Subtotal cholecystectomy for difficult gallbladder: pearls and pitfalls

Abstract

BACKGROUND: Many surgeons perform subtotal cholecystectomy (SC) to avoid serious biliovascular injury, when total laparoscopic cholecystectomy is unfeasible due to technical difficulty such as distorted anatomy at the Calot's triangle resulting from severe fibrosis. However, SC may bring its own risks besides its benefits. We reviewed our postoperative outcomes of SC in order to evaluate the advantages and complications of this procedure, and discussed in the light of relevant literature. METHODS: Records of 4003 patients who underwent cholecystectomy between 2011-2017 were reviewed. Only 25 patients with SC accepted further evaluation. Surgical indications, comorbidities, perioperative features, operation techniques. postoperative acute episodes (acute cholecystitis, obstructive jaundice. pancreatitis) and other morbidities were recorded. RESULTS: Patients were operated for cholelithiasis (80%), and severe cholecystitis (20%). Indications for SC were severe adhesions in all patients. All operations started laparoscopically, converted to laparotomy in 72% (N.=18) of patients. ended laparoscopically in 28% (N.=7) of patients. Follow-up ultrasonography (US) detected remnant gallbladder (RGB) in 604/0 (N.=15) of the patients. Postoperative stump cholecystitis was recorded in 16% (N.=4) of the patients within the first year of surgery. Remnant GB was not demonstrated in 10 patients under US. Remnant GB retaining GS and without GS. did not reveal significant difference with respect to presence of postoperative acute episodes (P>0.05). Postoperative ERCP due to obstructive jaundice was recorded in 12% (N.=3) of the patients within 5 months of surgery. Other morbidities were surgical site infection (SSI) (N.=5) and incisional hernia (N.=5) in the conversion group. We did not record any bile fistula or pancreatitis following the SC. None of the patients underwent completion cholecystectomy. There was no mortality. CONCLUSIONS: According to our data. SC is safe and efficient when applied under proper indication. Completion cholecystectomy is not mandatory following each SC, however patients must be well informed for the complications of SC.