Laparoscopic subtotal cholecystectomy is safe and effective when faced with challenging anatomy

R P Evans, MBBS, MRCS, N S Malik, BMed, Sci, Hons, BMBS, Hons, M A Khan, FRCS. Mid-Staffordshire NHS Trust, UK.

Background: Laparoscopic cholecystectomy has become a routine operation. The proportion of operations performed on an emergent or urgent basis is increasing. Laparoscopic cholecystectomy during acute inflammation is often significantly more challenging than the interval elective procedure. When faced with complicated cholecystitis, one must decide between sub-total laparoscopic cholecystectomy or conversion to open total cholecystectomy. The aim of the study is to determine whether complications can be kept to a minimum without needing to perform an open procedure.

Methods: Retrospective analysis of a prospectively managed database in a UK District General hospital between 02/2011 and 03/2013.

Results:
Overall: In the 25-month period, 466 laparoscopic cholecystectomies were performed; comprising 375 (80%) female and 91 (20%) male patients. 95 (20%) underwent simultaneous on-table cholangiogram. 60 cases (13%) were performed as ‘hot’ emergency or urgent procedures. Only two cases (0.4%) were converted to an open procedure: one in which a small incision was necessary to remove a large stone; another in which omental bleeding was encountered. 1 patients (0.2%) developed post-operative bile leak. No bile duct injuries occurred.
Laparoscopic subtotal cholecystectomy sub-group: 20 (4%) patients underwent laparoscopic subtotal cholecystectomy. The median age of patients was 68 (range 43 to 83), 13 were men. 16 patients presented with cholecystitis, two with biliary colic, one with cholangitis and one with pancreatitis. Three required pre-operative ERCP during immediate work-up for cholecystectomy. A further two had undergone ERCP with sphincterotomy during previous admissions. Only 5 of the procedures were performed on ‘hot’ gallbladders. Despite this, active inflammation was present in 12 cases. Empyema was present in four patients. Three gallbladders were perforated. 15 of the 20 cases required retrograde dissection. In one case Hartmann’s pouch was left open, in 5 Hartmann’s pouch was sutured and in the remaining 14 an Endoloop was applied. Post-operative management: All underwent sub-hepatic drain insertion. Of these, 14 were removed during admission and the remaining 6 were removed in clinic. Median time to drain removal was 2 days (range 1-13 days). Median length of stay was 2 days (range 1-6 days). Complications, follow up and re-intervention: No bile leakage or bile duct injury occurred. 7 patients were followed routinely, median follow up time was 10 days (range 6 days – 3 months). 2 patients were re-referred to clinic from primary care with on-going symptoms. Of these, one required laparoscopic completion cholecystectomy 13 months following the original procedure. Another suffered cholangitis attributed to pre-operative ERCP and sphincterotomy, managed conservatively. 2 patients re-presented to acute surgical services. One developed a sub-hepatic collection 6 months post operatively, managed conservatively. Another developed biliary obstruction due to small cell lung cancer and underwent stent insertion.

Conclusion: In the context of indefinable anatomy, laparoscopic sub-total cholecystectomy with retrograde dissection is a safe procedure with minimal complications. It is sufficient management in the majority of patients. It allows for safe re-intervention in the small proportion of patients suffering on-going biliary symptoms.