Abstract
Background
Laparoscopic subtotal cholecystectomy (LSC) is a safe bailout procedure in situations when dissection of "critical view of safety" is not possible. After the proposed classification of subtotal cholecystectomy into "fenestrating" and "reconstituting" techniques in 2016, a comparative review of the outcomes of both methods is timely.
Methods
A literature search of the PubMed, Cochrane Library, and Web of Science database was conducted up to January 31, 2020 for studies that reported LSC. Studies reporting LSC only in patients with Mirizzi syndrome or xanthogranulomatous cholecystitis were excluded. Our analysis includes 39 studies with 1784 cases of LSC. We report a comparison of outcomes between reconstituting and fenestrating LSC on 1505 cases [935 reconstituting (62.1%) and 570 fenestrating (37.9%)].
Results
Following LSC, the rate of open conversion is 7.7%, hemorrhage is 0.4%, bile duct injury is 0.3%, bile leak is 15.4%, retained stone is 4.6%, subhepatic or subphrenic collection is 2.9%, superficial surgical site infection is 2.0% and 30-day mortality is 0.2%. 8.8% of patients required postoperative endoscopic retrograde cholangiopancreatography (ERCP), 1.1% required percutaneous intervention, and 2.2% required reoperation. Compared to reconstituting LSC, fenestrating LSC has a higher incidence of open conversion (n = 58, 10.2% vs. n = 43, 4.6%, p < 0.001), retained stones (n = 38, 6.7% vs. n = 38, 4.1%, p = 0.0253), subhepatic or subphrenic collections (n = 33, 5.8% vs. n = 13, 1.4%, p < 0.001), superficial surgical site infections (n = 18, 3.2% vs. n = 14, 1.5%, p = 0.0303), postoperative ERCP (n = 82, 14.4% vs. n = 62, 6.6%, p < 0.001), and need for reoperation (n = 20, 3.5% vs. n = 12, 1.3%, p < 0.001).
Conclusions
Although reconstituting LSC has better outcomes, both techniques are complementary. Intraoperative findings and surgical expertise impact the choice.
Similar content being viewed by others
References
Yamashita Y, Takada T, Strasberg SM, Pitt HA, Gouma DJ, Garden OJ, Buchler MW, Gomi H, Dervenis C, Windsor JA, Kim SW, de Santibanes E, Padbury R, Chen XP, Chan AC, Fan ST, Jagannath P, Mayumi T, Yoshida M, Miura F, Tsuyuguchi T, Itoi T, Supe AN (2013) TG13 surgical management of acute cholecystitis. J Hepatobiliary Pancreat Sci 20:89–96
van de Graaf FW, Zaimi I, Stassen LPS, Lange JF (2018) Safe laparoscopic cholecystectomy: a systematic review of bile duct injury prevention. Int J Surg (London, England) 60:164–172
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 222:89–96
Strasberg SM, Brunt LM (2010) Rationale and use of the critical view of safety in laparoscopic cholecystectomy. J Am Coll Surg 211:132–138
Shea JA, Healey MJ, Berlin JA, Clarke JR, Malet PF, Staroscik RN, Schwartz JS, Williams SV (1996) Mortality and complications associated with laparoscopic cholecystectomy. a meta-analysis. Ann Surg 224:609–620
Beldi G, Glattli A (2003) Laparoscopic subtotal cholecystectomy for severe cholecystitis. Surg Endosc 17:1437–1439
Lee J, Miller P, Kermani R, Dao H, O’Donnell K (2012) Gallbladder damage control: compromised procedure for compromised patients. Surg Endosc 26:2779–2783
Michalowski K, Bornman PC, Krige JE, Gallagher PJ, Terblanche J (1998) Laparoscopic subtotal cholecystectomy in patients with complicated acute cholecystitis or fibrosis. Br J Surg 85:904–906
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 10:31–34
Sinha I, Smith ML, Safranek P, Dehn T, Booth M (2007) Laparoscopic subtotal cholecystectomy without cystic duct ligation. Br J Surg 94:1527–1529
