Laparoscopic subtotal cholecystectomy for the difficult gallbladder.

doi:10.21203/rs.3.rs-3595700/v1

Download PDF

Research Article

Laparoscopic subtotal cholecystectomy for the difficult gallbladder.

https://doi.org/10.21203/rs.3.rs-3595700/v1

This work is licensed under a CC BY 4.0 License

Version 1

posted

You are reading this latest preprint version

Background: Successful cholecystectomy hinges on accurate identification and secure closure of the cystic duct, a process made significantly more difficult when inflammation alters the usual anatomy. Especially when performing laparoscopic cholecystectomy. Subtotal laporoscopic cholecystectomy provides a solution by permitting near-total gallbladder removal and thorough stone evacuation, thus bypassing dissection in dangerous regions.

The aim of this study was to analyze our clinical experience with LSC in respect to safety, early and long-term outcomes.

Methods. We analyzed the operative records of 7188 patients who underwent LC from January 2005 to September 2019 in our clinic. In the first period from 2005 to 2008, in patients with technically difficult cases (Grade 3,4 Nassar) we performed conversion to open procedure, in the second period from 2009 to 2019 in patients with technically difficult cases (Grade 3,4 Nassar) we performed laparoscopic subtotal cholecystectomy instead of conversion to open procedure.

Results. During the I period from 2005 to 2008 LC was performed in 2720 patients. Serious technical difficulties (Nasar, Grade 3-4) were seen in 127 patients (4,7 %), 57 (45%) men and 70 (55%) women. In the second period from 2009 to 2019 LC was performed in 4468 patients. There was no significant difference between patients operated in the first and second period.Technical difficulties (Nassar, Grade 4) were seen in 134 (3%) patients.

Conclusion. Our study shows that LCS can be useful for the management of severe cholecystitis and difficult gallbladders. Our patients who underwent LCS had good outcomes with low incidence of complications. LCS is a safe alternative that minimizes the risk of bile duct and portal structure injuries.

LCS is an effective technique in patients with severe inflammation of gallbladders and fibrosis of cystohepatic triangle. Using LCS can dramatically improve the results of laparoscopic operations in patients with gallbladder disease.

Laparoscopic subtotal cholecystectomy

Cholecystitis laparoscopic

cholecystectomy

Nassar grade

Laparoscopic cholecystectomy is currently one of the most commonly performed operations worldwide [1-3]. Due to significantly improved recovery compared to open procedure, laparoscopic cholecystectomy (LC) has become the gold standard of care. Despite the clear advantages of laparoscopic cholecystectomy over OC, the Achilles heel of this technique is higher incidence of bile duct injuries. Bile duct injuries (BDI) continue to occur almost twice as frequently during LC compared to open surgery [4-7].

One third of BDI are complex injuries (complete bile duct transection, vascular injuries, central injuries near the hepatic hilum), whereas almost one in four BDI is a combined vasculo-biliary injury [8–10].

BDI is a catastrophic complication for patients. These complications increase morbidity and mortality [8]. They impair quality of life in the long-term follow-up [11, 12].

In the majority of patients LC is not a very complicated operation. In most cases, it can be safely performed by junior surgeons. But in patients with severe acute and chronic inflammation and fibrosis of the gallbladder, the dissection may be difficult and surgeons have to complete the procedure safely in this unfavorable environment. For objective grading of surgical difficulties in LC many surgeons use intraoperative difficulty scores [13–15]. Being able to stratify intraoperative difficulties allows for comparison of different research studies, facilitates risk adjustment for surgical outcomes and provides an aid in training surgeons and monitoring the training process.

For this purpose, we used the Nassar operative difficulty scale, which is a simple 4-point scale published in 1995 [16]. Many surgeons use this operative grading system for LC [13, 17–20].

Since we started performing LC in our clinic, we used to convert to an open procedure in the patients with serious operative difficulties (grade 3–4 Nassar).

In 2009 we started performing laparoscopic subtotal cholecystectomy (LSC) which has been described with safe outcomes [21–23].

The aim of this study was to analyze our clinical experience with LSC in respect to safety, early and long-term outcomes.

The project was approved by Odessa National Medical University Review Board. We analyzed the operative records of 7188 patients who underwent LC from January 2005 to September 2019 in our clinic.

In the first period from 2005 to 2008, in patients with technically difficult cases (Grade 3,4 Nassar) we performed conversion to open procedure, in the second period from 2009 to 2019 in patients with technically difficult cases (Grade 3,4 Nassar) we performed laparoscopic subtotal cholecystectomy instead of conversion to open procedure. All operations were done by 4 experienced surgeons. In simple cases residents performed LC under supervision of one of the four experienced surgeons.

Data on patients’ presentation, radiological and laboratory investigations were included. Pre and postoperative investigations, such as percutaneous drainage or endoscopic retrograde cholangiopancreatography (ERCP) were conducted.

We analyzed operative details, length of hospital stays, complications, morbidity and mortality in patients who underwent LSC. Patients were followed up from the time of surgery until June 2020.

