Clinical outcomes of subtotal cholecystectomy performed for difficult cholecystectomy

A comparison of outcomes including bile duct injury of subtotal cholecystectomy versus open total cholecystectomy as bailout procedures for severe cholecystitis: A multicenter real-world study

BACKGROUND

Dense inflammation obscuring the hepatocystic anatomy can hinder the ability to perform a safe standard laparoscopic cholecystectomy in severe cholecystitis, requiring use of a bailout procedure. We compared clinical outcomes of laparoscopic and open subtotal cholecystectomy against the traditional standard of open total cholecystectomy to identify the optimal bailout strategy for the difficult gallbladder.

METHODS

A multicenter, multinational retrospective cohort study of patients who underwent bailout procedures for severe cholecystitis. Procedures were compared using one-way analysis of variance/Kruskal-Wallis tests and χ2 tests with multiple pairwise comparisons, maintaining a family-wise error rate at 0.05. Multiple multivariate linear/logistical regression models were created.

RESULTS

In 11 centers, 727 bailout procedures were conducted: 317 laparoscopic subtotal cholecystectomies, 172 open subtotal cholecystectomies, and 238 open cholecystectomies. Baseline characteristics were similar among subgroups. Bile leak was common in laparoscopic and open fenestrating subtotal cholecystectomies, with increased intraoperative drain placements and postoperative endoscopic retrograde cholangiopancreatography(P < .05). In contrast, intraoperative bleeding (odds ratio = 3.71 [1.9, 7.22]), surgical site infection (odds ratio = 2.41 [1.09, 5.3]), intensive care unit admission (odds ratio = 2.65 [1.51, 4.63]), and length of stay (Δ = 2 days, P < .001) were higher in open procedures. Reoperation rates were higher for open reconstituting subtotal cholecystectomies (odds ratio = 3.43 [1.03, 11.44]) than other subtypes. The overall rate of bile duct injury was 1.1% and was not statistically different between groups. Laparoscopic subtotal cholecystectomy had a bile duct injury rate of 0.63%.

CONCLUSION

Laparoscopic subtotal cholecystectomy is a feasible surgical bailout procedure in cases of severe cholecystitis where standard laparoscopic cholecystectomy may carry undue risk of bile duct injury. Open cholecystectomy remains a reasonable option.

Evaluating Clinical Outcomes of Laparoscopic Subtotal and Total Cholecystectomy for Complicated Acute Cholecystitis: A Systematic Review and Meta-Analysis

INTRODUCTION

This systematic review and meta-analysis aimed to compare clinical outcomes in patients with complicated acute cholecystitis undergoing laparoscopic total vs subtotal cholecystectomy.

METHODS

This systematic review and meta-analysis was conducted according to PRISMA guidelines and queried PubMed, Embase, ProQuest, Google Scholar, and Cochrane databases from inception to May 2023. The primary outcome was complication rates including common bile duct injury, wound infection, reoperation, bile leak, retained stones, and subhepatic collection, whereas secondary outcomes were in-hospital mortality and hospital length of stay.

RESULTS

A total of 7 studies with 135,233 cases were included for meta-analysis. Patients who underwent laparoscopic total cholecystectomy had a significantly lower risk of postoperative bile leaks (RR: .15; 95% CI: .03, .80) and subhepatic fluid collection (RR: 0.19; 95% CI: .06, .63) and were 2.94 times less likely to die compared to those who underwent subtotal cholecystectomy (RR .34; 95% CI: .15, .77). Patients who underwent subtotal cholecystectomy had significantly longer hospital length of stay (mean difference 1.0 days; 95% CI: .5 days, 1.4 days).

CONCLUSIONS

In adult patients presenting with complicated cholecystitis, management with laparoscopic subtotal cholecystectomy presents a unique complication profile with increased risk of postoperative bile leak and subhepatic fluid collection, in-hospital mortality, and longer hospital length-of-stay when used as an alternative approach to laparoscopic total cholecystectomy. Further research into the most appropriate clinical scenarios and patient populations for the use of the subtotal cholecystectomy approach may prove useful in improving its associated outcomes.

A systematic review on laparoscopic subtotal cholecystectomy for difficult gallbladders: a lifesaving bailout or an incomplete operation?