Wolf AS, Nijsse BA, Sokal SM, Chang Y, Berger DL (2009) Surgical outcomes of open cholecystectomy in the laparoscopic era. Am J Surg 197:781–784
McCoy AC, Gasevic E, Szlabick RE, Sahmoun AE, Sticca RP (2013) Are open abdominal procedures a thing of the past? An analysis of graduating general surgery residents’ case logs from 2000 to 2011. J Surg Educ 70:683–689
Sharp CF, Garza RZ, Mangram AJ, Dunn EL (2009) Partial cholecystectomy in the setting of severe inflammation is an acceptable consideration with few long-term sequelae. Am Surg 75:249–252
Bornman PC, Terblanche J (1985) Subtotal cholecystectomy: for the difficult gallbladder in portal hypertension and cholecystitis. Surgery 98:1–6
Bickel A, Shtamler B (1993) Laparoscopic subtotal cholecystectomy. J Laparoendosc Surg 3:365–367
Crosthwaite G, McKay C, Anderson JR (1995) Laparoscopic subtotal cholecystectomy. J R Coll Surg Edinb 40:20–21
Ji W, Li LT, Li JS (2006) Role of laparoscopic subtotal cholecystectomy in the treatment of complicated cholecystitis. Hepatobiliary Pancreat Dis Int 5:584–589
Palanivelu C, Jani K, Maheshkumar GS (2007) Single-center experience of laparoscopic cholecystectomy. J Laparoendosc Adv Surg Tech A 17:608–614
Horiuchi A, Watanabe Y, Doi T, Sato K, Yukumi S, Yoshida M, Yamamoto Y, Sugishita H, Kawachi K (2008) Delayed laparoscopic subtotal cholecystectomy in acute cholecystitis with severe fibrotic adhesions. Surg Endosc 22:2720–2723
Philips JA, Lawes DA, Cook AJ, Arulampalam TH, Zaborsky A, Menzies D, Motson RW (2008) The use of laparoscopic subtotal cholecystectomy for complicated cholelithiasis. Surg Endosc 22:1697–1700
Hussain A, El-Hasani S (2009) The use of laparoscopic subtotal cholecystectomy for complicated cholelithiasis. Surg Endosc 23:913
Nakajima J, Sasaki A, Obuchi T, Baba S, Nitta H, Wakabayashi G (2009) Laparoscopic subtotal cholecystectomy for severe cholecystitis. Surg Today 39:870–875
Singhal T, Balakrishnan S, Hussain A, Nicholls J, Grandy-Smith S, El-Hasani S (2009) Laparoscopic subtotal cholecystectomy: initial experience with laparoscopic management of difficult cholecystitis. Surgeon 7:263–268
Tian Y, Wu SD, Su Y, Kong J, Yu H, Fan Y (2009) Laparoscopic subtotal cholecystectomy as an alternative procedure designed to prevent bile duct injury: experience of a hospital in northern China. Surg Today 39:510–513
Henneman D, da Costa DW, Vrouenraets BC, van Wagensveld BA, Lagarde SM (2013) Laparoscopic partial cholecystectomy for the difficult gallbladder: a systematic review. Surg Endosc 27:351–358
Tamura A, Ishii J, Katagiri T, Maeda T, Kubota Y, Kaneko H (2013) Effectiveness of laparoscopic subtotal cholecystectomy: perioperative and long-term postoperative results. Hepatogastroenterology 60:1280–1283
Elshaer M, Gravante G, Thomas K, Sorge R, Al-Hamali S, Ebdewi H (2015) Subtotal cholecystectomy for “difficult gallbladders”: systematic review and meta-analysis. JAMA Surg 150:159–168
Sabour AF, Matsushima K, Love BE, Alicuben ET, Schellenberg MA, Inaba K, Demetriades D (2020) Nationwide trends in the use of subtotal cholecystectomy for acute cholecystitis. Surgery 167:569–574
Hozo SP, Djulbegovic B, Hozo I (2005) Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol 5:13
Slater M, Midya S, Booth M (2019) Re-interventions and re-admissions in a 13-year series following use of laparoscopic subtotal cholecystectomy. J Minim Access Surg. https://doi.org/10.4103/jmas.JMAS_124_19
Hirajima S, Koh T, Sakai T, Imamura T, Kato S, Nishimura Y, Soga K, Nishio M, Oguro A, Nakagawa N (2017) Utility of laparoscopic subtotal cholecystectomy with or without cystic duct ligation for severe cholecystitis. Am Surg 83:1209–1213
