Safe laparoscopic subtotal cholecystectomy in the face of severe inflammation in the cystohepatic triangle: a retrospective review and proposed management strategy for the difficult gallbladder

Abstract

Background: Laparoscopic subtotal cholecystectomy (LSC) can be employed when extensive fibrosis or inflammation of the cystohepatic triangle prohibits safe dissection of the cystic duct and artery. The purpose of this study was to compare postoperative outcomes in patients with severe cholecystitis who underwent laparoscopic cholecystectomy (LC) or LSC. Methods: In this retrospective study, we compared the postoperative outcomes of patients with severe cholecystitis who underwent LC or LSC between July 2010 and July 2016 at St. Joseph's Health Centre, Toronto. We further stratified LSC cases on the basis of the extent of gallbladder (GB) dissection and GB remnant closure. Results: A total of 105 patients who underwent LC and 46 who underwent LSC were included in the study. There were 4 bile duct injuries in the LC group and 0 in the LSC group. Bile leaks (relative risk [RR] 3.4, 95% confidence interval [CI] 1.01-11.5) and subphrenic collections (RR 3.1, 95% CI 1.3-8.0) were more common in the LSC group. Overall postoperative morbidity did not differ significantly between the 2 groups. Postoperative endoscopic retrograde cholangiopancreatography (ERCP) (RR 3.2, 95% CI 1.1-9.5) and biliary stent insertion (RR 4.6, 95% CI 1.2-17.5) were more common in the LSC group. Bile leaks appeared to be more prominent with open GB remnants but all cases of leak were successfully managed with ERCP and biliary stenting. Conclusion: LSC may mitigate the risk of bile duct injury when dissection into the cystohepatic triangle is unsafe. There were more bile leaks in patients who underwent LSC; however, they were readily managed with endoscopic stents. Long-term biliary fistulae were not observed. LSC should be considered early as a means of completing difficult cholecystectomies safely without the need for cholecystostomy tube or conversion to laparotomy. Contexte : La cholécystectomie laparoscopique subtotale (CLS) peut être utilisée si une fibrose ou une inflammation étendue du triangle cystohépatique empêche l'ablation sécuritaire du canal et de l'artère cystiques. Cette étude avait pour but de comparer les résultats postopératoires chez des patients atteints de cholécystite grave ayant subi une cholécystectomie laparoscopique (CL) ou une CLS. Méthodes : Dans cette étude rétrospective, nous avons comparé les résultats postopératoires des patients atteints de cholécystite grave ayant subi une CL ou une CSL entre juillet 2010 et juillet 2016 au St. Joseph's Health Centre de Toronto. Nous avons ensuite stratifié les cas de CSL selon la proportion de la vésicule biliaire excisée et la suture du reliquat. Résultats : En tout, 105 patients ayant subi une CL et 46 une CLS ont été inclus dans l'étude. On a dénombré 4 lésions du canal cholédoque dans le groupe CL et 0 dans le groupe CLS. Les fuites biliaires (risque relatif [RR] 3,4, intervalle de confiance [IC] de 95 % 1,01-11,5) et les collections sous-diaphragmatiques (RR 3,1, IC de 95 % 1,3-8,0) ont été plus fréquentes dans le groupe CSL. Globalement, la morbidité postopératoire n'a p...

2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis

“…Support for subtotal cholecystectomy has also been reported from other studies. In a retrospective study on severely difficult gallbladders [98], 105 patients who underwent laparoscopic cholecystectomy were matched with 46 patients who underwent subtotal laparoscopic cholecystectomy. The authors observed no bile duct injury in the subtotal cholecystectomy group, but four instances in the complete cholecystectomy group.…”

Laparoscopic subtotal cholecystectomy in severe cholecystitis with unclear anatomy

“…Purzner et al reported that subphrenic collections after LSC were more common (21.7%) and percutaneous drains for postoperative intraabdominal collections were used in 15.2% of LSC patients versus 6.7% in the LC cohort. 17 In another study, 1.5% of LSC patients were readmitted posoperatively because of intraabdominal collection. 22 In this study, postoperative collections which needed percutaneous aspiration were also significantly higher in the LSC group (18.9%) than in the LC group (7.4%).…”

“…There is an acceptable higher bile leak rate, which matches with our study results, in the setting of LSC if compared with LC with risky severe cholecystitis as long as all of these patients eventually had favourable outcomes. 17 It has been recorded in up to 16% of cases, either from the open stump or from the remnant posterior wall if left. 15,18 We recommend routine closure of the remnant stump and excision of the whole remaining gall bladder walls as possible.…”

“…Similar tendency rates have been reported elsewhere. 17 Other known complication recorded includes common bile duct stricture, with an overall reported incidence of 2-4%. 14 Here, 3 patients (1.5%) in LC group had common bile duct strictures which were treated successfully by ERCP and stenting and no patient had developed this complication in LSC group.…”

“…Open cholecystectomy has lost its popularity, and LSC when needed, becomes more convenient as comfort with laparoscopy has progressed in the current technical training models for most surgery residents. 17 In this study, we attempted to provide a scope for the laparoscopic management in cases of severe cholecystitis and to support the use of LSC if achieving the "critical view of safety" would increase the risk of bile ducts injury.…”