INTRODUCTION

Laparoscopic subtotal cholecystectomy (LSTC) is a bailout procedure that is undertaken when it is not safe to proceed with a laparoscopic total cholecystectomy owing to dense adhesions in Calot's triangle. The main aim of this review was to investigate the early (≤30 days) and late (>30 days) morbidity and mortality of LSTC.

METHODS

A literature search of the PubMed® (MEDLINE®), Google Scholar™ and Embase® databases was conducted to identify all studies on LSTC published between 1985 and December 2020. A systematic review was then performed.

RESULTS

Overall, 45 studies involving 2,166 subtotal cholecystectomy patients (51% female) were identified for inclusion in the review. The mean patient age was 55 years (standard deviation: 15 years). Just over half (53%) of the patients had an elective procedure. The conversion rate was 6.2% (n=135). The most common indication was acute cholecystitis (49%). Different techniques were used, with the majority having a closed cystic duct/gallbladder stump (71%). The most common closure technique was intracorporeal suturing (53%), followed by endoloop closure (15%). Four patients (0.18%) died within thirty days of surgery. Morbidity within 30 days included bile duct injury (0.23%), bile leak (18%) and intra-abdominal collection (4%). Reoperation was reported in 23 patients (1.2%), most commonly for unresolving intra-abdominal collections and failed endoscopic retrograde cholangiopancreatography to control bile leak. Long-term follow-up was reported in 30 studies, the median follow-up duration being 22 months. Late morbidity included incisional hernias (6%), symptomatic gallstones (4%) and common bile duct stones (2%), with 2% of cases requiring completion of cholecystectomy.

CONCLUSIONS

LSTC is an acceptable alternative in patients with a "difficult" Calot's triangle.

Bailout Surgery for Difficult Gallbladders: Surgical Approach and Outcomes

INTRODUCTION

Inflammation in acute cholecystitis may cause a cholecystectomy to be more challenging. Due to the difficult dissection, conversion to subtotal cholecystectomy via laparoscopic or open procedure may be required. This is done to reduce the risk of bile duct injury and hemorrhage. We sought to describe the incidence and risk factors, safety, morbidity, and outcomes associated with bailout procedures.

METHODS

A single academic center, retrospective review of laparoscopic cholecystectomies that resulted in bailout procedures performed between January 2015 and December 2020. Data collected from the chart review included demographics, comorbidities, length of presenting symptoms, vital signs, laboratory and imaging, intraoperative findings, length of surgery, and outcome.

RESULTS

A total of 1892 cholecystectomies were performed with 147 bailout procedures. For bailout 92 (63.4%) were converted to open, with 66% resulting in complete cholecystectomy. Hypertension and diabetes were the most common comorbidities. The median duration of symptoms was 4 days. Difficult anatomy in the hepatocystic triangle (66%) and dense adhesions (31%) were the most common reasons for bailout. The mean duration of surgery was 145.76 (SD 102.94) minutes. There were 2 bile duct injuries, both in open total cholecystectomy subgroup. Bile leak occurred in 23.8% with majority in subtotal cholecystectomy group. There was no difference in hospital length of stay, surgical site infection, or mortality among different bailout procedures.

CONCLUSIONS

Subtotal cholecystectomy represents a safe alternative to total cholecystectomy during challenging cases to avoid damaging surrounding structures. The choice of laparoscopic or open subtotal approach is dependent on the surgeons' expertise.

Subtotal cholecystectomy: is it a safe option for difficult gall bladders?

INTRODUCTION

Subtotal cholecystectomy (STC) is an alternative to total cholecystectomy (TC) in patients with severe inflammation/adhesions around the hepatocystic triangle. This study aimed to evaluate the safety profile of STC.

METHODS

We retrospectively reviewed all patients who had STC at our unit between February 2009 and August 2019. STC was divided into two types, reconstituting (R-STC) and fenestrating (F-STC), depending on whether the gall bladder remnant was closed or left open. Patients who had cholecystectomy for gall bladder malignancy or as part of another operation were excluded from the study.