SURGICAL TECHNIQUE. In cases where the cystohepatic triangle was fused and cystic artery and cystic duct could not be safety skeletonized, we performed LSC. We used different techniques to perform LSC. One technique was to divide the gallbladder mid-portion, remove the stones and perform retrograde dissection of the proximal body and Hartmann’s pouch. Anterograde dissection was done to remove the fundus of gallbladder. The small remnant of gallbladder was carefully examined to ensure that all gallstones were removed. Where possible, we attempted to insert a catheter into the cystic duct and perform intraoperative cholangiography to exclude stones in common bile duct (CBD).

We regularly attempted to suture the gallbladder and cystic duct remnant closed. If it was too technically dangerous, we left the gallbladder remnant open and inserted a drainage tube into the remnant.

Another technique we used was dissecting the gallbladder from the fundus towards the hepato-cystic triangle. In patients with cirrhosis or severe bleeding from gallbladder bed we excised the visceral wall and left part of the posterior wall behind. The mucosa of the posterior wall of the gallbladder was carefully coagulated. In our practice, we avoid wedge resections of the gallbladder or small fundectomies because this technique leads to formation a small gallbladder with risk of gallstone recurrence and severe inflammation.

STATISTICAL METHODS. Initially, a range of factors and patient outcomes were compared between the two cohorts. Continuous variables were assessed for normality, prior to the analysis. Normally distributed variables were reported as mean ± standard deviation (SD), with p values from independent samples t-tests. Medians and interquartile ranges (IQRs) and Mann-Whitney tests were used where the normality assumption was not met. Nominal variables were compared using Fisher’s exact tests.

Patient outcomes were then correlated with Nassar operative difficultly scale, using Kendall’s tau for dichotomous variables.

From January 2005 to September 2019 7188 patients underwent LC in our clinic. Female/male ratio was 68/32%. Age range was from 18 to 97 years. Mean age was 58,6 ± 12,5 years. Acute cholecystitis was seen in 48% of our patients and they were operated in an emergency setting. 3738 patients were operated electively. In the first period from 2005 to 2008 we performed 2720 LC. During this period, in technically difficult cases (grade 3–4, Nassar) we converted to open procedure and performed a total cholecystectomy. In the second period from 2009 to 2019 we performed 4468 LC. In this period, in technically difficult cases (Nassar, Grade 4) we performed LSC instead of converting to open procedure.

There was no statistically significant difference between the two groups of patients operated in the first and second period of time. Patient demographics, operative factors and outcomes of the two cohorts are presented in Table 1. There were no statistical differences between the two groups (p > 0.05). During the I period from 2005 to 2008 LC was performed in 2720 patients. Serious technical difficulties (Nasar, Grade 3–4) were seen in 127 patients (4,7%), 57 (45%) men and 70 (55%) women. Mean age in this group of patients was 58 (42–79) years.

Serious comorbidities were diagnosed in all patients: ischemic heart disease in 36 (28%) patients; hypertension in 72 (57%) patients; diabetes mellitus in 32 (25,2%); kidneys disease in 27 (21,2%); anti-platelet medicine use in 30 patients (23,6%).

Acute cholecystitis was diagnosed in 73 patients; empyema of the gallbladder was seen in 22 patients; gangrenous cholecystitis in 19 patients; and perforated cholecystitis in 12 patients. Mirizzi syndrome was diagnosed in 12 patients (9,4%). Choledocholithiasis was diagnosed in 25 (19,7%) patients, cholangitis was seen in 16 patients (12,6%).

Chronic cholecystitis with acute and chronic inflammation was seen in 54 patients. Difficulties of pericholecystic tissue dissection because of fibrosis was the main indication for conversion to an open procedure. In all 127 patients conversion to open cholecystectomy was done. Morbidity rate was 22,8% in these patients. Bile leaks were seen in 16 patients. Bile leak causes included dislocation of clips or sutures from the cystic duct in 3 patients, retained CBD stones in 10 patients; bile peritonitis was diagnosed in 7 patients and they were re-operated. The most serious complication was bile duct injuries in 3 (2,4%) patients. CBD transection was seen in one patient. Transection of right and left bile duct were seen in two patients. In one patient we diagnosed bile duct injury intraoperatively. Hepatojejunal anastomosis was performed during the same operation with good long-term follow-up result.

Two other patients were operated 4–6 weeks after bile duct injury. Unfortunately, 2 patients with serious bile ducts injury who had delayed reconstruction died after 3 and 6 years from septic complications and stenosis at the site of anastomosis. 30-day mortality in the first group of patients operated from 2005 to 2008 was 1,6% (3 patients).

In the second period from 2009 to 2019 LC was performed in 4468 patients. There was no significant difference between patients operated in the first and second period.

