Overview
Definition:
Subtotal cholecystectomy is a surgical technique where the majority of the gallbladder is removed, leaving the cystic duct stump and a portion of the gallbladder wall (mucosa or seromuscular layer) in situ, primarily employed when complete dissection is unsafe due to severe inflammation, adhesions, or anatomical distortion.
Epidemiology:
The incidence of hostile gallbladders requiring subtotal cholecystectomy varies significantly, but it is encountered in approximately 2-10% of all cholecystectomies, with higher rates in cases of acute cholecystitis, prior abdominal surgery, or chronic inflammation.
Clinical Significance:
Choosing between subtotal and total cholecystectomy is crucial for patient safety, particularly in complex cases
A hostile gallbladder presents a high risk of intraoperative bile duct injury (BDI) and bleeding
Subtotal cholecystectomy offers a safer alternative when complete dissection is perilous, aiming to reduce morbidity and mortality while still addressing the primary pathology.
Indications
Absolute Indications:
Inability to identify critical structures (cystic duct, common bile duct) due to severe inflammation, edema, fibrosis, or adhesions
Rock-hard gallbladder with dense pericholecystic scarring
Intraoperative bleeding that compromises visualization of the critical view of safety
Perforation of the gallbladder with extensive contamination
Suspected malignancy in the gallbladder wall that prevents safe dissection.
Relative Indications:
Dense adhesions from previous surgery or inflammation
Extensive xanthogranulomatous cholecystitis
Acute cholecystitis with significant edema making dissection difficult
Tortuous or aberrant anatomy of the cystic duct or arteries
Limited surgeon experience in managing extremely difficult cases.
Contraindications:
Known or suspected gallbladder carcinoma requiring en bloc resection
Complete obstruction of the cystic duct without possibility of adequate decompression or drainage
Uncontrolled coagulopathy or sepsis that makes any prolonged procedure unsafe
Patient refusal of alternative surgical approaches.
Preoperative Preparation
Imaging Assessment:
Preoperative ultrasound to assess gallbladder wall thickness, stones, and surrounding structures
CT scan or MRI may be used to evaluate extent of inflammation, adhesions, and potential vascular anomalies in severely hostile cases.
Laboratory Evaluation:
Complete blood count (CBC) to assess for leukocytosis and anemia
Liver function tests (LFTs) to evaluate for cholestasis or hepatic dysfunction
Coagulation profile (PT/INR, aPTT) to assess bleeding risk
Serum electrolytes and renal function tests.
Antibiotic Prophylaxis:
Broad-spectrum intravenous antibiotics should be administered preoperatively, typically covering gram-negative and anaerobic organisms
Common regimens include cefazolin with metronidazole or piperacillin-tazobactam, depending on local resistance patterns and patient allergies.
Informed Consent:
Detailed discussion with the patient about the possibility of subtotal cholecystectomy, the rationale behind it, potential risks including retained stones, gallbladder remnant dysfunction, recurrent inflammation, and the need for potential future intervention
The possibility of conversion to open surgery should also be discussed.
Surgical Technique
Laparoscopic Subtotal Cholecystectomy:
After achieving adequate exposure, if dissection of Calot's triangle is impossible, the fundus and anterior wall are incised
Stones are removed, and the gallbladder mucosa is debrided as much as possible
The anterior wall remnant is then stapled or sutured, leaving the posterior wall and cystic duct stump intact
Sometimes, an open approach is required if laparoscopy is too challenging.
Open Subtotal Cholecystectomy:
A subcostal or midline incision may be used
Similar to the laparoscopic approach, the fundus is opened, stones are removed, and the mucosa is debrided
The remnant is then closed, leaving the posterior wall and cystic duct stump
This approach can offer better tactile feedback and control in extremely difficult dissections.
Drainage And Closure:
A drain may be placed in the gallbladder fossa if there is significant oozing or concern for bile leak from the stump
The abdominal incision is closed in layers
Meticulous hemostasis is crucial throughout the procedure.
Management Of Remnant
Mucosal Debridement:
Thorough removal of the gallbladder mucosa is essential to minimize the risk of retained stones and future inflammation
This can be achieved with sharp dissection, electrocautery, or endoscopic tools.
Cystic Duct Stump Management:
The cystic duct stump is typically ligated or stapled
It is important to ensure adequate closure to prevent bile leakage
If the stump is severely inflamed or distorted, clips may be preferred over sutures.
Drainage Of Remnant:
In some cases, particularly if significant inflammation persists or if there is concern for retained stones, a drain can be placed through the remnant into the common bile duct or left in the fossa
This is usually removed postoperatively once drainage is minimal and LFTs are stable.
Postoperative Care And Follow Up
Pain Management:
Adequate analgesia is required, usually with intravenous or oral opioids and NSAIDs as needed
Patient-controlled analgesia (PCA) may be beneficial in the immediate postoperative period.
Antibiotics:
Continue intravenous antibiotics if there was significant contamination or if the patient developed signs of infection
Oral antibiotics may be continued for a short duration post-discharge based on the intraoperative findings.
Mobilization And Diet:
Early mobilization is encouraged to prevent complications like deep vein thrombosis (DVT) and pneumonia
Patients can usually resume a clear liquid diet postoperatively, progressing to a regular diet as tolerated.
Follow Up Schedule:
Outpatient follow-up is typically scheduled at 2-4 weeks postoperatively to assess wound healing, pain, and overall recovery
Subsequent follow-up may involve LFT monitoring and imaging if symptomatic
Surveillance for retained stones or recurrent symptoms is important.
Complications
Early Complications:
Bile leak from the cystic duct stump or remnant
Retained stones in the gallbladder remnant or common bile duct
Postoperative bleeding
Wound infection
Postcholecystectomy syndrome (pain, nausea, diarrhea).
Late Complications:
Recurrent acute cholecystitis in the remnant
Biliary stricture or stone formation in the remnant
Formation of a mucocele in the remnant
Cholangitis if stones migrate into the common bile duct
Gallstone ileus if a large stone erodes into the bowel.
Prevention Strategies:
Meticulous surgical technique, complete mucosal debridement, secure closure of the cystic duct stump, judicious use of drains, and appropriate preoperative and postoperative antibiotic use are key
Careful patient selection and intraoperative decision-making are paramount
Postoperative imaging may be considered if symptoms suggest retained stones or bile leak.
Key Points
Exam Focus:
Understand the indications for subtotal cholecystectomy versus total cholecystectomy
Recognize the critical view of safety and when it cannot be achieved
Know the different techniques of subtotal cholecystectomy (laparoscopic vs
open) and remnant management.
Clinical Pearls:
In a hostile gallbladder, prioritize patient safety over complete removal
Do not hesitate to convert to an open procedure if laparoscopic dissection becomes too risky
Always consider the possibility of retained stones in the remnant and the need for potential future interventions.
Common Mistakes:
Attempting complete dissection in a clearly hostile field, leading to bile duct injury
Inadequate mucosal debridement of the gallbladder remnant, leading to retained stones or inflammation
Poorly secured cystic duct stump, resulting in bile leak
Failure to counsel the patient adequately about the implications of subtotal cholecystectomy.