RESULTS

A total of 5,664 patients underwent cholecystectomy during the study period. Of these, 97 (1.7%) underwent STC. The laparoscopic to open conversion rate was high at 48.8% (47 cases), as was the overall postoperative complication rate (45.4%, 44 cases). No patient suffered iatrogenic bile duct injury. Nineteen patients (19.6%) suffered postoperative bile leak. This was significantly higher in patients who had STC in the acute setting (41% vs 13% for elective STC cases; p=0.04). There was no significant difference in rate of bile leak or other complications between R-STC and F-STC types. The 90-day readmission rate was 8.2% (8 cases). No mortalities were recorded within 90 days post STC.

CONCLUSIONS

STC seems to be an effective technique to avoid bile duct injury in difficult cholecystectomy cases. However, the perioperative morbidity associated with STC is relatively high. Surgeons should be aware of the risks of STC and take appropriate steps to minimise them.

Review of the Literature on Partial Resections of the Gallbladder, 1898-2022: The Outline of the Conception of Subtotal Cholecystectomy and a Suggestion to Use the Terms 'Subtotal Open-Tract Cholecystectomy' and 'Subtotal Closed-Tract Cholecystectomy'

Current descriptions of the history of subtotal cholecystectomy require more details and accuracy. This study presented a narrative review of the articles on partial resections of the gallbladder published between 1898 and 2022. The Scale for the Assessment of Narrative Review Articles items guided the style and content of this paper. The systematic literature search yielded 165 publications. Of them, 27 were published between 1898 and 1984. The evolution of the partial resections of the gallbladder began in the last decade of the 19th century when Kehr and Mayo performed them. The technique of partial resection of the gallbladder leaving the hepatic wall in situ was well known in the 3rd and 4th decades of the 20th century. In 1931, Estes emphasised the term 'partial cholecystectomy'. In 1947, Morse and Barb introduced the term 'subtotal cholecystectomy'. Madding and Farrow popularised it in 1955-1959. Bornman and Terblanche revitalised it in 1985. This term became dominant in 2014. From a subtotal cholecystectomy technical execution perspective, it is either a single-stage (when it includes only the resectional component) or two-stage (when it also entails closure of the remnant of the gallbladder or cystic duct) operation. Recent papers on classifications of partial resections of the gallbladder indicate the extent of gallbladder resection. Subtotal cholecystectomy is an umbrella term for incomplete cholecystectomies. 'Subtotal open-tract cholecystectomy' and 'subtotal closed-tract cholecystectomy' are terms that characterise the type of completion of subtotal cholecystectomy.

Laparoscopic Lumen-guided cholecystectomy in face of the difficult gallbladder

BACKGROUND

Where the critical view of safety cannot be established during cholecystectomy, certain salvage techniques are indicated to reduce the likelihood of bile duct injury. The present study describes a salvage technique termed the "laparoscopic lumen-guided cholecystectomy" (LLC) and reports its peri-operative outcomes.

METHOD

A summary of the technique is as follows: (1) Hartmann's pouch is incised and stones are evacuated; (2) the cystic anatomy is inspected from the inside of the gallbladder; (3) the lumen is used to guide retrograde dissection towards the cystic pedicle; (4) cystic duct control is achieved if deemed safe. LLC cases performed between June 2020 and January 2022 in a single health board were included. The operative details and peri-operative outcomes of the technique are reported and compared to cases of similar difficulty where the LLC was not attempted.

RESULTS

LLC was performed in 4.6% (27/587) of cases. In all 27 cases, LLC was performed for a "frozen" cholecystohepatic triangle. Hartmann's pouch was completely excised in all cases (27/27) and cystic duct control was achieved in 85.2% of cases (23/27). No cases of bile leak or ductal injury were reported. Rates of bile leak, post-operative complications and ERCP were lower following LLC compared to the group where LLC was not attempted (p < 0.01).

CONCLUSION

LLC is a safe salvage technique and should be considered in cases where the critical view of safety cannot be established. The technique achieves cystic duct control in the majority of cases and favourable outcomes in the face of a difficult cholecystectomy.

