The second ‘gallbladder operation’

Abstract

Background: Subtotal cholecystectomy has been reported in 8% and 3.3% of patients undergoing open and laparoscopic cholecystectomy, respectively. According to a recent nationwide survey, the utilisation of subtotal cholecystectomy in the treatment of acute cholecystitis is on the rise. In 1.8% of subtotal cholecystectomies, a reoperation is required. Reoperations for residual gallbladder (GB), gallstones, and related complications accounted for half of the reoperations described in the literature after subtotal cholecystectomy. The purpose of this study was to evaluate the clinical profile, risk of complications, and feasibility of laparoscopic approaches and surgical procedures in patients with recurrent symptoms from a residual GB that necessitated a completion cholecystectomy. Methods: Patients who underwent surgery for residual GB with stones and/or complications between January 2007 and January 2020 were included in the study group. A prospectively maintained database was used to review patient information retrospectively. The demographic profile, operation details of the index surgery, current presentation, investigations performed, surgery details, morbidity and mortality were all included in the clinical information. Results: There were 13 patients who underwent completion cholecystectomy. The median age was 55 years (22–63 years). Prior operative notes mentioned subtotal cholecystectomy in only seven patients. The average time between the index surgery and the onset of symptoms was 30 months (2–175 months). A final diagnosis of residual GB with or without calculi was made by ultrasound (USG) in 11 patients and by magnetic resonance cholangiopancreatography (MRCP) in two others. Choledocholithiasis ( n = 4, 30.7%), acute cholecystitis ( n = 2, one with empyema and GB perforation) and Mirizzi syndrome ( n = 1) were seen as complications of residual gallstones in seven patients. All 13 patients underwent successful laparoscopic procedures. A fifth port was used in all. A critical view of safety was achieved in 12 patients. Two patients required laparoscopic common bile duct (CBD) exploration for CBD stones. Intraoperative cholangiograms were done in eight patients (61.5%). There were no conversions, injuries to the bile duct or deaths. Morbidity was seen in one. The patient required therapeutic endoscopic retrograde cholangiography for cholangitis and CBD clearance on the fifth post-operative day. The median hospital stay was 4 days (3–7 days). At a median follow-up of 99 months, symptom resolution was seen in all 13 patients. Conclusion: Gallstones in the residual GB are associated with more complications than conventional gallstones. The diagnosis requires a high level of suspicion. MRCP is more accurate in establishing the diagnosis and identifying the associated complications, even if the diagnosis is made on USG in most...

Safe postoperative outcomes following early cholecystectomy for acute calculus cholecystitis regardless of symptom onset

“…Despite this, there were no statistical difference in 95% cholecystectomy rates between the subgroups, no reported recurrent biliary colic/cholecystitis, and no recorded mortality. This is in contrast to studies that quote a 1.8% reoperation rate following 95% cholecystectomy (19)(20).…”

“…The duration of symptoms in AC was not an independent risk factor and should not influence the surgeon's decision to perform early LC (16). The authors suspect that this finding is attributed to increasing experience and technical skill over time, and the increasing utilization of laparoscopic subtotal cholecystectomy in the treatment of early AC (20).…”

State of the art in subtotal cholecystectomy: An overview

“…Patients must also have a nuclear magnetic resonance before the procedure in order to be familiarized with the patient's anatomy. If reaching the critical view of safety is not possible during cholecystectomy of the remnant gallbladder it can be revised with mucosal cauterization and gallstone extraction while attempting to leave as small a remnant as possible (36). The following algorithm has been designed for treatment of recurrent gallstones (Figure 8) (36).…”