Subtotal cholecystectomy for the hostile gallbladder: failure to control the cystic duct results in significant morbidity

Abstract Background Laparoscopic cholecystectomy is a well-established surgical procedure and is one of the most commonly performed gastroenterological surgeries. Therefore, strategy for the management of rare anomalous cystic ducts should be determined. Case presentation A 56-year-old woman was admitted to our hospital owing to upper abdominal pain and diagnosed with acute cholecystitis. Magnetic resonance cholangiopancreatography suspected that several small stones in gallbladder and the right hepatic duct drained into the cystic duct. Endoscopic retrograde cholangiopancreatography confirmed the cystic duct anomaly, and an endoscopic nasobiliary drainage catheter (ENBD) was placed at the right hepatic duct preoperatively. Intraoperative cholangiography with ENBD confirmed the place of division in the gallbladder, and laparoscopic subtotal cholecystectomy was safely performed. Conclusions The present case exhibited rare right hepatic duct anomaly draining into the cystic duct, which might have caused biliary tract disorientation and bile duct injury (BDI) intraoperatively. Any surgical technique without awareness of this anomaly preoperatively might insufficiently prevent BDI, and preoperative ENBD would facilitate safe and successful surgery.

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Authors' reply: Laparoscopic subtotal cholecystectomy without cystic duct ligation (Br J Surg 2007; 94: 1527-1529)

British Journal of Surgery ◽

10.1002/bjs.6196 ◽

2008 ◽

Vol 95 (4) ◽

pp. 534-534

Author(s):

M. Booth

Keyword(s):

Cystic Duct ◽

Subtotal Cholecystectomy ◽

Duct Ligation

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Laparoscopic subtotal cholecystectomy without cystic duct ligation

British Journal of Surgery ◽

10.1002/bjs.5889 ◽

2007 ◽

Vol 94 (12) ◽

pp. 1527-1529 ◽

Cited By ~ 31

Author(s):

I. Sinha ◽

M. Lawson Smith ◽

P. Safranek ◽

T. Dehn ◽

M. Booth

Keyword(s):

Cystic Duct ◽

Subtotal Cholecystectomy ◽

Duct Ligation

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OMENTUM PIECE FOR PREVENTION OF BILE LEAKAGE AFTER SUBTOTAL CHOLECYSTECTOMY

International Journal of Medical and Biomedical Studies ◽

10.32553/ijmbs.v4i1.872 ◽

2020 ◽

Vol 4 (1) ◽

Author(s):

Kaustubh Vasant Waikar

Keyword(s):

Gall Bladder ◽

Acute Cholecystitis ◽

Cystic Duct ◽

Primary Closure ◽

Bile Leak ◽

Bile Leakage ◽

Greater Omentum ◽

Closure Technique ◽

Subtotal Cholecystectomy ◽

History Of

Introduction: Acute cholecystitis is an acute inflammatory condition of the gallbladder of which 95% of cases of acute cholecystitis are due to an obstructing calculus in the gallbladder neck or cystic duct. Acute cholecystitis and difficult gall bladder have severe inflammation and anatomical deformities i.e. empyema, Mirizzi syndrome and sometimes gangrene. In recent years, there is an increasing trend towards subtotal cholecystectomy and general acceptance is higher due to higher incidence of complications in difficult gall bladder. Although, the results of subtotal cholecystectomy are satisfactory but the post-operative bile leak is a problem of great concern. There are many techniques that have been adopted, but bile leakage compared to closing of cystic duct directly is very high in subtotal cholecystectomy. Material and Methods: The Omentum Plugging Technique (OPT) and Primary Closure Technique (PCT) was done to prevent bile leak in cases were total cholecystectomy could not be performed. Patients were included in the study with the diagnosis of cholelithiasis and patients who had undergone subtotal cholecystectomy for gallstone diseases with both OPT and PCT Technique. Under general anaesthesia patients were operated. Patients were first decompressed at the fundus with the suction and harmonic scalpel or l-hook was used for transection of gall bladder and wash was given and both the anterior and posterior walls were excised leaving an anterior and posterior wall intact and OPT, a piece of omentum that matches the size of the opening of the gallbladder stump is resected from the greater omentum and plugged into the gallbladder stump. Results: A total of 486 patients were operated, of which 36 patients (7.4%) underwent subtotal cholecystectomy because it was not possible to close their cystic ducts because they had difficult gallbladders, of which 18 patients in taken in OPT and 18 patients taken in PCT group. Average age in OPT group was 49.48 ± 9.59 years while in PCT group was 54.47 ± 16.21. In OPT group there were 10 (62.5%) male and 6 (37.5%) female, in PCT group 11 (68.75%) male and 5 (31.25%) female were observed. History of CBD Stone was recorded in 3 (18.75%) and 2 (12.50%) patients in OPT and PCT group respectively. No History of Abdominal Surgery was noted in both the group. Intra-operative Haemorrhage in OPT Group was 118 (16-359) ml while in PCT group was 164 (10-578) ml. Duration of Operation Time OPT Group was 156 ± 15.77 ml while in PCT group it was 105 ± 17.35 minutes. Total post-operative complications and post-operative bile leakage were seen in 2 patients in OPT group while in PCT group it was seen in 10 patients. (P= 0.0040). Post-operative intervention was done on one patient in OPT group and on 9 patients in PCT group. Mean Duration of drain was 3.5 ± 1.24 days in OPT group and 8.59 ± 2.46 days in PCT group (P< 0.0001). Post-operative hospital stay was 8.84 ± 2.14days in OPT group and 13.45 ± 2.11days (P< 0.0001). Conclusion: In a difficult gall bladder SC is required during cholecystectomy and for prevention of postoperative bile leakage OPT technique can be safe and more feasible alternative than conventional procedures. Keywords: Subtotal cholecystectomy (SC), Omentum Plugging Technique (OPT), Primary Closure Technique (PCT), gall bladder.