The impact of the COVID-19 pandemic on elective laparoscopic cholecystectomy: A retrospective Cohort study

The coronavirus disease 2019 (COVID-19) pandemic had a significant impact on elective surgery for benign disease. We examined the effects of COVID-19 related delays on the outcomes of patients undergoing elective laparoscopic cholecystectomy (LC) in an upper gastrointestinal surgery unit in the UK. We have analysed data retrospectively of patients undergoing elective LC between 01/03/2019 to 01/05/2019 and 01/04/2021 to 11/06/2021. Demographics, waiting time to surgery, intra-operative details and outcome data were compared between the two cohorts. Indications for surgery were grouped as inflammatory (acute cholecystitis, gallstone pancreatitis, CBD stone with cholangitis) or non-inflammatory (biliary colic, gallbladder polyps, CBD stone without cholangitis). A p value of <0.05 was used for statistical significance. Out of the 159 patients included, 106 were operated pre-pandemic and 53 during the pandemic recovery phase. Both groups had similar age, gender, ASA-grades and BMI. In the pre-pandemic group, 68 (64.2%) were operated for a non-inflammatory pathology compared to 19 (35.8%) from the recovery phase cohort (p < 0.001). The waiting time to surgery was significantly higher amongst patients operated during the recovery phase (p = 0000.1). Less patients had complete cholecystectomy during the pandemic recovery phase (p = 0.04). There were no differences in intraoperative times and patient outcomes. These results demonstrate the impact of COVID-19 related delays to our cohort, however due to the retrospective nature of this study, the current results need to be backed up by higher evidence in order for strong recommendations to be made.

Laparoscopic subtotal reconstituting cholecystectomy in type II & III Mirizzi syndrome: Case series of 5 patients

BACKGROUND

Mirizzi syndrome Type II & III treatment is a true surgical challenge. The purpose was to determine whether the laparoscopic subtotal reconstituting cholecystectomy can be a safe and effective approach in our institution to treat Mirizzi Syndrome type II and III.

CASE PRESENTATION

We report a case series of 5 patients with Mirizzi syndrome type II and III who underwent laparoscopic subtotal reconstituting cholecystectomy.

DISCUSSION

We found only one patient had presurgical diagnosis, average surgical time of 218 min, average surgical bleeding of 230 ml and the mean hospital stay of 3.4 days; one patient presented low volume and auto limited biliary leak; no cases presented biliary injury, major complications, or reintervention.

CONCLUSIONS

Laparoscopic subtotal reconstituting cholecystectomy is a security and effective technique to treat type II and III Mirizzi syndrome in our context.

Comparison of Fenestrating and Reconstituting Subtotal Cholecystectomy Techniques in Difficult Cholecystectomy

Purpose

Cholecystectomy is one of the most frequently performed surgeries. Although laparoscopy is considered the gold standard approach, it cannot prevent biliary injuries. Subtotal cholecystectomy has been performed mainly to prevent biliary injuries during difficult cholecystectomies. This study aimed to analyse our subtotal cholecystectomy results for difficult cholecystectomy cases and to evaluate the fenestrating and reconstituting techniques.

Methods

Retrospective data were collected and analysed statistically for cases that underwent subtotal cholecystectomy in a single referral centre between 2015 and 2020. Comparisons were made of the patients’ age, gender, preoperative American Society of Anaesthesiologists (ASA) score, comorbidities, surgical timing, surgical procedure choice, postoperative complications, and mortality.

Results

The number of patients who underwent subtotal cholecystectomy was 46; 30.4% underwent emergent surgery and 69.6% underwent elective surgery. Twelve patients had subtotal fenestrating cholecystectomy and 34 had subtotal reconstituting cholecystectomy. Wound issues were noted in 17.4% of the patients, while 10.9% had temporary biliary fistulas that resolved spontaneously. Reoperation was performed in one patient due to high-output biliary drainage. Patients with postoperative complications had significantly higher co-morbid conditions (p=0.000), but surgery timing (p=0.192) and type of subtotal cholecystectomy (p=0.409) had no statistically significant effect on complications. Mortality showed a statistically significant correlation with patient comorbidities, surgery timing, and the type of procedure (p<0.05). Postoperative complications showed a statistically significant correlation with mortality (p<0.05).

