Modified Subtotal Cholecystectomy: Results of a Laparotomy Procedure During the Laparoscopic Era

Resection of the remnant gallbladder after subtotal cholecystectomy: An institutional experience

BACKGROUND

Laparoscopic subtotal cholecystectomy is an acceptable method of preventing bile duct injuries in "difficult" gallbladders. However, it is associated with postoperative bile leaks and retained gallstones that may necessitate resection of the gallbladder remnant. This study evaluates the outcomes of patients who underwent completion cholecystectomy for ongoing symptoms or complication after subtotal cholecystectomy.

METHODS

We performed a retrospective review of adults who underwent laparoscopic completion cholecystectomy after previous subtotal cholecystectomy at a single institution from 2009 to 2023. Indications for reoperation were collected and intraoperative findings, operative outcomes, and rates of postoperative morbidity were evaluated.

RESULTS

Over 14 years, 46 patients underwent completion cholecystectomy, with 40 (80%) in the last 5 years. Remnant cholecystitis was the most common reason for reoperation in 37 patients (80.4%). Choledocholithiasis was seen in 4 cases (8.7%). Bile leak, gallstone pancreatitis, and abdominal abscess were observed in 8 (17.4%), 4 (8.7%), and 5 (10.8%) patients, respectively. Four patients (8.7%) had intestinal fistulas intraoperatively. Laparoscopic completion cholecystectomy was attempted in all, with 2 (4.4%) converted to open laparotomy. The median operative time was 111 minutes (interquartile range, 83-140 minutes), and the median hospital stay was 1 day (interquartile range, 0-2 days). Minor complications occurred in 5 patients (10.9%), which were managed conservatively. Four patients had major complications requiring endoscopic retrograde cholangiopancreatography or percutaneous intervention. There were no bile duct injuries or reoperations, and 44 (95.6%) patients had complete symptom resolution at follow-up.

CONCLUSION

Laparoscopic completion cholecystectomy is feasible and safe but technically challenging. With the increased use of subtotal cholecystectomy, patients presenting with persistent postoperative pain require timely work-up and management of their symptoms.

Acute cholecystitis: how to avoid subtotal cholecystectomy-preliminary results

BACKGROUND

The aim of this manuscript is to illustrate a new method permitting safe cholecystectomy in terms of complications with respect to the common bile duct (CBD).

METHODS

The core of this new technique is identification of the continuity of the cystic duct with the infundibulum. The cystic duct can be identified between the inner gallbladder wall and inflamed outer wall.

RESULTS

In the last 2 years, from January 2019 until December 2021, 3 patients have been treated with the reported technique without complications.

CONCLUSIONS

Among the various cholecystectomy procedures, this is a new approach that ensures the safety of the structures of Calot's triangle while providing the advantages gained from total removal of the gallbladder.

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.

Subtotal Cholecystectomy After Failed Critical View of Safety Is an Effective and Safe Bail Out Strategy

BACKGROUND

Bile duct injury (BDI) is accompanied by significant morbidity and long-term impact in quality of life. Subtotal cholecystectomy (STC) is an alternative to prevent this outcome but is associated with other complications. The aim of this work is to demonstrate that BDI associated morbidity exceeds STC associated morbidity, underscoring STC as a reasonable bail out strategy.

METHODS

We compared 115 patients who underwent STC with 293 patients who were referred to our center with BDI type E1-E3 and underwent surgical repair. The groups were comparable because in both instances the surgeon had the opportunity to decide not to perform a total cholecystectomy once critical view of safety (CVS) was not achieved.

RESULTS

Bile leakage was found in 21% of the STC group with only one BDI (0.9%). More Accordion ≥ 4 were found in the STC group (10.4% vs 4.8%, p = 0.035); however, reoperations were more frequent in the BDI group (8.2% vs 0.9%, p = 0.006). No patient in the STC group required reintervention for completion cholecystectomy. After 3.8 years follow-up, 2.4% of patients had secondary biliary cirrhosis in the BDI group; none in the STC group.

CONCLUSIONS

Despite complications of STC, morbidity associated with BDI is much higher due to high long-term reoperation rate, in addition to secondary biliary cirrhosis. STC is a safe alternative that can prevent BDI if properly and timely performed in the context of difficult cholecystectomy.

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.

Open conversion for laparoscopically difficult cholecystectomy is still a valid solution with unsolved aspects

The difficult laparoscopic cholecystectomy remains a surgical challenge for surgeons who must decide between laparoscopic continuation and open conversion. The balance between the lack of open surgery training of young surgeons and the risk of maintaining the laparoscopic approach in difficult laparoscopic cholecystectomy is still an unresolved problem. Furthermore, the time that must be spent in an attempt to complete laparoscopic surgery before conversion is still controversial. The authors in this letter discuss about these and other questions that still require an answer.

Use of a piece of free omentum to prevent bile leakage after subtotal cholecystectomy

BACKGROUND

Bile leakage after subtotal cholecystectomy (SC) is clinically serious. To prevent such leakage, we developed a new surgical technique in which a free piece of omentum is plugged into the gallbladder stump (omentum plugging technique). We evaluated whether the omentum plugging technique prevents bile leakage after subtotal cholecystectomy.

METHODS

Prospectively collected data of patients who had undergone subtotal cholecystectomy without cystic duct closure in the Department of Surgery of Kansai Medical University during the 12 years from January 2006 to March 2018 were reviewed retrospectively. The outcomes of patients who had undergone subtotal cholecystectomy with the omentum plugging technique (omentum plugging technique group) were compared with those of patients who had undergone subtotal cholecystectomy without the omentum plugging technique (Control group). The outcomes of interest were perioperative data and postoperative complications including bile leakage, necessity for interventions for complications, and duration of hospitalization.

RESULTS

Fifty of 2,447 consecutive patients (2.0%) had undergone subtotal cholecystectomy. Of these 50 patients, 18 were treated with the omentum plugging technique (omentum plugging technique group) and 32 were treated without the omentum plugging technique (Control group). One of 18 patients in the omentum plugging technique group and 14 of 32 in the Control group developed postoperative bile leakage. One postoperative interventional treatment for complications was performed in the omentum plugging technique group and 12 in the Control group. The duration of postoperative hospitalization was less in the omentum plugging technique group.

CONCLUSION

The omentum plugging technique appears to be an effective operative technique for preventing postoperative bile leakage in selected situations when a "difficult gallbladder" is encountered.

Subtotal Cholecystectomy versus Total Cholecystectomy in Complicated Cholecystitis

Complicated cholecystitis can make dissections around the triangle of Calot difficult with a higher risk of duct and arterial injury. We reviewed a series of patients with cholecystitis receiving either partial or subtotal cholecystectomies and compared it with total cholecystectomies with respect to complications. A retrospective chart review was performed on all subtotal cholecystectomies performed for cholecystitis at University Medical Center of El Paso from June 2004 to December 2010. A similar number of patients who had total cholecystectomies for cholecystitis were selected as a comparison group from that same time period. A total of 116 patients who had subtotal and total cholecystectomies were reviewed (58 patients in each group). There were seven postoperative complications noted in the subtotal cholecystecomy (SC) group versus 14 for the total cholecystectomy (TC) group. Three patients in the SC group had cystic duct leaks, all successfully treated by endoscopic retrograde cholangiopancreatography with biliary stenting. There were two patients who had common bile duct injuries in the TC group and none in the SC group. Two patients had duodenal injuries in the TC group. Subtotal cholecystectomy is a viable alternative to total cholecystectomy in cases of complicated cholecystitis