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Laparoscopic Management of Remnant Cystic Duct Calculi: A Retrospective Study

Annals of The Royal College of Surgeons of England ◽

10.1308/003588409x358980 ◽

2009 ◽

Vol 91 (1) ◽

pp. 25-29 ◽

Cited By ~ 39

Author(s):

Chinnusamy Palanivelu ◽

Muthukumaran Rangarajan ◽

Priyadarshan Anand Jategaonkar ◽

Madhupalayam Velusamy Madankumar ◽

Natesan Vijay Anand

Keyword(s):

Bile Duct ◽

Common Bile Duct ◽

Cystic Duct ◽

Imaging Modality ◽

Operating Time ◽

Laparoscopic Management ◽

Subtotal Cholecystectomy ◽

Laparoscopic Excision ◽

The Common ◽

The Mean

INTRODUCTION Even though cholecystectomy relieves symptoms in the majority of cases, a significant percentage suffer from ‘postcholecystectomy syndrome’. Cystic duct/gall bladder remnant calculi is a causative factor. We present our experience with the laparoscopic management of cystic duct remnant calculi. PATIENTS AND METHODS We managed 15 patients with cystic duct remnant calculi from 1996 to 2007 in our institute. All these patients had earlier undergone laparoscopic subtotal cholecystectomy at our centre. They were successfully managed by laparoscopic excision of the remnant. RESULTS The mean duration between first and second surgery was 8.35 months (range, 6–10.7 months). The mean operating time was 103.5 min (range, 75–132 min). Duration of hospital stay was 4–12 days. There was a higher incidence of remnant duct calculi following laparoscopic subtotal cholecystectomy than conventional laparoscopic cholecystectomy 13/310 (4.19%) versus 2/9590 (0.02%). The morbidity was 13.33%, while there were no conversions and no mortality. CONCLUSIONS Leaving behind a cystic duct stump for too long predisposes stone formation, while dissecting too close to the common bile duct and right hepatic artery in acute inflammatory conditions is dangerous. We believe that the former is a wiser policy to follow, as cystic duct remnant calculi are easier to manage than common bile duct or vessel injury. Laparoscopic excision of the remnant is effective, especially when performed by experienced laparoscopists. ‘T’-tube is used to canulate the common bile duct in case the tissue is friable. Magnetic resonance cholangiopancreaticography is the imaging modality of choice, and is mandatory.

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Laparoscopic subtotal cholecystectomy for difficult cases of acute cholecystitis: a simple technique using barbed sutures

Surgical Case Reports ◽

10.1186/s40792-020-01026-1 ◽

2020 ◽

Vol 6 (1) ◽

Author(s):

Sho Fujiwara ◽

Kenji Kaino ◽

Kazuki Iseya ◽

Nozomi Koyamada

Keyword(s):

