Subtotal Cholecystectomy

Subtotal Cholecystectomy

David Ray Velez, MD

Table of Contents

Definitions
Procedures
   – Fenestrating Technique
   – Reconstituting Technique

See Also:

*See Cholecystectomy

Definitions

Definitions

  • Subtotal Cholecystectomy: Removal of Almost All of the Gallbladder
  • Partial Cholecystectomy: Removal of Only Part of the Gallbladder
    • Quantitively Less Than a Subtotal Cholecystectomy Although Often Used Interchangeably
  • Fundectomy: Removal of Only the Top-Half or Less of the Gallbladder

Types of Subtotal Cholecystectomy

  • Subtotal Fenestrating Cholecystectomy: Leaves the Lumen Open and Does Not Produce a Remnant Gallbladder
    • Generally the Preferred Technique in These Situations
  • Subtotal Reconstituting Cholecystectomy: Closes the Lumen to Produce a Small Remnant Gallbladder

Outcomes

  • Subtotal Fenestrating Cholecystectomy
    • Higher Risk of Bile Leak (14.1% vs 7.9%) – 20% Resole Spontaneously and 75% Resolve with ERCP
  • Subtotal Reconstituting Cholecystectomy
    • Higher Risk for Recurrent Stones or Remnant Cholecystitis (11.6% vs 3.1%)
  • No Difference in Bile Duct Injury, Infection, Re-Operation, or Need for Completion Cholecystectomy

Fenestrating Technique

Generally Start by Attempting a Routine Cholecystectomy and Then Transition to a Subtotal Cholecystectomy as a “Bail Out” Once Approaching a Zone of Significant Risk

Open and Drain the Gallbladder

  • Gallbladder is Opened and Drained at the Fundus
    • *Gallbladder May Already Be Perforated and Inadvertently Opened During a Difficult Dissection
  • Bile, Stones, and Debris are Suctioned or Removed

Safety Landmarks

  • The Cystic Duct/Artery are Not Dissected
  • “Line of Safety” – An Imaginary Line Extending from Rouviere’s Sulcus to the Base of Segment 4b
    • All Dissection Should Remain Superior to This “Line of Safety”
  • “Shield of McElmoyle” – Refers to the Peritoneum Overlying the Cystohepatic Triangle
    • The Bottom Lip of the Free Peritonealized Gallbladder is Left Behind to Protect from Entering the Hepatocytic Triangle

Remove the Gallbladder*

  • The Gallbladder Incision is Extended Posteriorly Around the Gallbladder Neck
  • The Anterior Wall of The Gallbladder is Completely Removed
    • The Posterior Wall is Generally Left on the Cystic Plate Although the Superior-Most Portion May Be Excised
  • Remnant Mucosa is Ablated by Cautery or Argon Beam

Completion

  • May Consider Purse-String Closure of the Cystic Duct from the Inside if Feasible – Often Foregone Due to Safety Concerns
  • Leave a Drain Near the Stump to Drain the Presumed Bile Leak (3x Risk)
  • Close the Port Sites or Laparotomy Incision

Fenestrating Subtotal Cholecystectomy

Line of Safety Above a Retracted CBD (B) 1

Reconstituting Technique

Generally Start by Attempting a Routine Cholecystectomy and Then Transition to a Subtotal Cholecystectomy as a “Bail Out” Once Approaching a Zone of Significant Risk

The Procedure is Similar to a Fenestrating Technique

Instead of Leaving Open, The Lumen is Closed with Sutures or Staplers

Reconstituting Subtotal Cholecystectomy

References

  1. Gupta V. How to achieve the critical view of safety for safe laparoscopic cholecystectomy: Technical aspects. Ann Hepatobiliary Pancreat Surg. 2023 May 31;27(2):201-210. (Liscence: CC BY-NC-4.0)