Subtotal Cholecystectomy and Open Total Cholecystectomy: Alternatives in Complicated Cholecystitis

Abstract

Subtotal cholecystectomy (SC) is an alternative to open total cholecystectomy (OTC) when variable anatomy or other intraoperative findings preclude safe dissection of Calot's triangle. The objective of this study was to compare the outcomes between SC and OTC in patients with complicated cholecystitis, cases that could not be completed with the original surgical approach and required intraoperative conversion to either SC or OTC. All cases of cholecystectomy converted to SC or OTC from January 2008 to December 2012 were retrospectively identified. Preoperative laboratory values, imaging studies, and clinical demographics were compared between the two groups. The outcome variables analyzed included hospital and intensive care unit length of stay as well as intraoperative complications. In this study, 214 cases of complicated cholecystitis were analyzed; 63 SC and 151 laparoscopic converted to OTC. From the SC group, 46 (73%) were converted to open, 12 (19%) were primary open, and five (8%) were done laparoscopically. There were no statistically significant differences in demographics, preoperative serologic markers, or intraoperative findings ( P > 0.05). Five (3.3%) common bile duct (CBD) injuries occurred in the OTC group, whereas none occurred in the SC group. Overall there were 23 (15.2%) complications in the OTC group and nine (14.3%) in the SC group. The aggregate severe complication rate (CBD injury, vascular injury, gastrointestinal injury) was significantly higher in the OTC group (0.0 to 7.9%, P = 0.036). In conclusion, SC may be considered as a safe alternative in complicated cholecystitis.

Factors that Predict the Need for Subtotal Cholecystectomy

“…20 Although no studies have correlated low socioeconomic status to likelihood of subtotal cholecystectomy, it is known that difficult gallbladders and complex acute cholecystitis may lead to more subtotal cholecystectomies performed. 2 This study has several limitations. First, it was limited to attending surgeons from a single center with various training backgrounds and a limited range of years of experience.…”

“…1 In recent studies, subtotal cholecystectomy was associated with a lower rate of conversion to open, reduced bile duct injuries, and similar overall morbidity compared to total cholecystectomy, making it a safe option for difficult gallbladder cases. 1,2 Subtotal cholecystectomy techniques include fenestrating and reconstituting cholecystectomy. In a subtotal fenestrating cholecystectomy, residual gallbladder mucosa is typically ablated, and occasionally, the cystic duct is oversewn resulting in no gallbladder remnant.…”

Analysis of bailout procedure in laparoscopic cholecystectomy for acute cholecystitis

“…However, whether open conversion is really safe remains questionable 11,12,13,14 , and the TG18 recommend other approaches such as fundus-rst and subtotal cholecystectomy 5 . Indeed, Kaplan et al 12 showed that the incidence of BDI was much higher in open than subtotal cholecystectomy. Several studies reported the e cacy of Fundus rst 15,16 and subtotal approach.…”

Tokyo Guidelines 2018: surgical management of acute cholecystitis: safe steps in laparoscopic cholecystectomy for acute cholecystitis (with videos)

“…If severe fibrosis in the Calot's triangle prevents safe completion of LC with/without using the fundus first technique, BDI can be avoided by subtotal LC or open conversion . In a retrospective study of patients who underwent subtotal LC or open conversion, BDI occurred in 3.3% who underwent open conversion but in none of the patients who underwent subtotal LC . Subtotal LC should be considered as an option when straightforward LC cannot be completed safely.…”