you take biliary colic as the one and only symptom of indication for cholecystectomy, the ratio of postcholecystectomy syndrome is 3% to 5% and the reason is 50% organic.

[Abdominal pain syndrome and quality of life in patients with cholelithiasis after cholecystectomy during a 10-year follow-up]

AIM

To estimate the incidence of abdominal pain syndrome (APS) and to assess quality of life (QOL) in patients within 10 years after cholecystectomy (CE).

SUBJECTS AND METHODS

This investigation is part of a long-term prospective follow-up study of patients after CE for cholelithiasis (CL). It enrolled 145 people: 30 (21.5%) patients with baseline asymptomatic CL and 115 (80.7%) with its clinical manifestations. The time course of changes in APS and QOL were analyzed.

RESULTS

Over 10 years, all the patients showed a decrease in the incidence of APS from 84.1% (n=95) to 66.4% (n=75; p=0.004). In Group 1 (n=89), APS was at baseline detected in all the patients; 10 years later, its incidence declined to 67.4% (n=60; p < 0.001). Biliary pains were predominant; these had been identified significantly less frequently over the 10-year period in 47 (52.8%) patients; p<0.001). In Group 2 (n=24), pre-CE APS was generally detected in 6 (25%) patients; following 10 years, the incidence rates of pain significantly increased to 62.5% (n=15; p=0.035), among which there were predominant biliary pains (in 54.2%; p<0.001) and dyspepsia from 33.3% (n=8) up to 66.7% (n=16; p=0.039). QOL in the physical and mental health domains was found to decrease in both groups.

CONCLUSION

Ten years after CE, the group with the baseline clinical manifestations of CL and poorer QOL showed a lower incidence of APS mainly due to the reduced incidence of biliary pains and the baseline asymptomatic group exhibited a rise in the incidence of APS due to the appearance of biliary pains and dyspepsia.

Laparoscopic removal of a gallbladder remnant in a patient with severe biliary pancreatitis

Many surgeons opt to perform subtotal cholecystectomy to limit duct injuries in difficult cases. In these cases, however, there is a risk for the gallbladder remnant to become diseased. In these cases, a completion cholecystectomy is necessary.

Although technically challenging, the laparoscopic approach to completion cholecystectomy is feasible and safe, when performed by surgeons with advanced laparoscopic experience.

Stump cholecystitis: laparoscopic completion cholecystectomy with basic laparoscopic equipment in a resource poor setting

Introduction. Stump cholecystitis is a recognised condition in which a large gallbladder remnant becomes inflamed after subtotal cholecystectomy. When this occurs, a completion cholecystectomy is indicated. Traditionally, these patients were subjected to open surgery because the laparoscopic approach was anticipated to be technically difficult. We present a case of completion cholecystectomy using basic laparoscopic equipment in a resource poor setting to demonstrate that the laparoscopic approach is feasible. Case Description. A 57-year-old woman presented with right upper quadrant pain and vomiting. She had an elective open cholecystectomy seven years before but reported remarkably similar symptoms. Abdominal ultrasound suggested calculous acute cholecystitis. MRCP confirmed the presence of a large gallbladder remnant with stones. Gastroduodenoscopy excluded other differentials. She had an uneventful laparoscopic completion cholecystectomy performed. Discussion. Although traditional dogma suggested that a completion cholecystectomy should be performed through the open approach, several small studies have demonstrated that laparoscopic completion cholecystectomy is feasible and safe. This report adds to the existing data in support of the laparoscopic approach.