Ransom KJ (1998) Laparoscopic management of acute cholecystitis with subtotal cholecystectomy. Am Surg 64:955–957
Rosenberg J, Bisgaard T (2000) The difficult gallbladder: technical tips for laparoscopic cholecystectomy. Surg Laparosc Endosc Percutan Tech 10:249–252
Palanivelu C, Rajan PS, Jani K, Shetty AR, Sendhilkumar K, Senthilnathan P, Parthasarthi R (2006) Laparoscopic cholecystectomy in cirrhotic patients: the role of subtotal cholecystectomy and its variants. J Am Coll Surg 203:145–151
Bonavina L (2007) Laparoscopic subtotal cholecystectomy. J Am Coll Surg 204:337
Hubert C, Annet L, van Beers BE, Gigot JF (2010) The “inside approach of the gallbladder” is an alternative to the classic Calot’s triangle dissection for a safe operation in severe cholecystitis. Surg Endosc 24:2626–2632
Jeong IO, Kim JY, Choe YM, Choi SK, Heo YS, Lee KY, Kim SJ, Cho YU, Ahn SI, Hong KC, Kim KR, Shin SH (2011) Efficacy and feasibility of laparoscopic subtotal cholecystectomy for acute cholecystitis. Korean J Hepatobiliary Pancreat Surg 15:225–230
Kuwabara J, Watanabe Y, Kameoka K, Horiuchi A, Sato K, Yukumi S, Yoshida M, Yamamoto Y, Sugishita H (2014) Usefulness of laparoscopic subtotal cholecystectomy with operative cholangiography for severe cholecystitis. Surg Today 44:462–465
Dissanaike S (2016) A step-by-step guide to laparoscopic subtotal fenestrating cholecystectomy: a damage control approach to the difficult gallbladder. J Am Coll Surg 223:e15-18
Harilingam MR, Shrestha AK, Basu S (2016) Laparoscopic modified subtotal cholecystectomy for difficult gall bladders: a single-centre experience. J Minim Access Surg 12:325–329
Kulen F, Tihan D, Duman U, Bayam E, Zaim G (2016) Laparoscopic partial cholecystectomy: a safe and effective alternative surgical technique in “difficult cholecystectomies.” Ulus Cerrahi Derg 32:185–190
Yoon PD, Pang T, Siriwardhane M, Richardson A, Hollands M, Pleass H, Johnston E, Yuen L, Lam V (2016) Laparoscopic partial cholecystectomy: a way of getting out of trouble. Int J Hepatobiliary Pancreat Dis 6:68–75
Shin M, Choi N, Yoo Y, Kim Y, Kim S, Mun S (2016) Clinical outcomes of subtotal cholecystectomy performed for difficult cholecystectomy. Ann Surg Treat Res 91:226–232
Shingu Y, Komatsu S, Norimizu S, Taguchi Y, Sakamoto E (2016) Laparoscopic subtotal cholecystectomy for severe cholecystitis. Surg Endosc 30:526–531
Abdelrahim WE, Elsiddig KE, Wahab AA, Saad M, Saeed H, Khalil EAG (2017) Subtotal laparoscopic cholecystectomy influences the rate of conversion in patients with difficult laparoscopic cholecystectomy: case series. Ann Med Surg (Lond) 19:19–22
Jara G, Rosciano J, Barrios W, Vegas L, Rodriguez O, Sanchez R, Sanchez A (2017) Laparoscopic subtotal cholecystectomy: a surgical alternative to reduce complications in complex cases. Cir Esp 95:465–470
Lidsky ME, Speicher PJ, Ezekian B, Holt EW, Nussbaum DP, Castleberry AW, Perez A, Pappas TN (2017) Subtotal cholecystectomy for the hostile gallbladder: failure to control the cystic duct results in significant morbidity. HPB 19:547–556
Matrafi MSA, Aljehani MJA, Bisri AMO, Alghamdi BSA, Almalki SAM, Alziyadi AH, Almarkhan MHN, Bukhari HSH, Ashmawi MT, Al-Anezi AM, Emam MA, Aljishi BF, Awami EKA, Anani EJ, Alnami AMQ, Abdulmohsen AS (2017) Subtotal cholecystectomy for the treatment of difficult gall bladder. EC Gastroenterol Dig Syst 3:56–61
Ozcinar B, Memisoglu E, Gok AFK, Agcaoglu O, Yanar F, Ilhan M, Yanar HT, Gunay K (2017) Damage-control laparoscopic partial cholecystectomy with an endoscopic linear stapler. Turk J Surg 33:37–39