Conclusion

Subtotal cholecystectomy prevents major biliary complications after cholecystectomy. Yet, the frequency of postoperative complications after subtotal cholecystectomy is incontrovertible. Intraoperative characteristics and the surgeon’s expertise decide the optimal choice of the subtotal cholecystectomy technique.

Subtotal cholecystectomy for difficult acute cholecystitis: how to finalize safely by laparoscopy-a systematic review

Background

Aim of this study was to clarify the best laparoscopic subtotal cholecystectomy (LSTC) technique for finalizing a difficult cholecystectomy.

Patients and methods

A review was performed (1987–2021) searching "difficulty cholecystectomy" AND/OR "subtotal cholecystectomy". The LSTC techniques considered were as follows: type A, leaving posterior wall attached to the liver and the remainder of the gallbladder stump open; type B, like type A but with the stump closed; type C, resection of both the anterior and posterior gallbladder walls and the stump closed; type D, like type C but with the stump open. Morbidity (including mortality) was analysed with Dindo–Clavien classification.

Results

Nineteen articles were included. Of the 13,340 patients screened, 678 (8.2%) had cholecystectomy finalized by LSTC: 346 patients (51.0%) had type A LSTC, 134 patients (19.8%) had type B LSTC, 198 patients (29.2%) had type C LSTC, and 198 patients (0%) had type D LSTC. Bile leakage was found in 83 patients (12.2%), and recorded in 58 patients (69.9%) treated by type A. Twenty-three patients (3.4%) developed a subhepatic collection, 19 of whom (82.6%) were treated by type A. Other complications were reported in 72 patients (10.6%). The Dindo–Clavien classification was four for grade I, 27 for grade II, 126 for grade IIIa, 18 for grade IIIb, zero for grade IV and three for grade V.

Conclusion

In the case of LSTC, closure of the gallbladder stump represents the best method to avoid complications. Careful exploration of the gallbladder stump is mandatory, washing the abdominal cavity and leaving drainage.

Colecistectomía segura: ¿Qué es y cómo hacerla? ¿Cómo lo hacemos nosotros?

La colecistectomía laparoscópica es uno de los procedimientos más realizados a nivel mundial. La técnica laparoscópica se considera el estándar de oro para la resolución de la patología de la vesícula biliar secundaria a litiasis, y aunque es un procedimiento seguro, no se encuentra exenta de complicaciones. La complicación más grave es la lesión de la vía biliar, que, aunque es poco frecuente, con una incidencia de 0,2 a 0,4%, conduce a una disminución en la calidad de vida y contribuye a un aumento en la morbi-mortalidad. El objetivo de este artículo es reportar nuestra técnica quirúrgica, enfatizando los principios del programa de cultura para una colecistectomía segura, propuesta y descrita por the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), para minimizar los riesgos y obtener un resultado quirúrgico satisfactorio.

Laparoscopic subtotal cholecystectomy: comparison of reconstituting and fenestrating techniques

BACKGROUND

Laparoscopic subtotal cholecystectomy (LSC) is a safe bailout procedure in situations when dissection of "critical view of safety" is not possible. After the proposed classification of subtotal cholecystectomy into "fenestrating" and "reconstituting" techniques in 2016, a comparative review of the outcomes of both methods is timely.

METHODS

A literature search of the PubMed, Cochrane Library, and Web of Science database was conducted up to January 31, 2020 for studies that reported LSC. Studies reporting LSC only in patients with Mirizzi syndrome or xanthogranulomatous cholecystitis were excluded. Our analysis includes 39 studies with 1784 cases of LSC. We report a comparison of outcomes between reconstituting and fenestrating LSC on 1505 cases [935 reconstituting (62.1%) and 570 fenestrating (37.9%)].