Technical difficulties (Nassar, Grade 4) were seen in 134 (3%) patients. During this period in technically difficult cases, we performed LSC in 108 (2,4%) patients. The remaining 22 patients (0,5%) had conversion to open cholecystectomy. The reasons for conversion included Mirizzi syndrome in 5 patients, biliodigestive fistulas in nine patients, colon perforation in 3 patients, significant adhesions post prior laparotomy in five patients.

We used different techniques for LSC. After identification of difficult dissection due to fibrosis and dense adhesions at hepatocystic triangle in 69 patients, we divided the mid-portion of the gallbladder and remove all the stones. We then continued retrograde dissection of the proximal body of the gallbladder and Hartmann’s pouch. We attempted to leave a small remnant of the gallbladder. After careful exposure of the remnant in Hartmann’s pouch in 16 patients we used fibrocholedochoscope to inspect the gallbladder and the cystic duct. In 7 cases we retrieved small stones from the cystic duct. In 19 patients we performed intraoperative cholangiography through the cystic duct and in 7 patients we detected small CBD stones. In three cases we performed laparoscopic choledochotomy and attempted to retrieve CBD stones and place T-tube drainage in the CBD. In the other 5 patients with retained stones, we performed ERCP and papillotomy on postoperative day 5–6. After papillotomy, extraction of CBD stones and stenting, the bile leaks stopped.

In 42 of the 69 patients, we stitched closed the small remnant of Hartmann’s pouch and cystic duct. In the other 27 patients it was deemed dangerous to put stitches in this area, and we placed a drain inside the remnant of the gallbladder. Usually, bile leaks stopped spontaneously on 3rd to 5th postoperative day. In 5 patients with retained CBD stones, bile leaks continued until we performed ERCP and papillotomy with extraction of retained stones.

In 39 patients the fundus of the gallbladder was dissected first and dissection was extended towards the hepatocystic triangle. In this group of patients, we succeeded to suture the gallbladder remnant closed in 31 patients, and in 8 patients the gallbladder remnant was leaved open. In 7 patients with liver cirrhosis, we excised the anterior wall of the gallbladder and left part of the posterior wall behind due to bleeding from hepatic parenchyma.

In 3 patients after removing all stones from the gallbladder we left part of the gallbladder and placed 3–4 stitches to close it. Unfortunately, in 2 from these 3 patients after 12–36 months we detected stones in the gallbladder remnant with symptoms of acute cholecystitis. These two patients were re-operated: in one case we succeeded to remove the gallbladder remnant laparoscopically, in the other patient open surgery was performed.

Following this we avoided leaving a gallbladder remnant, because this predisposed to formation of new stones in the remnant.

In 108 patients who underwent LSC we succeed to stitch closed the remnant of Hartmann’s pouch and cystic duct in 73 patients. Bile leaks were detected in only 5 patients and stopped spontaneously in 2–3 days. In the other 35 patients we didn’t close the cystic duct and placed a drain in the gallbladder remnant. Prolonged bile leak was seen in 5 patients with retained CBD stones. After ERCP and papillotomy bile leaks stopped in all patients. The average duration of LSC was 132 ± 27 min. Average blood loss was 258 ± 55 ml. Minor complications were seen in 30 (27,8%) patients (Table 2). Clavien-Dindo class IIIa were seen in only 14 patients (12,4%). Importantly, there were no CBD injuries or re-operations. Subhepatic biloma was seen in 5 patients, subdiaphragmatic collection was seen in 3 patients. In 4 patients’ collections were drained under ultrasound guidance, while the rest of the patients were treated conservatively. Postoperative histology after LSC is summarized in Table 3.

Quality of life was assessed 16–48 months after surgery in 102 patients with conversion to open cholecystectomy and in 84 patients with LSC. Quality of life (using global quality of life scale) was better after laparoscopic subtotal cholecystectomy than in converted patients (84,6 ± 31 vs 63,9 ± 7,2; p < 0,05).

The incidence of difficult cholecystitis reported in the literature is 10–15% of the total cases of acute calculous cholecystitis [24, 25]. This discrepancy depends on the method used to classify the difficulty of the surgical procedure. Major reasons to classify a cholecystectomy as difficult are the severity of disease, presence of adhesions with consequent anatomical alteration, laparoscopic experience of the surgeon and devices available for surgical treatment [13, 26]. Severe inflammation of Calot's triangle can produce fibrosis with alteration of all anatomic landmarks and consequent risk of iatrogenic injury to the common hepatic duct, the common bile duct and the cystic duct [27–29]. According to the Tokyo 2018 guidelines, the degree of severity of acute cholecystitis correlates with an increased risk of bile duct injury (BDI) [30]. BDI leads to increased hospital costs and mortality rates and can require liver resection or even liver transplantation [31–33].

Despite increasing laparoscopic experience, technological advances and improvements in surgical training, BDI continue to occur almost twice as frequently compared to open surgery [34–37]. BDI significantly increase postoperative morbidity and mortality [31, 38–40].

