The Difficult Cholecystectomy

  • Nathaniel Stoikes
  • L. Michael BruntEmail author


A number of conditions can be associated with increased difficulty of cholecystectomy. These include acute cholecystitis, severe chronic cholecystitis, Mirizzi syndrome, cirrhosis, and other non-gallbladder-related factors such as morbid obesity and extensive previous upper abdominal surgery. Preoperative recognition and awareness as well as modifications of technical strategies are important to a successful outcome and avoiding major complications in these patients. Percutaneous cholecystostomy tube drainage is an important option in patients with severe acute cholecystitis who are too high risk to undergo surgery. At operation, if it is not possible to obtain the critical view of safety, an operative bailout strategy should be considered such as surgical tube cholecystostomy, laparoscopic subtotal cholecystostomy, conversion to an open operation, or aborting the procedure. This chapter will review conditions that increase the difficulty of cholecystectomy and will highlight technical modifications one can employ to enhance the safety of cholecystectomy in these patients.


Difficult cholecystectomy Critical view Fenestrated Non-fenestrated Cholecystitis 


  1. 1.
    Strasberg S, Hertl M, Soper N. The analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg. 1995;180:101–25.PubMedPubMedCentralGoogle Scholar
  2. 2.
    Strasberg SM, Brunt LM. Rationale and use of the critical view of safety in laparoscopic cholecystectomy. J Am Coll Surg. 2010;211(1):132–8.CrossRefGoogle Scholar
  3. 3.
    The SAGES Safe Cholecystectomy Program. 2014.
  4. 4.
    Pucher PH, Brunt LM, Fanelli RD, et al. SAGES expert Delphi consensus: critical factors for safe surgical practice in laparoscopic cholecystectomy. Surg Endosc. 2015;29(11):3074–85.CrossRefGoogle Scholar
  5. 5.
    Panni RZ, Strasberg SM. Preoperative predictors of conversion as indicators of local inflammation in acute cholecystitis: strategies for future studies to develop quantitative predictors. J Hepatobiliary Pancreas Sci. 2018;25:101–8. Scholar
  6. 6.
    Augustin T, Moslim MA, Brethauer S, et al. Obesity and its implications for morbidity and mortality after cholecystectomy: a matched NSQIP analysis. Am J Surg. 2017;213:539.CrossRefGoogle Scholar
  7. 7.
    Strasberg SM. Clinical practice. Acute calculous cholecystitis. N Engl J Med. 2008;358:2804.CrossRefGoogle Scholar
  8. 8.
    Yokoe M, Hata J, Strasberg SM, et al. Tokyo guidelines 2018: diagnostic criteria and severity of grading of acute cholecystitis. J HBP Surg. 2018;25:42–54.Google Scholar
  9. 9.
    Gutt CN, Encke J, Köninger J, et al. Acute cholecystitis: early versus delayed cholecystectomy, a multicenter randomized trial (ACDC study, NCT00447304). Ann Surg. 2013;258:385.CrossRefGoogle Scholar
  10. 10.
    de Mestral C, Rotstein OD, Laupacis A, et al. Comparative operative outcomes of early and delayed cholecystectomy for acute cholecystitis: a population-based propensity score analysis. Ann Surg. 2014;259:10.CrossRefGoogle Scholar
  11. 11.
    Zafar SN, Obirieze A, Adesibikan B, et al. Optimal time for early laparoscopic cholecystectomy for acute cholecystitis. JAMA Surg. 2015;150:129.CrossRefGoogle Scholar
  12. 12.
    Roulin D, Saadi A, Di Mare L, et al. Early versus delayed cholecystectomy for acute cholecystitis, are the 72 hours still the rule?: a randomized trial. Ann Surg. 2016;264:717.CrossRefGoogle Scholar
  13. 13.
    Cao AM, Eslick GD, Cox MR. Early cholecystectomy is superior to delayed cholecystectomy for acute cholecystitis: a meta-analysis. J Gastrointest Surg. 2015;19:848.CrossRefGoogle Scholar
  14. 14.
    Wu XD, Tian X, Liu MM, et al. Meta-analysis comparing early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Br J Surg. 2015;102:1302.CrossRefGoogle Scholar
  15. 15.
    Cengiz Y, Dalenback J, Edlund G, et al. Improved outcomes after laparoscopic cholecystectomy with ultrasound dissection: a randomized multicenter trial. Surg Endocsc. 2010;24:624–30.CrossRefGoogle Scholar
  16. 16.
    Testini M, Sgaramella LI, De Luca GM, et al. Management of Mirizzi syndrome in emergency. J Laparoendosc Adv Surg Tech A. 2017;27:28.CrossRefGoogle Scholar
  17. 17.
    Erben Y, Benavente-Chenhalls LA, Donohue JM, et al. Diagnosis and treatment of Mirizzi syndrome: 23-year Mayo Clinic experience. J Am Coll Surg. 2011;213:114.CrossRefGoogle Scholar
