Introduction

Severely inflamed gallbladders due to acute or chronic infections are challenging to operate on laparoscopically. This is due to the difficulty of adequate ductal identification using the critical view of safety (CVS), which increases the risk of bile duct injury. The safer method would be to avoid dissection in the hepatocystic triangle and perform a subtotal laparoscopic cholecystectomy. The two types of subtotal cholecystectomy, based on the remaining remnant gallbladder would be fenestrating (no remnant) and reconstituting (remnant present) [1].

Indications [2]

  • Severe cholecystitis.

  • Cholelithiasis in liver cirrhosis and portal hypertension.

  • Empyema or perforated gallbladder.

Contraindications

  • Severe adhesions make it hard to access the gallbladder.

  • Hemodynamic instability (systolic pressure < 90 mmHg).

  • Bleeding and clotting problems.

Instruments

  • Laparoscopic hook.

  • Laparoscopic blunt graspers.

  • Laparoscopic toothed graspers.

  • Maryland forceps.

  • Laparoscopic needle holders.

  • Suction-Irrigation cannula.

  • Advanced bipolar forceps (if available).

Conduct of the Operation

A 10 mm umbilical incision for a 10 mm Hasson Trocar. Three 5 mm incisions at the right subcostal area for 5 mm working trocars. Pressure is set initially at 8 mmHg with a flow rate of low flow (5 L/min). Once an ideal pneumoperitoneum is established, pressure is increased to 12 mmHg and high flow is established (20 L/min). The patient is set wherein the head is elevated (reverse Trendelenburg position) and the right side of the patient is also elevated just enough to let the bowels fall for exposure of the gallbladder.

A limited diagnostic laparoscopy is conducted by sweeping the scope around the abdomen to check for concomitant abdominal pathologies, active bleeding at port site insertions, and/or bowel injuries that might have occurred during trocar insertions. The area of the gallbladder (GB) is assessed for accessibility. In the presence of dense and hard omental adhesions or significant bowel adhesions to the GB, a decision to convert to an open procedure is executed due to difficulty to access. If the GB is readily visualized, dissection proceeds to isolate the cytic duct and artery. Additional maneuvers like the fundus down approach can be done at this point. If the cystohepatic triangle is fused with the cystic artery and/or the cystic duct cannot be safely dissected, a decision will be made to abort dissection into the cystohepatic triangle and initiate a laparoscopic subtotal cholecystectomy, so as to avoid a bile duct injury (Fig. 1).

Fig. 1
A close-up photo of the gallbladder during an operation. Three labels are placed on the photo, that are, clockwise, enlarged cystic duct, C B D, and Rouviere's fissure.

Cystic duct is greatly enlarged making it unsafe to continue dissecting into the cystohepatic triangle

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Fenestrating Subtotal Cholecystectomy

Decompression of the GB is started with an open laparoscopic bowel grasper, on the lateral most trocar, which is used to push the GB cephalad. A suction cannula on the surgeon’s left hand is situated at the fundus while a monopolar hook is on the surgeon’s right hand to puncture the fundus of the GB just large enough to fit the suction cannula tip. Decompression of the GB is continued by suctioning the liquid contents present in the GB [3] (Fig. 2).

Fig. 2
A close-up photo of an operation. Three medical instruments are in the photo, the one on top is labeled a suction cannula, has a rounded body placed close to the tissue. The one on the right, with a hooked tip punctures a portion of the tissue, another instrument is beside the cannula.

Decompression of a distended gallbladder

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The bowel grasper is replaced with a toothed grasper, situated inside the newly created puncture in the fundus to grasp the GB and push it upwards with just enough space to carry out dissection around the GB. Dissection to remove the anterior wall of the GB is started at the fundus and carried down either medially or laterally towards the neck of the GB. A monopolar hook can be used, being mindful to address small arterial bleeding with bipolar forceps. An alternative is to carry out dissection with advanced bipolar forceps to minimize bleeding, as this has both cutting and vessel sealing capability (Fig. 3). The posterior wall of the GB is left attached to the liver with the mucosa exposed. Monopolar energy is applied to the exposed mucosa so as to limit the production of mucin.