In many patients BDI is a cause of disability and poor quality of life. In Ukraine BDI incidence was not officially recorded. However, discussions with colleagues show that BDI can occur in 1.5-2% of all laparoscopic cholecystectomies. It is especially common in small rural hospitals and with cohort of young surgeons who have insufficient experience.

Many guidelines emphasize safe dissection during laparoscopic cholecystectomy. SAGES safe cholecystectomy program considers it essential to have Critical View of Safety (CVS) before dividing the cystic duct and artery. Dr Manatakis et al confirmed that CVS was feasible in 90% of cases [41].

Laparoscopic subtotal cholecystectomy was the most frequent technique used by authors to prevent BDI [41, 42]. This technique is not new. Madding in 1955 suggested that SC should be considered when complete removal of the gallbladder cannot be safety accomplished [43]. In 1985 Bormann in his series of SC for difficult gallbladders concluded that SC is an option in patients where cholecystectomy is not technically possible [44].

Various techniques have been reported in the literature to avoid BDI: obtaining a critical view of safety (CVS) [41, 45], identifying Rouvière's sulcus [46], performing intraoperative cholangiogram (IOC) [47], performing intraoperative fluorescent cholangiogram using indocyanine green [48], and converting to an open procedure [49].

CVS is a method of identifying cystic structures (cystic artery and cystic duct) described by Strasberg. The term "CVS" was first coined in 1995 [50]. Three requirements are needed for CVS: 1) Calot's triangle must be cleared of fatty and fibrous tissue without exposing the common bile duct and the common hepatic duct, 2) the lower third of the gallbladder must be separated from the liver to expose plaque cysts, and 3) only two structures need to enter the gallbladder.

Rouvière's sulcus (RS), also called incisura hepatis dextra or Gans incisura, is a cleft in the liver that is located anterior to segment 1. The cystic duct and the cystic artery are located antero-superior to the sulcus, while the common bile duct is located under the sulcus [46].

In 1950, the partial cholecystectomy technique was described in which three-quarters of the gallbladder was removed, leaving a portion of the posterior wall attached to the liver without electrocoagulating the mucosa. The cystic duct was not closed [51]. In 1985, the subtotal cholecystectomy technique was modified: the posterior wall of the gallbladder was left attached to the liver, and the cystic duct was closed with a purse-string technique [44].

Currently, the most reputed method to solve this problem is subtotal cholecystectomy removing both the anterior and posterior walls with suturing of the infundibulum. This method is reported for open, open converted or laparoscopic procedures [52–54]. A different method called partial cholecystectomy consists of resection of the fundus [55, 56], but it has been abandoned because of reported complications [57, 58].

Articles with a limited number of patients report that subtotal cholecystectomy is associated with a reduction in BDI and conversion rate but report an increase in bile leaks and retained stones that require reintervention [53, 59]. ERCP can be performed not only in cases of biliary leakage but also for clearance of the biliary tract from residual stones, which can increase the common bile duct pressure and predispose to leakage from the cystic duct, especially if left open. These two complications were solved using ERCP and endoscopic papillotomy [60, 61]. Early or late, this procedure can be applied for stenosis of the biliary tract post cholecystectomy.

Biliary leakage represents the most frequent complication of incomplete resection of the gallbladder wall in difficult cases of acute cholecystitis treated with subtotal cholecystectomy. This complication is rarely fatal but requires correct treatment. If bile leakage does not stop spontaneously seven days postoperatively, the possible treatments are endoscopic biliary sphincterotomy [53], endoscopic plastic stent, and a fully covered self-expanding metal stent [62, 63]. In our series we had 5 patients with prolonged bile leakage due to retained CBD stones. Bile leaks stopped in all 5 patients after endoscopic papillotomy and stenting.

Subhepatic collections are usually described as a non-infective fluid collection, but an abscess may also be present. Some of these collections may resorb without any clinical signs or complications. In our study, it was well demonstrated that these complications are strictly related to the gallbladder wall being left open. When the latter is performed, it becomes mandatory to drain the abdomen at the end of the surgical procedure. Both in order to avoid complications and to monitor the patient's requirement for and plan the timing of treatment. Abdominal drainage after difficult laparoscopic cholecystectomy prevents abdominal fluid collections and infection, as well as consequent treatment thereof, with increase in hospitalization, costs and deterioration of patient’s quality of life [64]. In all cases after LSC we used two drains: one was placed near the gallbladder remnant and the other one under the diaphragm. This allowed us to decrease the number of patients with fluid collections. We encountered fluid collections in only 8 patients. In 4 patients, collections were drained under ultrasound guidance. In the other 4 patients, collections resolved with conservative treatment.

A small number of patients who had drains placed, developed subhepatic collections likely due to drains being removed prematurely. When subhepatic collections develop, radiological intervention is needed, and in most difficult cases, reoperation may be necessary.

Development of intra-abdominal infection in cases of difficult cholecystectomies depends on preoperative status and intraoperative procedure. Intraoperatively, it is of utmost importance to perform a wash out at the end of the procedure and to position appropriate drains to evacuate any collections and prevent consequent infection. In patients with intra-abdominal infection or subhepatic collections, the quality of life can be affected.