RESULTS

Following LSC, the rate of open conversion is 7.7%, hemorrhage is 0.4%, bile duct injury is 0.3%, bile leak is 15.4%, retained stone is 4.6%, subhepatic or subphrenic collection is 2.9%, superficial surgical site infection is 2.0% and 30-day mortality is 0.2%. 8.8% of patients required postoperative endoscopic retrograde cholangiopancreatography (ERCP), 1.1% required percutaneous intervention, and 2.2% required reoperation. Compared to reconstituting LSC, fenestrating LSC has a higher incidence of open conversion (n = 58, 10.2% vs. n = 43, 4.6%, p < 0.001), retained stones (n = 38, 6.7% vs. n = 38, 4.1%, p = 0.0253), subhepatic or subphrenic collections (n = 33, 5.8% vs. n = 13, 1.4%, p < 0.001), superficial surgical site infections (n = 18, 3.2% vs. n = 14, 1.5%, p = 0.0303), postoperative ERCP (n = 82, 14.4% vs. n = 62, 6.6%, p < 0.001), and need for reoperation (n = 20, 3.5% vs. n = 12, 1.3%, p < 0.001).

CONCLUSIONS

Although reconstituting LSC has better outcomes, both techniques are complementary. Intraoperative findings and surgical expertise impact the choice.

Is a difficult gallbladder worth removing in its entirety? - Outcomes of subtotal cholecystectomy

Background:

Laparoscopic Cholecystectomy one of the commonest procedures performed worldwide isn't spared from the risks of disastrous iatrogenic complications. In patients with obscured anatomy, the idea of performing a safe total cholecystectomy can be hindered with a high risk of biliovascular injuries. In such a situation STC (subtotal cholecystectomy) comes to the rescue, where the diseased organ can be tackled fairly, without any further damage.

Aims and Objectives:

The primary aim was to look at the immediate and long-term outcomes of subtotal cholecystectomy. Subgroup analysis was done based on demographics, indications and surgical approach.

Materials and Methods:

We reviewed our prospectively maintained computerized operation database over nine years. STC was defined as leaving behind any portion of gallbladder other than the cystic duct. They were subclassified as per the description given by Palanivelu. Patients were evaluated with laboratory and radiological assessment.

Results:

A total of 70 out of 602 patients (11.6%) underwent STC. Dense adhesion at the calot's was the most important reason for STC. Subtype B was the most common. Nine patients (12.85%) had a bile leak in the postoperative period. There were no biliary/vascular injuries and 30-day mortality was zero. 22.8% developed SSI (surgical site infection). Over a median follow up of 38 months (range 5-98), clinical examination, LFT and USG revealed no abnormality in any of the patients.

Conclusion:

Subtotal cholecystectomy is a useful alternative during difficult gallbladder surgery. It should be considered early into the procedure preferably prior to conversion to an open procedure. Biliovascular injuries can be avoided and the Immediate and long-term outcomes are acceptable.

Less is more in the difficult gallbladder: recent evolution of subtotal cholecystectomy in a single HPB unit

INTRODUCTION

Subtotal cholecystectomy (SC) is a technique to manage the difficult gallbladder and avoid hazardous dissection and biliary injury. Until recently it was used infrequently. However, because of reduced exposure to open total cholecystectomy in resident training, we recently adopted subtotal cholecystectomy as the bail-out procedure of choice for resident teaching. This study reports our experience and outcomes with subtotal cholecystectomy in the years immediately preceding adoption and since adoption.

METHODS

A retrospective analysis was conducted of patients undergoing SC from July 2010 to June 2019. Outcomes, including bile leak, reoperation and need for additional procedures, were analyzed. Complications were graded by the Modified Accordion Grading Scale (MAGS).

RESULTS

1571 cholecystectomies were performed of which 71 were SC. Subtotal cholecystectomy patients had several indicators of difficulty including prior attempted cholecystectomy and previous cholecystostomy tube insertion. The most common indication for SC was marked inflammation in the hepatocystic triangle (51%). As our experience increased, fewer patients required open conversion to accomplish SC and SC was completed laparoscopically, usually subtotal fenestrating cholecystectomy (SFC). Most patients (85%) had a drain placed and 28% were discharged with a drain. The highest MAGS complication observed was grade 3 (11 patients, 15%). Six patients had a bile leak from the cystic duct resolved by ERCP. At mean follow-up of about 1 year no patient returned with recurrent symptoms.

CONCLUSIONS

Subtotal fenestrating cholecystectomy is a useful technique to avoid biliary injury in the difficult gallbladder and can be performed with very satisfactory rates of bile fistula, ERCP, and reoperation.

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.

