Laparoscopic subtotal cholecystectomy in severe cholecystitis with unclear anatomy

Abstract

Background: Aim of the study was to determine the differences between laparoscopic cholecystectomy and laparoscopic subtotal cholecystectomy as regards bile duct injury and post-operative complications rates in patients with severe cholecystitis and obscure anatomy.Methods: We retrospectively reviewed the charts and postoperative outcomes of 293 patients with severe cholecystitis who underwent either laparoscopic cholecystectomy or laparoscopic subtotal cholecystectomy between September 2011 and January 2020. Patients with intraoperative altered anatomy which leaded to difficult dissection were defined as having severe cholecystitis.Results: There were 304 cholecystectomies done for patients with severe cholecystitis. Of those, 203 underwent laparoscopic cholecystectomy (LC group), 90 underwent laparoscopic subtotal cholecystectomy (LSC group). There was no significant difference in male to female ratio, age, cases performed on an elective or emergency basis, hospital length of stay or initial operative findings. There were 5 patients with detected intraoperative biliary injury in LC group only. Postoperative bile leaks were significantly higher in the LSC (11.1%) than in the LC group (3.9%). Postoperative collections which needed percutaneous aspiration were also significantly higher in the LSC group (18.9%) than in the LC group (7.4%). Reoperation for collection was required in 8 patients in LC group and in 5 patients in LSC group. The rates of retained common bile duct stones, port site hernia, wound infections, and total complications were not significantly different between the two groups (28.1% v. 45.6%).Conclusions: Our study demonstrated that laparoscopic subtotal cholecystectomy is a safe procedure which reduces the risk of bile duct injury and is comparable to laparoscopic cholecystectomy in patients with severe cholecystitis with unclear anatomy.

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

“…Seven studies investigating a total of 135,233 patients with acute cholecystitis undergoing either laparoscopic subtotal or laparoscopic total cholecystectomy (%) for complicated acute cholecystitis (%) were pooled to perform this meta-analysis. 13–19 The mortality rate for the patients who underwent laparoscopic subtotal cholecystectomy was .6% and .3% for those who underwent laparoscopic total cholecystectomy. The meta-analysis indicated that overall, those patients who underwent total cholecystectomy were 2.94 times less likely to die compared to those who underwent subtotal cholecystectomy [RR .34; 95% CI (.15, .77)] (Figure 4).…”

“…12,13,15 Two studies 12,13 found a greater rate of subhepatic collection in the subtotal cohort, and one study 15 found no difference. Seven studies evaluated in-hospital mortality, of which one study 19 reported significantly higher in-hospital mortality in the subtotal group compared to the total group, and six studies 13–18 did not find a significant difference between cohorts. 13,16–18 Seven studies evaluated hospital length of stay (H-LOS), of which two studies 15,19 reported significantly higher H-LOS days for the subtotal group, and four studies 14,16–18 reported no significant difference.…”

“…Seven studies evaluated in-hospital mortality, of which one study 19 reported significantly higher in-hospital mortality in the subtotal group compared to the total group, and six studies 13–18 did not find a significant difference between cohorts. 13,16–18 Seven studies evaluated hospital length of stay (H-LOS), of which two studies 15,19 reported significantly higher H-LOS days for the subtotal group, and four studies 14,16–18 reported no significant difference. One study found higher H-LOS in the subtotal group but did not provide a P -value (Table 1) (Table 2).…”

“…Complicated acute cholecystitis was defined by the presence of pericholecystic adhesions, empyema, gangrene, perforation, or severe inflammation. [13][14][15][16][17][18][19] Data Collection…”

“…The quality of evidence was assessed by using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group Criteria. 20 The quality of evidence was high to moderate in five studies 13,15,16,18,19 and low in two studies 14,17 (Supplementary file: eTable 2). The risk of bias was evaluated using the Joanna Briggs Institute (JBI) critical appraisal checklist for observational studies (Supplementary file: eTable 3).…”