Introduction

Laparoscopic cholecystectomy has replaced open cholecystectomy as the surgical procedure of choice for treating symptomatic gallstones. Whichever approach is used, performing standard cholecystectomy requires safe dissection of the structures in Calot’s triangle. This becomes difficult in the presence of acute or chronic inflammation, dense omental adhesions or gangrene of the gallbladder, resulting in higher rates of bile duct injury [1]. The traditional response to encountering a difficult laparoscopic cholecystectomy procedure is to perform conversion to an open procedure; however, this may result in increased postoperative pain, delayed mobility, prolonged hospitalization, adhesion formation and incisional hernia formation. In addition, conversion does not necessarily improve exposure or facilitate cystic duct identification [2]. Laparoscopic subtotal cholecystectomy (LSC) has been reported to be a safe and feasible alternative to conversion to open surgery during difficult laparoscopic cholecystectomy [1, 3–6]. These reports describe the use of excision of the anterior wall of the gallbladder, largely as a means of preventing undue bleeding from the gallbladder fossa. The present study assessed the feasibility of performing LSC with operative cholangiography, thus avoiding the need for potentially hazardous dissection in the area of Calot’s triangle and confirming the existence of a common bile duct stone. We herein assessed the safety and effectiveness of this approach.

Materials and methods

Patients

All patients who underwent laparoscopic cholecystectomy at our hospital between January 1, 2005 and December 31, 2008 were included in this study. All patients underwent laparoscopic cholecystectomy after recovering from severe inflammation of the gallbladder [7]. The case notes for patients who underwent LSC were retrieved and analyzed for demographic data, operative findings, the duration of the procedure, the duration of hospitalization, complications and long-term outcomes.

Operative procedure

First, we divided the gallbladder neck and Calot’s triangle. After skeletonizing the cystic duct and artery, operative cholangiography was attempted in all patients. The cystic duct and artery were closed using clips or ligation. When significant difficulties were encountered in dissecting the gallbladder neck and Calot’s triangle and further dissection would expose the patient to a higher risk of common bile duct injury or hemorrhage, the cystic duct was not isolated. Total cholecystectomy was performed even if the inflammation was severe. The operative method was changed to subtotal cholecystectomy when the operation was judged to be excessively high risk. We often performed cholangiography by puncturing the gallbladder or cannulating the cystic duct from inside the gallbladder after incising the gallbladder neck wall (Fig. 1). We then gradually excised the anterior wall of the gallbladder and sutured the wall of the gallbladder neck using forceps for laparoscopic surgery (knocked suturing). The inferior wall was cauterized with the electric scalpel to prevent relapse of cholecystolithiasis. A subhepatic drain was often placed.

Fig. 1
figure 1

Laparoscopic subtotal cholecystectomy. The cystic duct is cannulated from inside the gallbladder after incising the gallbladder neck wall

Full size image

Results

LSC was performed in 26 patients (eight females, 18 males). During the 48-month study period, 246 laparoscopic cholecystectomies were performed at our institution. The incidence of LSC was therefore 10.6 %. The median age at the time of surgery was 69 years (range 43–82 years). The median duration from the onset of symptoms to surgery was 81 days (range 12–231 days). All patients, who were unable to undergo early surgery, were receiving antibiotics and exhibited an acute condition. Percutaneous transhepatic gallbladder drainage (PTGBD) was performed preoperatively in four patients (Table 1). The median operative time was 125 min (range 60–215 min). The median duration of postoperative hospitalization was 6 days (range 3–21 days). Subhepatic drains were placed in 15 patients and remained in situ for a median of 2 days (range 1–3 days). Operative cholangiography was performed in 24 patients. Two patients were unable to undergo this evaluation due to cystic duct obstruction.

Table 1 Patient characteristics
Full size table

One patient underwent postoperative EST for a retained common bile duct stone diagnosed on operative cholangiography. The underlying pathology was acute cholecystitis in four cases and chronic cholecystitis in 22 cases. No malignancies were found in any case. No complications or conversion to open surgery were encountered (Table 2).

Table 2 Outcomes
Full size table

Discussion

Safely dissecting the structures in Calot’s triangle, when treating cases of cholecystitis, can pose a considerable challenge in both laparoscopic and open procedures. During open surgery, partial cholecystectomy with drainage of the gallbladder stump is occasionally used when the tissues in Calot’s triangle prove hostile [8]. As in many other areas of surgical practice, the lessons of open surgery can be relearned and adapted to laparoscopy. The present results show that LSC represents a viable alternative to open conversion when performing dissection of Calot’s triangle is deemed unsafe.