Residual CBD stones may be found postoperatively. These stones can migrate during the procedure or be concomitant with inflammation of the gallbladder. In the present study, we diagnosed retained stones only in 5 patients. Usually, ERCP and endoscopic papillotomy definitively resolves this problem. Residual stones can also remain in the gallbladder stump when both anterior and posterior walls are sutured. It is of utmost importance during the procedure to explore the remnant cavity before suturing. For these purposes we used fibrocholedochoscope which helps us retrieve stones from the gallbladder remnant. If the cystic duct can be cannulated, intraoperative cholangiography can be performed, and if small stones are identified in the cystic duct, tentative elimination of these small stones with low-pressure irrigation of the cystic duct must be performed [65]. Furthermore, a large residual stump of the gallbladder can recreate the lumen, and therefore, new stones can form. In our experience, two of three patients who had a large gallbladder remnant had recurrence of gallbladder disease [58].

Bile duct injuries can be a significant complication in this type of surgery. Prevention of this complication with either conversion from laparoscopic to open procedure, or requesting an opinion of a more experienced surgeon in difficult cases is strongly recommended. BDI recognized and repaired intraoperatively can improve immediate and late results [38].

Mortality is a very rare complication. In our research, only a few cases have been recorded and due to causes unrelated to the procedure. Important to note that quality of life in patients after LSC was much better than in group of patients after converted to open procedure. In our opinion, this was mainly due to intra-abdominal adhesions after open procedures.

Our study shows that LCS can be useful for the management of severe cholecystitis and difficult gallbladders. Our patients who underwent LCS had good outcomes with low incidence of complications. LCS is a safe alternative that minimizes the risk of bile duct and portal structure injuries.

Disclosures: Dr. Viktor V. Grubnyk, Prof. Volodymyr V. Grubnik, Prof. Yurii V. Grubnik, Dr. Roman S. Parfentiev, Dr Vadym V.Ilyashenko have no conflicts of interest to disclose.