Laparoscopic Cholecystectomy ◽

Acute Cholecystitis ◽

Cystic Duct ◽

Severe Heart Failure ◽

Pathological Diagnosis ◽

Barbed Suture ◽

Barbed Sutures ◽

Subtotal Cholecystectomy ◽

Grade Ii

Abstract Background Laparoscopic cholecystectomy (LC) for difficult acute cholecystitis (AC) cases bears a high risk of vasculobiliary injuries (VBI). The Tokyo Guidelines 2018 (TG18) recommend the use of bailout procedures and subtotal cholecystectomy to prevent VBI. Performing a safe LC is challenging, even when followed by an accurate pre-surgical assessment. Laparoscopic cholecystectomy (LSC) requires advanced skills, and there is a risk of recurrence of cancer and/or gallbladder stones (GBS) in the remnant gallbladder (GB). Moreover, it is sometimes impossible to safely close the cystic duct with either a loop tie or linear staples because of anatomical and fragility problems. Here, we report a novel technique employing barbed sutures for LSC in difficult AC cases. Case presentation We performed urgent LSC using barbed sutures for the stump of the cystic duct in two patients. In preoperative assessments, we found that these cases were qualified for operations rather than GB drainages, but the cystic ducts appeared difficult to close due to their severe inflammation and fragility during the operations. We applied barbed suture as a surrogate technique to close the stump of cystic duct. In patient 1, a 67-year-old woman with severe heart failure and type 2 diabetes mellitus was diagnosed with grade III AC. Pathological diagnosis was gangrenous cholecystitis. In patient 2, a 68-year-old woman who was referred to our hospital after 15 days of treatment for AC with antibiotics without drainage. The severity of AC was grade II according to TG18. Pathological diagnosis was acute-on-chronic cholecystitis. Both patients were discharged without complication. Conclusions The utilization of barbed sutures in LSC stems as a feasible and safe surrogate technique. Furthermore, this approach could decrease the risks associated with the remnant GB.

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Late postcholecystectomy Mirizzi syndrome due to a sessile gall bladder remnant calculus managed by laparoscopic completion cholecystectomy: a feasible surgical option

BMJ Case Reports ◽

10.1136/bcr-2018-228156 ◽

2019 ◽

Vol 12 (8) ◽

pp. e228156 ◽

Cited By ~ 2

Author(s):

Gunjan S Desai ◽

Prasad Pande ◽

Rajvilas Narkhede ◽

Prasad Wagle

Keyword(s):

Gall Bladder ◽

Cystic Duct ◽

Mirizzi Syndrome ◽

Algorithmic Approach ◽

Postcholecystectomy Syndrome ◽

Laparoscopic Management ◽

Subtotal Cholecystectomy ◽

Surgical Clip ◽

Surgical Option

Postcholecystectomy Mirizzi syndrome (PCMS) is an uncommon entity that can occur due to cystic duct stump calculus, gall bladder remnant calculus or migrated surgical clip. It can be classified into early PCMS or late PCMS. It is often misdiagnosed and the management depends on the site of impaction of stone or clip. Endoscopy can be performed for cystic duct stump calculus. However, surgery is the treatment for remnant gall bladder calculus. Role of laparoscopic management is controversial. We present here a case of a 48-year-old woman with late PCMS due to an impacted calculus in a sessile gall bladder remnant following a subtotal cholecystectomy, managed with laparoscopic completion cholecystectomy, review the literature, provide tips for safe laparoscopy for PCMS and summarise our algorithmic approach to the management of the postcholecystectomy syndrome.

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Utility of Laparoscopic Subtotal Cholecystectomy with or without Cystic Duct Ligation for Severe Cholecystitis

The American Surgeon ◽

10.1177/000313481708301121 ◽

2017 ◽

Vol 83 (11) ◽

pp. 1209-1213 ◽

Cited By ~ 3

Author(s):

Shoji Hirajima ◽

Toshimori Koh ◽

Tomohito Sakai ◽

Taisuke Imamura ◽

Shunji Kato ◽

...

Keyword(s):

Cystic Duct ◽

Open Cholecystectomy ◽

Gallbladder Disease ◽

Long Term Outcomes ◽

Operative Blood Loss ◽

Subtotal Cholecystectomy ◽

Calot’S Triangle ◽

Duct Ligation ◽

Hospitalization Period

We use open cholecystectomy (OC) to treat severe cholecystitis in cases in which we are worried that inflammation might cause anatomical changes in Calot's triangle. Furthermore, in cases of severe cholecystitis in which marked inflammation leads to fibrosis, we perform subtotal cholecystectomy (SC), i.e., incomplete gallbladder resection. Laparoscopic SC (LSC) without cystic duct dissection is considered to be effective at reducing the incidence of serious complications in patients with severe cholecystitis. The cases of 246 patients who underwent cholecystectomy for benign gallbladder disease between January 2011 and May 2015 were evaluated retrospectively. Of these patients, 14 were treated with LSC, and 19 underwent OC. Moreover, three patients in the LSC group underwent LSC without cystic duct ligation because it was considered that it would be difficult to dissect and ligate the cystic duct. The LSC group suffered significantly less intra-operative blood loss than the OC group. However, the operative times of the two groups were similar. Moreover, the duration of the postoperative hospitalization period was significantly shorter in the LSC group than in the OC group. Next, we compared the long-term outcomes of the SC and total cholecystectomy groups, regardless of the surgical method. No cases of cholecystitis or gallbladder cancer were encountered in either group. It is suggested that LSC is safe, effective, and helps to prevent serious complications in cases of severe cholecystitis that require conversion to OC, regardless of whether cystic duct ligation is performed.

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