Supit C, Supit T, Mazni Y, Basir I (2017) The outcome of laparoscopic subtotal cholecystectomy in difficult cases—a case series. Int J Surg Case Rep 41:311–314
van Dijk AH, Donkervoort SC, Lameris W, de Vries E, Eijsbouts QAJ, Vrouenraets BC, Busch OR, Boermeester MA, de Reuver PR (2017) Short- and long-term outcomes after a reconstituting and fenestrating subtotal cholecystectomy. J Am Coll Surg 225:371–379
Matsumura T, Komatsu S, Komaya K, Ando K, Arikawa T, Ishiguro S, Saito T, Osawa T, Kurahashi S, Uchino T, Yasui K, Kato S, Suzuki K, Kato Y, Sano T (2018) Closure of the cystic duct orifice in laparoscopic subtotal cholecystectomy for severe cholecystitis. Asian J Endosc Surg 11:206–211
Sormaz IC, Soytas Y, Gok AFK, Ozgur I, Avtan L (2018) Fundus-first technique and partial cholecystectomy for difficult laparoscopic cholecystectomies. Ulus Travma Acil Cerrahi Derg 24:66–70
Purzner RH, Ho KB, Al-Sukhni E, Jayaraman S (2019) Safe laparoscopic subtotal cholecystectomy in the face of severe inflammation in the cystohepatic triangle: a retrospective review and proposed management strategy for the difficult gallbladder. Can J Surg 62:402–411
Roesch-Dietlen F, Perez-Morales AG, Martinez-Fernandez S, Diaz-Roesch F, Gomez-Delgado JA, Remes-Troche JM (2019) Safety of laparoscopic subtotal cholecystectomy in acute cholecystitis. Experience in Southeast Mexico. Rev Gastroenterol Mex 84:461–466
Kohn JF, Trenk A, Denham W, Linn JG, Haggerty S, Joehl R, Ujiki MB (2020) Long-term outcomes after subtotal reconstituting cholecystectomy: a retrospective case series. Am J Surg. 220:736–740. https://doi.org/10.1016/j.amjsurg.2020.01.030
Bhattacharjee P (2005) Bile duct injuries: Mechanism and prevention. Indian J Surg 67:73–77
Chia CL, Shelat VG, Low W, George S, Rao J (2014) The use of Collatamp G, local gentamicin-collagen sponge, in reducing wound infection. Int Surg 99:565–570
Isherwood J, Oakland K, Khanna A (2019) A systematic review of the aetiology and management of post cholecystectomy syndrome. Surgeon 17:33–42
Singh A, Kapoor A, Singh RK, Prakash A, Behari A, Kumar A, Kapoor VK, Saxena R (2018) Management of residual gall bladder: A 15-year experience from a north Indian tertiary care centre. Ann Hepatobiliary Pancreat Surg 22:36–41
Gupta V, Sharma AK, Kumar P, Gupta M, Gulati A, Sinha SK, Kochhar R (2019) Residual gall bladder: an emerging disease after safe cholecystectomy. Ann Hepatobiliary Pancreat Surg 23:353–358
Randi G, Franceschi S, La Vecchia C (2006) Gallbladder cancer worldwide: geographical distribution and risk factors. Int J Cancer 118:1591–1602
Mak MHW, Chew WL, Junnarkar SP, Woon WWL, Low J-K, Huey TCW, Shelat VG (2019) Patient reported outcomes in elective laparoscopic cholecystectomy. Ann Hepatobiliary Pancreat Surg 23:20–33
Amirthalingam V, Low JK, Woon W, Shelat V (2017) Tokyo Guidelines 2013 may be too restrictive and patients with moderate and severe acute cholecystitis can be managed by early cholecystectomy too. Surg Endosc 31:2892–2900
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Disclosures
Drs. Koo, Chan, and Shelat have no conflicts of interest or financial ties to disclose.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Rights and permissions
About this article
Cite this article
Koo, J.G.A., Chan, Y.H. & Shelat, V.G. Laparoscopic subtotal cholecystectomy: comparison of reconstituting and fenestrating techniques. Surg Endosc 35, 1014–1024 (2021). https://doi.org/10.1007/s00464-020-08096-0
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00464-020-08096-0