NIH consensus conference. Gallstones and laparoscopic cholecystectomy. JAMA. 1993;269:1018–24;
The role of laparoscopic cholecystectomy (L.C.). Guidelines for clinical application. Society of American Gastrointestinal Endoscopic Surgeons (SAGES). (1993). Surgical endoscopy, 7(4), 369–370.
Yamashita, Y., Takada, T., Kawarada, Y., Nimura, Y., Hirota, M., Miura, F., Mayumi, T., Yoshida, M., Strasberg, S., Pitt, H. A., de Santibanes, E., Belghiti, J., Büchler, M. W., Gouma, D. J., Fan, S. T., Hilvano, S. C., Lau, J. W., Kim, S. W., Belli, G., Windsor, J. A., … Sachakul, V. (2007). Surgical treatment of patients with acute cholecystitis: Tokyo Guidelines. Journal of hepato-biliary-pancreatic surgery, 14(1), 91–97. https://doi.org/10.1007/s00534-006-1161-x
Flum DR et al (2003) Intraoperative cholangiography and risk of common bile duct injury during cholecystectomy. JAMA 289(13):1639–1644;
Törnqvist, B., Zheng, Z., Ye, W., Waage, A., & Nilsson, M. (2009). Long-term effects of iatrogenic bile duct injury during cholecystectomy. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association, 7(9), 1013–915. https://doi.org/10.1016/j.cgh.2009.05.014
Philip Rothman, J., Burcharth, J., Pommergaard, H. C., Viereck, S., & Rosenberg, J. (2016). Preoperative Risk Factors for Conversion of Laparoscopic Cholecystectomy to Open Surgery - A Systematic Review and Meta-Analysis of Observational Studies. Digestive surgery, 33(5), 414–423. https://doi.org/10.1159/000445505
Karvonen, J., Gullichsen, R., Laine, S., Salminen, P., & Grönroos, J. M. (2007). Bile duct injuries during laparoscopic cholecystectomy: primary and long-term results from a single institution. Surgical endoscopy, 21(7), 1069–1073. https://doi.org/10.1007/s00464-007-9316-7
Holzheimer, R. G., & Mannick, J. A. (Eds.). (2001). Surgical Treatment: Evidence-Based and Problem-Oriented. Zuckschwerdt.
Hamad, M. A., Nada, A. A., Abdel-Atty, M. Y., & Kawashti, A. S. (2011). Major biliary complications in 2,714 cases of laparoscopic cholecystectomy without intraoperative cholangiography: a multicenter retrospective study. Surgical endoscopy, 25(12), 3747–3751. https://doi.org/10.1007/s00464-011-1780-4
Lau WY, Lai ECH, Lau SHY (2010) Management of bile duct injury after laparoscopic cholecystectomy: a review. ANZ J Surg 80(1–2):75–81;
Nuzzo, G., Giuliante, F., Giovannini, I., Ardito, F., D'Acapito, F., Vellone, M., Murazio, M., & Capelli, G. (2005). Bile duct injury during laparoscopic cholecystectomy: results of an Italian national survey on 56 591 cholecystectomies. Archives of surgery (Chicago, Ill. : 1960), 140(10), 986–992. https://doi.org/10.1001/archsurg.140.10.986
Waage, A., & Nilsson, M. (2006). Iatrogenic bile duct injury: a population-based study of 152 776 cholecystectomies in the Swedish Inpatient Registry. Archives of surgery (Chicago, Ill. : 1960), 141(12), 1207–1213. https://doi.org/10.1001/archsurg.141.12.1207
Griffiths, E. A., Hodson, J., Vohra, R. S., Marriott, P., CholeS Study Group, Katbeh, T., Zino, S., Nassar, A. H. M., & West Midlands Research Collaborative (2019). Utilisation of an operative difficulty grading scale for laparoscopic cholecystectomy. Surgical endoscopy, 33(1), 110–121. https://doi.org/10.1007/s00464-018-6281-2
Sugrue, M., Sahebally, S. M., Ansaloni, L., & Zielinski, M. D. (2015). Grading operative findings at laparoscopic cholecystectomy- a new scoring system. World journal of emergency surgery : WJES, 10, 14. https://doi.org/10.1186/s13017-015-0005-x
Randhawa, J. S., & Pujahari, A. K. (2009). Preoperative prediction of difficult lap chole: a scoring method. The Indian journal of surgery, 71(4), 198–201. https://doi.org/10.1007/s12262-009-0055-y
Nassar AHM, Ashkar KA, Mohamed AY, Hafiz AA (1995) Is laparoscopic cholecystectomy possible without video technology? Minim Invasive Ther Allied Technol 4:63–65;
Gupta N, Ranjan G, Arora MP, Goswami B, Chaudhary P, Kapur A, Kumar R, Chand T (2013) Validation of a scoring system to predict difficult laparoscopic cholecystectomy. Int J Surg 11:1002–1006;
Sutton AJ, Vohra RS, Hollyman M, Marriott PJ, Buja A, Alderson D, Pasquali S, Griffiths EA (2017) Cost-effectiveness of emergency versus delayed laparoscopic cholecystectomy for acute gallbladder pathology. Br J Surg 104:98–107;
Sutcliffe RP, Hollyman M, Hodson J, Bonney G, Vohra RS, Griffiths EA, CholeS Study Group WMRC (2016) Preoperative risk factors for conversion from laparoscopic to open cholecystectomy: a validated risk score derived from a prospective U.K. database of 8820 patients. HPB 18:922–928;
Vohra RS, Spreadborough P, Johnstone M, Marriott P, Bhangu A, Alderson D, Morton DG, Griffiths EA (2015) Protocol for a multicentre, prospective, population-based cohort study of variation in practice of cholecystectomy and surgical outcomes (The CholeS study). BMJ Open 5:e006399;
Elshaer M, Gravante G, Thomas K, Sorge R, Al-Hamali S, Ebdewi H. Subtotal cholecystectomy for “difficult gallbladders”: systematic review and meta-analysis. JAMA Surg. 2015;150:159–68;
Henneman D, da Costa DW, Vrouenraets BC, van Wagensveld BA, Lagarde SM. Laparoscopic partial cholecystectomy for the difficult gallbladder: a systematic review. Surg Endosc. 2013;27:351–8;
Harilingam MR, Shrestha AK, Basu S. Laparoscopic modified subtotal cholecystectomy for difficult gall bladders: a single-centre experience. J Minim Access Surg. 2016;12:325–9
Lengyel BI, Azagury D, Varban O, Panizales MT, Steinberg J, Brooks DC, et al. Laparoscopic cholecystectomy after a quarter century: why do we still convert? Surg Endosc. 2012;26:508–13;
Szderlund C, Frozanpor F, Linder S (2005) Bile duct injuries at laparoscopic cholecystectomy: a single-institution prospective study. Acute cholecystitis indicates an increased risk. World J Surg 29(8):987–993
Borzellino G et al (2008) Laparoscopic cholecystectomy for severe acute cholecystitis. A meta-analysis of results. Surg Endosc 22(1):8–15;
Kelly MD. Laparoscopic retrograde (fundus first) cholecystectomy. BMC Surg. 2009;9:19-2482-9-19;
Fullum TM, Kim S, Dan D, Turner PL. Laparoscopic “domedown” cholecystectomy with the LCS-5 harmonic scalpel. JSLS. 2005;9:51–7;
Huang SM, Hsiao KM, Pan H, Yao CC, Lai TJ, Chen LY, et al. Overcoming the difficulties in laparoscopic management of contracted gallbladders with gallstones: possible role of fundusdown approach. Surg Endosc. 2011;25:284–91