Retained gallbladder secondary to retrieval bag rupture during laparoscopic cholecystectomy-A case report

INTRODUCTION

Retrieval bags are used in laparoscopic cholecystectomies to reduce the risk of bile and gallstone spillage during removal of the gallbladder. Retrieval bag rupture is rare, and its complications have never been previously documented.

PRESENTATION OF CASE

A 17-year-old female presented three months post-laparoscopic cholecystectomy with a tender periumbilical mass. Her operative report noted difficulty removing the retrieval bag from the infra-umbilical port site. Imaging of the lump revealed an intra-abdominal fluid collection communicating with the umbilicus. A diagnostic laparoscopy uncovered significant pus in the peritoneal cavity and a gallbladder remnant with multiple gallstones. A combination of sharp and blunt dissections was used to free the gallbladder remnant from its adherent surroundings for removal. A peritoneal washout was performed following extraction of the retained gallstones. The patient's presentation could be traced back to her laparoscopic cholecystectomy where it was confirmed that the retrieval bag ruptured during removal. This would have transected the gallbladder, causing its remnants and associated gallstones to be retained in the peritoneal cavity.

DISCUSSION

Retrieval bag rupture can result in retained gallbladder remnants in the peritoneal cavity. Abdominal abscess can manifest months after the initial operation.

CONCLUSION

Retrieval bags should be inspected following removal to ensure it is completely intact. Surgeons should consider extending the fascial incision if there is any difficulty during removal. Any damage to the retrieval bag mandates immediate pneumoperitoneum for further exploration of retained products. Governance bodies should incorporate practice guidelines related to retrieval bag rupture as these are currently not present.

Closure of the cystic duct orifice in laparoscopic subtotal cholecystectomy for severe cholecystitis

INTRODUCTION

Laparoscopic subtotal cholecystectomy (LSC) has been recognized as an alternative to conversion to laparotomy for severe cholecystitis. However, it may be associated with an increased risk of recurrent stones in the gallbladder remnant. The objective of this study was to evaluate the safety and feasibility of the complete removal of the gallbladder cavity in LSC for severe cholecystitis using the cystic duct orifice suturing (CDOS) technique.

METHODS

In a consecutive series of 412 laparoscopic cholecystectomies that were performed from January 2015 to June 2017, 12 patients who underwent LSC with CDOS were enrolled in this retrospective study. In this procedure, Hartmann's pouch was carefully identified, and the infundibulum-cystic duct junction was transected while the posterior wall adherent to Calot's triangle was left behind. The clinical records, including the operative records and outcomes, were analyzed.

RESULTS

The median operating time and blood loss were 158 min and 20 mL, respectively. In all cases, LSC with CDOS was completed without conversion to open surgery. No injuries to the bile duct or vessels were experienced. The median postoperative hospital stay was 6 days. Postoperative complications occurred in two patients (bile leakage, n = 1: common bile duct stones, n = 1) and were successfully treated by endoscopic management. A gallbladder remnant was not delineated by postoperative imaging in any of the cases.

CONCLUSION

These results suggest that LSC with CDOS is a promising approach that can avoid dissection of Calot's triangle and achieve the complete removal of the gallbladder cavity in patients with severe cholecystitis.

Laparoscopic subtotal cholecystectomy: a surgical alternative to reduce complications in complex cases

INTRODUCTION

Laparoscopic cholecystectomy is a common procedure in general surgery, and in complex cases it is important for the surgeon to know all the alternatives with low associated morbidity. Laparoscopic subtotal cholecystectomy should be considered as an option when a critical view of safety cannot be obtained, because it has a low complication rate and gives the advantages of minimally invasive surgery.

METHODS

Retrospective study of laparoscopic subtotal cholecystectomies in an eight years period.

RESULTS

A total of 1,059 laparoscopic cholecystectomies were performed; 22 were subtotal cholecystectomies, without conversion. Biliary fistula (9%) and intraabdominal collections (4.5%) were the most common complications described. No iatrogenic bile duct injuries or deaths were reported. Our follow-up period was 32months, no recurrences were reported.

CONCLUSIONS

Laparoscopic subtotal cholecystectomy is a safe and effective procedure. It should be considered as an option in complex cases.