Laparoscopic Subtotal Cholecystectomy for Difficult Acute Calculous Cholecystitis

Abstract

Background: When the critical view of safety (CVS) can't be obtained during dissection of Calot's triangle in difficult gallbladder, conversion to open surgery or other "damage control" alternatives as cholecystostomy and subtotal cholecystectomy are recommended to prevent bile duct injury. Materials and methods: The medical records of all patients presented with acute calculous cholecystitis (ACC) during the study period were retrospectively reviewed and analyzed. Results: Laparoscopic cholecystectomy (LC) was attempted in 71 difficult gallbladders out of 379 patients presenting with ACC. In 6 patients (8.5%), conversion to open surgery or laparoscopic cholecystostomy was performed. Laparoscopic subtotal cholecystectomy (LSC) with dissection and control of the cystic duct was performed for the remaining 65 patients (91.5%) including 50 females (77%) and 15 males (23%) with a mean age of 42.35±12.4 years. The mean operative blood loss was 45.28±18.6 CC and the mean operative time was 96.3±24.19 minutes. There were no operative complications or mortality. The mean hospital stay was 28±17.8 hours. There was no postoperative jaundice, bile leak, intra-abdominal collections or mortality. Conclusion: When surgery is indicated for difficult ACC, LSC with control of the cystic duct is safe with excellent outcomes. However, if the CVS can't be achieved due to obscured anatomy at Calot's triangle, conversion to open surgery or cholecystostomy must be performed to prevent bile duct injury.

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

“…The literature search yielded 45 studies with a total of 2,166 STC cases where the procedure started laparoscopically (intention-to-treat analysis). 13 – 57 Tables 1 and 2 summarise the patient characteristics and indications. The mean patient age was 55 years (standard deviation [SD]: 15 years).…”

“…Thirty of the forty-five studies (including 1,125 patients) described cohorts where not a single case was converted to an open procedure. 13 , 16 , 17 , 19 , 22 , 24 – 28 , 30 , 33 , 35 – 40 , 42 , 44 – 46 , 48 – 50 , 52 – 55 , 57 This gave us data on outcomes relating solely to LSTC (per-protocol analysis).…”

“…Forty of the studies included in this review described the operative techniques performed. 13 – 30 , 32 – 40 , 42 – 45 , 47 – 53 , 55 – 57 Half of the patients had the posterior gallbladder wall left in situ (904/1,773, 51%). Different techniques were described for dealing with the cystic duct or gallbladder stump.…”

“…Four studies did not specify how closure was performed (197/1,188, 17%). 13 , 24 , 35 , 56 The majority of patients had a drain inserted (1,875/2,096, 89%). Table 3 summarises the technical details for all patients.…”

“…Thirty studies (1,418 patients) reported on long-term follow-up. 13 – 15 , 17 , 18 , 20 , 24 , 26 – 30 , 32 , 34 – 37 , 40 – 47 , 50 , 51 , 53 , 54 , 56 The median follow-up period was 22 months. Four deaths occurred in the period after thirty days following surgery.…”