Wakabayashi G, Iwashita Y, Hibi T, et al. Tokyo Guidelines 2018: surgical management of acute cholecystitis: safe steps in laparoscopic cholecystectomy for acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci. 2018;25(1):73-86. doi:10.1002/jhbp.517
Connor S, Garden OJ (2006) Bile duct injury in the era of laparoscopic cholecystectomy. Br J Surg 93(2):158–168;
Sakpal SV, Bindra SS, Chamberlain RS (2010) Laparoscopic cholecystectomy conversion rates two decades later. JSLS 14(4):476;
Mangieri CW, Hendren BP, Strode MA, Bandera BC, Faler BJ. Bile duct injuries (BDI) in the advanced laparoscopic cholecystectomy era. Surg Endosc. 2019;33(3):724-730. doi:10.1007/s00464-018-6333-7
Way LW, Stewart L, Gantert W, Liu K, Lee CM, Whang K, Hunter JG (2003) Causes and prevention of laparoscopic bile duct injuries: analysis of 252 cases from a human factors and cognitive psychology perspective. Ann Surg 237:460–469;
MacFadyen BV et al (1998) Bile duct injury after laparoscopic cholecystectomy. Surg Endosc 12(4):315–321;
Duca S et al (2003) Laparoscopic cholecystectomy: incidents and complications. A retrospective analysis of 9542 consecutive laparoscopic operations. HPB 5(3):152–158;
Rystedt J, Lindell G, Montgomery A (2016) Bile duct injuries associated with 55,134 cholecystectomies: treatment and outcome from a national perspective. World J Surg 40:73–80
Archer SB et al (2001) Bile duct injury during laparoscopic cholecystectomy: results of a national survey. Ann Surg 234(4):549;
Melton GB, Lillemoe KD, Cameron JL, Sauter PA, Coleman J, Yeo CJ. Major bile duct injuries associated with laparoscopic cholecystectomy: effect of surgical repair on quality of life. Ann Surg. 2002;235:888–95;
Nijssen MA, Schreinemakers JM, Meyer Z, van der Schelling GP, Crolla RM, Rijken AM. Complications after laparoscopic cholecystectomy: a video evaluation study of whether the critical view of safety was reached. World J Surg. 2015;39:1798–803;
Manatakis DK, Papageorgiou D, Antonopoulou MI, et al. Ten-year Audit of Safe Bail-Out Alternatives to the Critical View of Safety in Laparoscopic Cholecystectomy. World J Surg. 2019;43(11):2728-2733. doi:10.1007/s00268-019-05082-z
Purzner RH, Ho KB, Al-Sukhni E, Jayaraman S. 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. Can J Surg. 2019;62(6):402-411. doi:10.1503/cjs.014617;
Madding GF (1955) Subtotal cholecystectomy in acute cholecystitis. Am J Surg 89(3):604–607;
Bornman PC, Terblanche J (1985) Subtotal cholecystectomy; for the difficult gallbladder in portal hypertension and cholecystitis. Surgery 98:l–6;
Strasberg SM. A three-step conceptual roadmap for avoiding bile duct injury in laparoscopic cholecystectomy: an invited perspective review. J Hepatobiliary Pancreat Sci. 2019;26(4):123-127. doi:10.1002/jhbp.616;
Hugh TB, Kelly MD, Mekisic A. Rouviere’s sulcus: a useful landmark in laparoscopic cholecystectomy. Br J Surg. 1997;84:1253–4;
Reynolds W Jr (2001) The first laparoscopic cholecystectomy. JSLS 5(1):89; Hamad MA et al (2011) Major biliary complications in 2,714 cases of laparoscopic cholecystectomy without intraoperative cholangiography: a multicenter retrospective study. Surg Endosc 25(12):3747–3751;
Nassar AHM, Mirza A, Qandeel H, Ahmed Z, Zino S (2016) Fluorocholangiography: reincarnation in the laparoscopic era—evaluation of intra-operative cholangiography in 3635 laparoscopic cholecystectomies. Surg Endosc 30:1804–1811;
Shamiyeh A, Danis J, Wayand W, Zehetner J. A 14-year analysis of laparoscopic cholecystectomy: conversion–when and why? Surg Laparosc Endosc Percutan Tech. 2007;17:271–6;
Strasberg SM, Hertl M, Soper NJ (1995) An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 180:101–125;
Henneman D, da Costa DW, Vrouenraets BC, van Wagensveld BA, Lagarde SM. Laparoscopic partial cholecystectomy for the difficult gallbladder: a systematic review. Surg Endosc. 2013;27:351–8;
Henneman D, da Costa DW, Vrouenraets BC, van Wagensveld BA, Lagarde SM (2013) Laparoscopic partial cholecystectomy for the difficult gallbladder: a systematic review. Surg Endosc 27:315–358;
Elshaer M, Gravante G, Thomas K, Sorge R, Al-Hamali S, Ebdewi H. Subtotal cholecystectomy for "difficult gallbladders": systematic review and metaanalysis. JAMA Surg. 2015;150:159e168;
Sabour AF, Matsushima K, Love BE, et al. Nationwide trends in the use of subtotal cholecystectomy for acute cholecystitis. Surgery. 2020;167(3):569-574. doi:10.1016/j.surg.2019.11.004
Tornqvist B, Waage A, Zheng Z, et al. Severity of acute cholecystitis and risk of iatrogenic bile duct injury during cholecystectomy, a population-based case-control study. World J Surg 2016;40:1060-7;
Strasberg SM, Pucci MJ, Brunt LM, et al. Subtotal cholecystectomy — “fenestrating” vs “reconstructing” subtypes and the prevention of bile duct injury: definition of the optimal procedure in difficult operative conditions. J Am Coll Surg 2016;222:89-96;
Kaplan D, Inaba K, Chouliaras K, Low GM, Benjamin E, Lam L, et al. Subtotal cholecystectomy and open total cholecystectomy: alternatives in complicated cholecystitis. Am Surg. 2014;80:953–5;
Gupta V, Sharma AK, Kumar P, et al. Residual gall bladder: An emerging disease after safe cholecystectomy. Ann Hepatobiliary Pancreat Surg. 2019;23(4):353-358. doi:10.14701/ahbps.2019.23.4.353;
Kaplan D, Inaba K, Chouliaras K, et al. Subtotal cholecystectomy and open total cholecystectomy: Alternatives in complicated cholecystitis. Am Surg. 2014;80: 953e955;
Tay WM, Toh YJ, Shelat VG, et al. Subtotal cholecystectomy: early and long-term outcomes. Surg Endosc. 2020;34(10):4536-4542. doi:10.1007/s00464-019-07242-7;
Davis B et al (2012) Subtotal cholecystectomy versus total cholecystectomy in complicated cholecystitis. Am Surg 78(7):814–817
Shin M, Choi N, Yoo Y, Kim Y, Kim S, Mun S. Clinical outcomes of subtotal cholecystectomy performed for difficult cholecystectomy. Ann Surg Treat Res. 2016;91:226e232;
Hirajima S, Koh T, Sakai T, et al. Utility of laparoscopic subtotal cholecystectomy with or without cystic duct ligation for severe cholecystitis. Am Surg. 2017;83:1209e1213;
Okamoto K, Suzuki K, Takada T, Strasberg SM, Asbun HJ, Endo I, et al. Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25:55–72;
Strasberg SM, Pucci MJ, Brunt LM, et al. Subtotal cholecystectomy — “fenestrating” vs “reconstructing” subtypes and the prevention of bile duct injury: definition of the optimal procedure in difficult operative conditions. J Am Coll Surg 2016;222:89-96.