Fig. 3
A close-up photo of the human body during an operation. Two labels are written on the photo which reads, posterior part of G B attached to the liver, and anterior part of gallbladder being.

Fenestrating subtotal cholecystectomy wherein part of the GB is attached to the liver

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During dissection of the GB, a specimen bag is placed inside beside the GB so that the stones extracted can be safely set aside by placement in a specimen bag. Smaller stones can be suctioned off. This prevents stones from being scattered around the abdomen, which can be challenging for multiple small stones. The removed anterior wall of the GB can also be placed inside the specimen bag at this point.

It must be noted that there must be no more stones inside the GB stump and bile flow is visualized in the orifice of the cystic duct. This is the time that intracorporeal suturing of the orifice of the cystic duct with a 2–0, braided, nonabsorbable suture via purse string closure is done.

Using the suction irrigation cannula, copious lavage with plain saline solution for irrigation is done at the operative field, around the inferior and lateral borders of the liver to clean out small stones and spilled bile. A closed suction drain is placed at the inferior margin of the liver close to the GB stump with the proximal end exiting the most lateral 5 mm trocar. A last look to assess the integrity of the anatomy of the extrahepatic biliary tree is done by taking note that there are no signs of bleeding and bile leak. The remaining working trocars are removed under direct vision making sure that there are no signs of active port site bleeding. Dessuflation is done and the specimen bag is extracted through the umbilical incision. Proper closure of incision sites is done.

Reconstituting Subtotal Cholecystectomy

With the same indications for doing a subtotal cholecystectomy, since it is very difficult to approach the hepatocystic triangle, the fundus of the GB is perforated with the same technique discussed above. A dome-down technique is commenced wherein the GB is separated from the liver by a monopolar hook from the posterior part of the fundus up to the posterior part of the neck of the GB [4] (Fig. 2). Bleeding is common in this step, wherein control can be done with advanced bipolar forceps from time to time. If the GB has a thickened wall, a 5 mm advanced bipolar forceps can be used throughout the dissection, being cautious when reaching the neck of the GB as the common hepatic duct can be adherent to the inflamed neck of the GB. It is of importance that dissection has proceeded to a point that the GB is freed from the liver up to the area of the neck. This is the point wherein transection of the neck of the GB is done, either with a monopolar hook or an advanced bipolar forceps (Fig. 4). Proper hemostasis must be done once arterioles are transected. The stones are removed and placed into a specimen bag, together with the transected part of the GB. Visualization of the orifice of the cystic duct is done with minimal probing with the Maryland forceps just to make sure that there are no stones lodged inside the cystic duct and that flow of bile is noted. Burning of the stump mucosa is commenced with a monopolar hook. Intracorporeal suturing with a 2–0 absorbable barbed suture is needed to close off the stump (Fig. 5).

Fig. 4
A close-up photo of an operation. A metal hooked tip of a medical instrument is inserted into a layer of tissue, a label that reads transection of the neck of the G B.

Reconstituting subtotal cholecystectomy by transecting the neck of the GB

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Fig. 5
Two photographs of an operation. Image A has a metal hook held by a pincer-like instrument that pierces a layer of tissue, The metal hook has a thread attached to it. Image B is a photo of the instrument that holds a portion of the thread that was inserted into the tissue to close it up.

Closure of the GB stump with a barbed suture

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Copious suction and irrigation are done around the operative field so as to clean away small stones and bile. A closed suction drain is placed lateral and inferior to the gallbladder stump with the distal end coming out of the lateral trocar insertion site. A last look to assess the integrity of the anatomy of the extrahepatic biliary tree is done by taking note that there are no signs of bleeding and bile leak. Remaining working trocars are removed under direct vision making sure that there are no signs of active port site bleeding. Dessuflation is done and the specimen bag is extracted through the umbilical incision. Proper closure of incision sites is done.