Subtotal Laparoscopic Cholecystectomy for Complicated Cholelitiasis

Francesco Fleres, MD1, Carmelo Mazzeo, MD1, Vincenzo Pruiti, MD2, Massimo Trovato, MD3, Eugenio Cucinotta, MD1. 1University of Messina, AOU Policlinico G. Martino Messina, 2University of Milan, 3AOU Policlinico G. Martino Messina

Introduction

Laparoscopic cholecystectomy has become the gold standard for managing of cholelithiasis. However patients with complicated cholecystectomy and difficult dissection around Calot’s triangle are still converted to open procedure. Open subtotal cholecystectomy was performed but with the advent of laparoscopic surgery this has fallen from his role. Nevertheless,subtotal cholecystectomy is a safe option in case of severe inflammation at Calot’s triangle because it may reduce the potential injury for common duct. Difficult gallbladder is a procedure with an increased surgical risk compared with standard cholecystectomies, and it is usually associated with severe inflammation that distorts the local anatomy and renders dissections more difficult: acute cholecystitis, empyema, gangrene, perforation, Mirizzi syndrome, cirrhotic livers that increase the risk of bleeding.

The Authors report their experience using laparoscopic subtotal cholecystectomy (LSC) to avoid bile duct injury and conversion in difficult cholecystectomy.

Methods and procedures

A retrospective review was performed on 16 laparoscopic subtotal cholecystectomy from January 2006  to December 2014. Length of post-surgical hospitalization, morbidity, mortality and follow-up were assessed.

Results

LSC was performed in 16 patients for severe fibrosis in 13 cases and cirrhosis in 3 cases. The median age of the patients was 69 years (range, 43-82 years). The median postoperative in patients stay was 6 days (range, 3-16 days). The median operative time for LSC was 95 minutes (range, 50-185 minutes). During the postoperative period no patient presented a biliary leak. A lithiasis of cystic remains in two patients. One patient underwent post-operative ERCP for a retained common bile duct stone. No postoperative mortality occurred. The cystic duct or Hartmann’s pouch stump was closed using endo-loop application in 10 (62%), intracorporeal suturing of stump of Hartmann’s pouch in 4 (25%) with endo-gia in 2 (13%).

Conclusion

Subtotal Cholecystectomy (SC) removes portions of the GB when the structures of the Calot’s triangle cannot be identified and the critical view of safety cannot be achieved.

The results suggest that laparoscopic subtotal cholecystectomy is a favourable surgical alternative to total cholecystectomy in cases with technically difficult severe cholecystitis. LSC is advantageous over open surgery, but it remains a non-routine choice.

Subtotal cholecystectomy is a safe option in case of severe inflammation at Calot’s triangle, because it reduces the potential injury for common duct, and it is a valid technique to take into account also in patients with cirrhosis.

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