Table 1

Characteristic of patients who were operated in the first and second period.
	I group (Operated from 2005–2008).	II group (Operated from 2009–2019).
Number of patients	2720	4468
Age	62.8 ± 11.7	64.5 ± 12.0
Gender (female)	1795 (66%)	3083(69%)
Gender (male)	925 (34%)	1365 (31%)
Patients comorbidities
Diabetes	272 (10%)	384 (8.6%)
Ischemic heart desease	1142 (42%)	2055 (46%)
Hypertention	789 (29%)	1474 (33%)
Liver cirrhosis	299 (11%)	625 (14%)
Admission type
Delay	861 (21.4%)	3247 (37.1%)
Elective surgery	1442 (53%)	2457 (55%)
Emergency	1278 (47%)	2000 (45%)
Acute cholecystitis	1142 (42%)	1966 (44%)
Gangrenous cholecystitis	326 (12%)	625 (14%)
Empyema	653 (24%)	1206 (27%)
Symptomatic gallstones	816 (30%)	1251 (28%)
Choledocholithiasis	312 (11,5%)	589 (13,2%)
Cholangitis	190 (7%)	424 (9,5%)
Pancreatitis	109 (4%)	295 (6,6%)
Mirizzi syndrom	95 (3,5%)	208 (4,6%)

Table 2

Complications after LSC.
Complications	N = 108	Clavien-Dindo class I n	Clavien-Dindo class II n	Clavien-Dindo class III a
Hemorrhage	2 (1,8%)		2
Wound infection	5 (4,6%)	2	3
Collections	8 (7,4%)		4	4
Common bile duct injury	0 (0)
Bile leak	10 (9,3%)		5	5
Retained gallstones	5 (4,6%)			5
30-day mortality	0 ()	0

Table 3

Histology after LSC.
Histology	N = 108
Acute cholecystitis	19 (17,6%)
Gangrenous cholecystitis	14 (13,0%)
Acute chronic cholecystitis	45 (46,9%)
Chronic cholecystitis	30 (27,8%)

No competing interests reported.

Download PDF

Version 1

posted

You are reading this latest preprint version

Laparoscopic subtotal cholecystectomy for the difficult gallbladder.

Status:

Version 1

Abstract

INTRODUCTION

METHODS

RESULT

DISCUSSION

CONCLUSION

Declarations

References

Tables

Additional Declarations

Status:

Version 1