Usefulness of laparoscopic subtotal cholecystectomy with operative cholangiography for severe cholecystitis

Abstract

PurposeCholecystectomy can become hazardous when inflammation develops, leading to anatomical changes in Calot’s triangle. We attempted to study the safety and efficacy of laparoscopic subtotal cholecystectomy (LSC) to decrease the incidence of complications and the rate of conversion to open surgery.MethodsPatients who underwent LSC between January 2005 and December 2008 were evaluated retrospectively. The operations were performed laparoscopically irrespective of the grade of inflammation estimated preoperatively. However, patients with severe inflammation of the gallbladder underwent LSC involving resection of the anterior wall of the gallbladder, removal of all stones and placement of an infrahepatic drainage tube. To prevent intraoperative complications, including bile duct injury, intraoperative cholangiography was performed.ResultsLSC was performed in 26 elective procedures among 26 patients (eight females, 18 males). The median patient age was 69 years (range 43–82 years). The median operative time was 125 min (range 60–215 min) and the median postoperative inpatient stay was 6 days (range 3–21 days). Cholangiography was performed during surgery in 24 patients. One patient underwent postoperative endoscopic sphincterotomy for a retained common bile duct stone that was found on cholangiography during surgery. Neither complications nor conversion to open surgery were encountered in this study.ConclusionsLSC with the aid of intraoperative cholangiography is a safe and effective treatment for severe cholecystitis.

Subtotal Cholecystectomy for “Difficult Gallbladders”

“…23 Intraoperative cholangiography was used in 4 studies. 19,22,23,27 Three studies left the CD or the GB stump opened, 13,29,35 and the other studies used surgical clips, suture ligation, Endoloop (Ethicon), Endo GIA 30 (Covidien), purse string suture, or intracorporeal sutures for closure. ‡ A drain was used in all but one study.…”

Risk Factors for Difficult Laparoscopic Cholecystectomy in Acute Cholecystitis

“…1,2 Recent analyses are in favor of early surgery, which seems to be feasible and safe, and it offers both medical and socioeconomic benefits compared with delayed-interval surgery. 3–7 As a result, delayed surgery is now chosen under certain situations, such as a prolonged time from onset to presentation, patient's comorbidity and age, and emergency medical system in each hospital, among other reasons. LC for AC is surgery with a high degree of surgical difficulty, and surgeons sometimes encounter difficult cases that require conversion.…”

Predicting conversion from laparoscopic to open cholecystectomy presented as a probability nomogram based on preoperative patient risk factors

“…Such accurate prediction may also provide a rational basis for the discussion of elective open cholecystectomy with an informed patient in the preoperative setting. This may also involve the presence of a surgeon experienced in open cholecystectomy or alternatives to total cholecystectomy should they become necessary7,9,30,31 The user-friendly characteristics of these nomograms and their very high internal validity suggest that this model can be usefully incorporated into current surgical practice. These nomograms are presently being used in clinical practise by surgeons in Cairns, Australia.…”