Comparing Outcomes of Sub-Total Cholecystectomy Versus Open Cholecystectomy as Bailout Procedures for the Difficult Gallbladder

Abstract

Background Although laparoscopic cholecystectomy is one of the most common operations performed, there is no consensus on the best surgical approach when inflammation obscures hepatocystic anatomy in severe cholecystitis. Traditionally, this situation triggered conversion to open cholecystectomy (COC); however, in recent decades, alternative approaches have been described. We compared outcomes of bailout procedures for severe cholecystitis, primarily focusing on COC versus laparoscopic subtotal cholecystectomy (LSTC). Study Design Retrospective review comparing outcomes of intended laparoscopic cholecystectomy cases that were converted to bailout procedures between 2015–2020 at a single institution. Bailout procedures were categorized into LSTC and COC groups. Demographics, clinical presentation, time to surgery, operative indications, operative duration, and post-operative outcomes were compared using independent sample t-tests with Welch-Satterthwaite correction or Wilcoxon rank-sum tests (continuous variables) or Fisher’s exact/χ2 tests. A P-value of less than .05 was considered significant. Results Final analysis included 158 subjects: 55 LSTC and 99 COC. Patient demographics and clinical presentations were similar between groups. LSTC had shorter operative time, fewer ICU admissions, and shorter length of stay than COC ( P < .05). There were 9 (9.2%) cases of ileus, 4 (4.0%) cases of post-operative bleeding, and 2 (2.0%) cases of bile duct injury in COC. There was 1 (1.8%) case of ileus, 1 (1.8%) case of post-operative bleeding, and no bile duct injury in LSTC. Conclusion LSTC was associated with fewer complications than COC, which had higher rates of biliary injury, bleeding, ileus, ICU admission, and longer hospital stay.

Bailout Surgery for Difficult Gallbladders: Surgical Approach and Outcomes

“…10 The ratio of laparoscopic subtotal cholecystectomy to open cholecystectomy has increased from 1:12 in 2015 to approximately 6: 7 in 2020. 12 This has been attributed to increased laparoscopic and robotic training for surgeons and surgical residents leading to greater minimally invasive skills. Another study found attending years of experience (≤5 vs >5) was not associated with whether a subtotal cholecystectomy would be performed.…”

“…Laparoscopic subtotal cholecystectomies have been associated with lower incidences of bleeding than total (standard) laparoscopic cholecystectomies for difficult gallbladders. 12,13 Grossman et al found one-third of intraoperative bleeding began prior to conversion to an open procedure. In our study, we found 8.8% of cases experienced intraoperative bleeding that resulted in conversion to a bailout procedure.…”

“…Bile leaks are an expected and known outcome with fenestrated procedures. 12 Laparoscopic subtotal cholecystectomy has been shown to have a shorter hospital stay than those who had open procedures. 12 In our study, there was no difference in hospital length of stay amongst open or laparoscopic procedures; however, there were significantly higher readmissions in subtotal cholecystectomy patients.…”

State of the art in subtotal cholecystectomy: An overview

“…Subtotal cholecystectomy should be performed using a laparoscopic approach whenever possible; conversion to open procedure seems to be unnecessary and counterproductive because using this approach doesn't provide an adequate visualization of anatomical structures and the outcome for the procedure would still be a subtotal cholecystectomy. Furthermore, conversion to open procedure seems to be associated with higher rates of bile duct injury, bleeding, postoperative ileum, ICU admission and longer hospital stay (46).…”

ROBOtic Care Outcomes Project (ROBOCOP) for Acute Gallbladder Pathology

“…Braschi found lower incidence of bile leak, intra-abdominal abscess, biloma, postoperative endoscopic retrograde cholangiopancreatography (ERCP), and readmission with total cholecystectomy compared with subtotal 22 . Grossman compared laparoscopic subtotal cholecystectomy to attempted laparoscopic with conversion to open total cholecystectomy and found that the minimally invasive approach was associated with shorter operative room time, reduced rate of ICU admission, and shorter length of stay 23 …”