The primary reasons for conversion include factors such as difficulties in dissecting the tissues of Calot’s triangle, an unclear anatomy, bleeding from the gallbladder fossa and bile duct injury [9, 10]. In the early edematous phase that occurs within 3–4 days from symptom onset, a plane exists between the gallbladder and surrounding viscera that assists in dissection [11]. Conversely, scarring and dense fibrotic adhesions render performing dissection more difficult in the delayed phase, increasing the conversion rate. Many reports thus recommend performing surgery early, within 3–4 days after symptom onset [12–15]. However, many patients are actually referred to the department of surgery after this early period and, therefore undergo elective surgery. In this study, the duration from the onset of symptoms to surgery was more than 2 months. Using methods to decrease the conversion rate is necessary in patients undergoing elective laparoscopic cholecystectomy for acute cholecystitis.

Twenty-two patients in this study were discharged within 1 week after undergoing surgery. Importantly, no wound infections were identified in any patient undergoing LSC. Our study group was relatively small; however, this finding may simply reflect the reduced wound infection rates observed in laparoscopic surgery [16].

When performing subtotal cholecystectomy, dissecting and ligating the cystic duct are very difficult. Using methods to close the cystic duct and prevent postoperative bile leakage is thus crucial. In this study, when significant difficulty was encountered in dissecting the gallbladder neck and Calot’s triangle, we changed the procedure, suturing the remnant wall in the gallbladder neck for closure instead of ligating the cystic duct.

Intraoperative cholangiography is useful for improving the safety of LSC. In fact, no complications were encountered in the present study. One patient underwent postoperative EST for a retained common bile duct stone diagnosed on intraoperative cholangiography. Therefore, this procedure appears to help clinicians to understand the anatomy of the bile duct and avoid complications.

We cut open the part identified as most likely representing the cystic duct and performed operative cholangiography. If this process can correct a diagnosis intraoperatively, even if symptoms of common bile duct injury are identified, the damage can at least be stopped. As biliary tract problems can develop postoperatively, operative cholangiography should be performed in as many patients as possible.

One study reported a risk of conversion of 36.0 % and an overall incidence of postoperative complications of 18.5 % in patients with severe acute cholecystitis treated with laparoscopic cholecystectomy [17]. In comparison to the present findings, a previous study evaluating the use of LSC without operative cholangiography reported a similar postoperative patient stay and median operative time, with a superior rate of conversion and fewer complications [18]. Performing LSC with operative cholangiography appears to be a very useful manual skill.

One of the problems of LSC is that patients exhibiting complications of gallbladder cancer are not identified preoperatively. Gallbladder cancer is reportedly found unexpectedly in 0.2–0.8 % of patients undergoing laparoscopic cholecystectomy [19, 20]. If the gallbladder wall is cut open in patients with gallbladder cancer, abdominal dissemination and remnant tumors are always observed. In our series of LSC, no cases of unexpected gallbladder cancer were identified. No reports have described diagnosing gallbladder cancer after LSC at our hospital. Distinguishing gallbladder tumors from simple inflammatory wall thickness can be difficult. At our institute, we carefully examine the thickness of the gallbladder wall preoperatively, and when laboratory findings, such as ultrasonography, contrast-enhanced computed tomography or tumor markers, show results suspicious of cancer, we perform open cholecystectomy. When even the slight suspicion of cancer is present, we perform laparoscopic total cholecystectomy, taking care to prevent leakage of bile juice. The rate of gallbladder cancer recurrence increases when the gallbladder is punctured intraoperatively and pancreatic juice leaks into the peritoneal cavity [19]. LSC should not be performed in patients with gallbladders with an increased wall thickness due to cancer, and gallbladder tumors must be excluded preoperatively. The use of LSC should thus be restricted to patients with benign gallbladders in which dissecting the neck and wall is difficult. Providing additional treatment can be considered when cancer is diagnosed on pathological examinations after surgery. General treatments for gallstones include bile duct resection, liver floor excision, lymph node dissection and port site excision.

We do not advocate the use of LSC as a routine procedure or consider it to be a substitute for the presence of an experienced and skilled laparoscopic surgeon. However, we have demonstrated that LSC is a viable technique that reduces the risk of bile duct injury in the most difficult cases of emergency or elective cholecystectomy while maintaining the other benefits of a laparoscopic approach.

Performing LSC for acute cholecystitis is safe and particularly effective in patients unable to undergo early surgery. Using this procedure, if difficulty is encountered when dissecting the neck and Calot’s triangle, isolating the cystic duct is unnecessary; and the conversion rate decreases by devising suitable treatments of the gallbladder neck. Although our method has shown good results with minimal invasiveness, the risk of recurrence of gallstones cannot be completely denied. Ablation of the mucosa of the gallbladder may indeed minimize the recurrence of gallstones; however, we should evaluate the outcomes based on the long-term follow-up.