Surgical Endoscopy

, Volume 31, Issue 12, pp 5258–5266 | Cite as

Gangrenous cholecystitis: innovative laparoscopic techniques to facilitate subtotal fenestrating cholecystectomy when a critical view of safety cannot be achieved

  • Rebekah Kirkwood
  • Lauren Damon
  • Jennifer Wang
  • Esther Hong
  • Kimberly Kirkwood



Gangrenous cholecystitis is associated with a higher conversion rate of conversion from laparoscopic to open than acute non-gangrenous cholecystitis. New strategies and techniques are needed to decrease conversion rates and improve outcomes.


In this article, we provide a richly detailed, illustrated description of a modified fundus-first technique that we have developed over the last 15 years and now use routinely with rare conversions. We also compared outcomes of laparoscopic (LC) and open (OC) approaches for pathologically confirmed gangrenous cholecystitis in 146 patients during 1995–2005, the first 10 years during which these two approaches were performed contemporaneously at our institution on comparable patients.


Among the 142 patients that met the inclusion criteria, laparoscopic procedures were started in 112 (79%) of these patients, with successful completion in 72 resulting in an overall conversion rate of 36%. During the last 5 years, however, in cases where the described laparoscopic technique was used, no patient has required conversion. The laparoscopic LC group had shorter average ICU stay (p < 0.05) and overall length of stay (2 vs 6 days, p < 0.001). Intraoperative cholangiography was completed in 37 of 72 LC patients (52%) versus 6 of 30 OC (20%). In five of the LC patients, a filling defect was seen on the cholangiogram and laparoscopic transcystic common bile duct stones, thereby avoiding a second anesthetic and endoscopic procedure.


In the setting of severe inflammation, a number of procedural modifications can be incorporated to allow the surgeon to approach dissection of the gangrenous gallbladder using a flexible operative plan designed to optimize safe completion of this challenging procedure, with the expected improvement in surgical outcomes.


Gangrenous Cholecystectomy Technique Laparoscopic Cholecystitis Fundus-first 



The authors thank Jessica Norum, for her help in the preparation of the manuscript.

Compliance with ethical standards


Rebekah Kirkwood, Lauren Damon, Jennifer Wang, Esther Hong, Kimberly Kirkwood have no conflict of interest or financial ties to disclose.


  1. 1.
    Ganapathi AM, Speicher PJ, Englum BR, Perez A, Tyler DS, Zani S (2015) Gangrenous cholecystitis: a contemporary review. J Surg Res. doi: 10.1016/j.jss.2015.02.058 PubMedGoogle Scholar
  2. 2.
    Karakavli FY, Akdur A, Kirnap M, Harman A, Ekici Y, Moray G (2014) Emergency cholecystectomy vs percutaneous cholecystostomy, plus delayed cholecystectomy for patients with acute cholecystitis. Hepatobiliary Pancreat Dic Int 13(3):316–322CrossRefGoogle Scholar
  3. 3.
    Viste A, Jensen D, Angelsen J, Hoem D (2015) Percutaneous cholecystostomy in acute cholecystitis: a retrospective analysis of a large series of 104 patients. BMC Surg. doi: 10.1186/s12893-015-0002-8 PubMedPubMedCentralGoogle Scholar
  4. 4.
    Ambe PC, Kaptanis S, Papadakis M, Weber S, Zirngibl H (2015) Cholecystectomy vs percutaneous cholecystostomy for the management of critically ill patients with acute cholecystitis: a protocol for a systemic review. Syst Rev. doi: 10.1186/s13643-015-0065-8 PubMedPubMedCentralGoogle Scholar
  5. 5.
    Strasberg SM, Pucci MJ, Brunt LM, Deziel DJ (2016) Subtotal cholecystectomy—“fenestrating” vs “reconstituting” subtypes and the prevention of bile duct injury: definition of the optimal procedure in difficult operative conditions. J Am Coll Surg 222(1):89–96CrossRefPubMedGoogle Scholar
  6. 6.
    Strasberg SM, Brunt LM (2010) Rationale and use of the critical view of safety in laparoscopic cholecystectomy. J Am Coll Surg 211(1):132–138CrossRefPubMedGoogle Scholar
  7. 7.
    Kanaan SA, Murayama KM, Merriam LT, Dawes LG, Prystowsky JB, Rege RV, Joehl RJ (2002) Risk factors for conversion of laparoscopic to open cholecystectomy. J Surg Res 106(1):20–24CrossRefPubMedGoogle Scholar
  8. 8.
    Stefanidis D, Bingener J, Richards M, Schwesinger W, Dorman J, Sirinek K (2005) Gangrenous cholecystitis in the decade before and after the introduction of laparoscopic cholecystectomy. Jsls 9(2):169–173PubMedPubMedCentralGoogle Scholar
  9. 9.
    Strasberg SM (2005) Biliary injury in laparoscopic surgery: part 2. Changing the culture of cholecystectomy. J Am Coll Surg 201(4):604–611CrossRefPubMedGoogle Scholar
  10. 10.
    Chowbey PK, Sharma A, Khullar R, Mann V, Baijal M, Vashistha A (2000) Laparoscopic subtotal cholecystectomy: a review of 56 procedures. J Laparoendosc Adv Surg Tech A. doi: 10.1089/lap.2000.10.31 Google Scholar
  11. 11.
    Chaudery M, Hunjan T, Beggs A, Nehra D (2013) Pitfalls in the use of laparoscopic staplers to perform subtotal cholecystectomy. BMJ Case Rep. doi: 10.1136/bcr-2013-009047 PubMedPubMedCentralGoogle Scholar
  12. 12.
    Soleimani M, Mehrabi A, Mood ZA, Fonouni H, Kashfi A, Büchler MW, Schmidt J (2007) Partial cholecystectomy as a safe and viable option in the emergency treatment of complex acute cholecystitis: a case series and review of the literature. Am Surg 73(5):498–507PubMedGoogle Scholar
  13. 13.
    Bat O (2015) The analysis of 146 patients with difficult laparoscopic cholecystectomy. Int J Clin Exp Med 8(9):16127PubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2017

Authors and Affiliations

  • Rebekah Kirkwood
    • 1
  • Lauren Damon
    • 1
  • Jennifer Wang
    • 1
  • Esther Hong
    • 1
  • Kimberly Kirkwood
    • 1
  1. 1.Department of SurgeryUniversity of California San FranciscoSan FranciscoUSA

Personalised recommendations