  18. 18.
    Kulkarni SS, Hotta M, Sher L, et al. Complicated gallstone disease: diagnosis and management of Mirizzi syndrome. Surg Endosc. 2017;31:2215.CrossRefGoogle Scholar
  19. 19.
    Antoniou SA, Antoniou GA, Makridis C. Laparoscopic treatment of Mirizzi syndrome: a systematic review. Surg Endosc. 2010;24:33.CrossRefGoogle Scholar
  20. 20.
    Delis S, Bakoyiannis A, Madariaga J, et al. Laparoscopic cholecystectomy in cirrhotic patients: the value of MELD score and Child-Pugh classification in predicting outcome. Surg Endosc. 2010;24:407.CrossRefGoogle Scholar
  21. 21.
    Machado NO. Laparoscopic cholecystectomy in cirrhotics. JSLS. 2012;16:392.CrossRefGoogle Scholar
  22. 22.
    Puggioni A, Wong LL. A metaanalysis of laparoscopic cholecystectomy in patients with cirrhosis. J Am Coll Surg. 2003;197:921.CrossRefGoogle Scholar
  23. 23.
    Currò G, Iapichino G, Melita G, et al. Laparoscopic cholecystectomy in Child-Pugh class C cirrhotic patients. JSLS. 2005;9:311.PubMedPubMedCentralGoogle Scholar
  24. 24.
    Hamad MA, Thabet M, Badawy A, et al. Laparoscopic versus open cholecystectomy in patients with liver cirrhosis: a prospective, randomized study. J Laparoendosc Adv Surg Tech A. 2010;20:405.CrossRefGoogle Scholar
  25. 25.
    Melloul E, Denys A, Demartines N, et al. Percutaneous drainage versus emergency cholecystectomy for treatment of acute cholecystitis in critically ill patients: does it matter? World J Surg. 2011;35:826–33.CrossRefGoogle Scholar
  26. 26.
    Hsieh YC, Chun-Ku C, Chien-Wei S, et al. Outcome after percutaneous cholecystostomy for acute cholecystitis: a single center experience. J Gastrointest Surg. 2012;16:1860–8.CrossRefGoogle Scholar
  27. 27.
    Chang YR, Young-Joon A, Jang JY, et al. Percutaneous cholecystostomy for acute cholecystitis in patients with high comorbidity and re-evaluation of treatment efficacy. Surgery. 2014;155:615–22.CrossRefGoogle Scholar
  28. 28.
    El-Gendi A, El-Shafei M, Emara D. Emergency versus delayed cholecystectomy after percutaneous transhepatic gallbladder drainage in grade II acute cholecystitis patients. J Gastrointest Surg. 2017;21:284–93.CrossRefGoogle Scholar
  29. 29.
    Alvino DML, Fong ZV, McCarthy CJ, et al. Long-term outcomes following percutaneous cholecystostomy tube placement for treatment of acute calculous cholecystitis. J Gastrointest Surg. 2017;21:761.CrossRefGoogle Scholar
  30. 30.
    Abi-Haidar Y, Sanchez V, Williams SA, et al. Revisiting percutaneous cholecystostomy for acute cholecystitis based on 10-year experience. Arch Surg. 2012;147:416–21.CrossRefGoogle Scholar
  31. 31.
    Simorov A, Ranade A, Parcells J, et al. Emergent cholecystostomy is superior to open cholecystectomy in extremely ill patients with acalculous cholecystitis: a large multicenter outcome study. Am J Surg. 2013;206:935–41.CrossRefGoogle Scholar
  32. 32.
    Dimou FM, Adhikari D, Mehta HB, et al. Outcomes in older patients with grade III cholecystitis and cholecystostomy tube placement: a propensity score analysis. J Am Coll Surg. 2017;224:502–14.CrossRefGoogle Scholar
  33. 33.
    Cherng N, Witkowski ET, Sneider EB, et al. Use of cholecystostomy tubes in the management of patients with primary diagnosis of acute cholecystitis. J Am Coll Surg. 2012;214:196–201.CrossRefGoogle Scholar
  34. 34.
    Navez B, Ungureanu F, Michiels M, et al. Surgical management of acute cholecystitis: results of a 2-year prospective multicenter survey in Belgium. Surg Endosc. 2012;26(9):2436–45.CrossRefGoogle Scholar
  35. 35.
    Strasberg SM, Pucci MJ, Brunt LM, Deziel DJ. 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. 2016;222(1):89–96.PubMedPubMedCentralGoogle Scholar
  36. 36.
    van Dijk AH, Donkervoort SC, Lameris W, et al. Short and long-term outcomes after a reconstituting and fenestrating subtotal cholecystectomy. J Am Coll Surg. 2017;225(3):371–9.CrossRefGoogle Scholar

Copyright information

© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020

Authors and Affiliations

  1. 1.Section of Minimally Invasive SurgeryUniversity of Tennessee – MemphisMemphisUSA
  2. 2.Section of Minimally Invasive SurgeryWashington University School of Medicine, Barnes-Jewish HospitalSaint LouisUSA

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