Overview
Definition:
Subtotal cholecystectomy is a surgical technique where only a portion of the gallbladder is removed, leaving a stump
Fenestrating refers to creating openings or windows in the gallbladder remnant to allow drainage of bile and prevent retention
This is typically performed when complete removal is technically challenging or poses significant risks to surrounding structures, particularly the common bile duct.
Epidemiology:
While not a primary indication for elective cholecystectomy, subtotal cholecystectomy is employed in a small percentage of cases presenting with severe inflammation, adhesions, or anatomical distortion of the gallbladder
The incidence is higher in re-operative cases or when impacted stones are present.
Clinical Significance:
This procedure is crucial for managing complex cholecystitis, particularly when the gallbladder neck or cystic duct is obscured by edema, inflammation, or adhesions, making standard cholecystectomy unsafe
It allows for the removal of diseased gallbladder tissue while mitigating the risk of bile duct injury, a potentially devastating complication.
Indications
Absolute Indications:
Severe cholecystitis with dense adhesions obscuring the Calot's triangle
Gallbladder cancer involving the cystic duct or neck
Distorted anatomy due to previous surgery or inflammation
Impacted stones in the gallbladder neck or cystic duct that cannot be safely dissected.
Relative Indications:
Perforation of the gallbladder requiring urgent intervention
Anatomical variations that increase the risk of bile duct injury
Inability to achieve adequate visualization for dissection.
Contraindications:
Complete obstruction of the cystic duct or common bile duct by a stone
Suspected gallbladder malignancy requiring en bloc resection of adjacent structures
Inability to mobilize the gallbladder adequately for even partial resection.
Preoperative Preparation
Patient Assessment:
Thorough history and physical examination focusing on previous abdominal surgeries, inflammatory conditions, and symptoms suggestive of biliary obstruction
Assessment of comorbidities and anesthetic risk.
Imaging Studies:
Abdominal ultrasonography to assess gallbladder wall thickness, stones, and pericholecystic fluid
CT scan or MRI/MRCP may be used for detailed anatomical assessment and to rule out other pathologies
ERCP may be indicated if common bile duct stones are suspected.
Laboratory Tests:
Complete blood count (CBC) to assess for infection or anemia
Liver function tests (LFTs) to evaluate for cholestasis or hepatocellular damage
Coagulation profile to assess hemostasis
Serum electrolytes and renal function tests.
Antibiotic Prophylaxis:
Broad-spectrum intravenous antibiotics should be administered preoperatively, typically covering gram-negative organisms and anaerobes
Examples include ceftriaxone with metronidazole or piperacillin-tazobactam.
Procedure Steps
Access And Exposure:
Laparoscopic or open approach is chosen based on patient factors and surgeon preference
For laparoscopic surgery, standard ports are inserted
The liver is retracted superiorly to expose the gallbladder bed and porta hepatis
Careful dissection begins to delineate the gallbladder wall and surrounding structures.
Identification Of Structures:
Meticulous dissection is performed to identify the liver, duodenum, and porta hepatis
The cystic artery and duct are typically identified as far distally as possible
In cases of severe inflammation, identification may be challenging, leading to the decision for subtotal cholecystectomy.
Fenestration And Excision:
If complete dissection is unsafe, the anterior wall of the gallbladder is opened (fenestrated) just proximal to the gallbladder neck
Diseased mucosa and stones are removed from the lumen
The remnant gallbladder wall is then carefully dissected off the liver bed, leaving a small stump of the posterior wall attached to the cystic duct remnant or a carefully ligated cystic duct stump.
Cystic Duct Management:
The cystic duct remnant is typically ligated securely or clipped
If a significant portion of the distal cystic duct is involved in inflammation or cannot be dissected, it may be left as a short stump that drains into the remnant posterior wall or is left open for drainage if fenestrated distally.
Drainage And Closure:
A drain may be placed in the subhepatic space if there is significant contamination or concern for bile leak
The abdominal incisions are closed in layers
For laparoscopic surgery, trocars are removed, and port sites are closed.
Postoperative Care
Monitoring:
Close monitoring of vital signs, urine output, and fluid balance
Assessment for signs of pain, fever, jaundice, or abdominal distension
Monitor drain output if placed.
Pain Management:
Adequate analgesia is provided, typically with intravenous patient-controlled analgesia (PCA) or oral analgesics
Early mobilization is encouraged to prevent deep vein thrombosis and pulmonary complications.
Fluid And Electrolyte Balance:
Intravenous fluids are administered to maintain adequate hydration
Electrolytes are monitored and corrected as needed
Nasogastric tube insertion may be necessary if there is persistent nausea or vomiting.
Antibiotics:
Postoperative antibiotics are usually continued for 24-48 hours, especially in cases of acute cholecystitis
Extended courses may be indicated if infection is suspected or confirmed.
Dietary Advancement:
Patients are typically started on clear liquids once bowel sounds return and nausea subsides
Diet is advanced as tolerated to a low-fat diet
Patients are advised to avoid fatty foods for a period postoperatively.
Complications
Early Complications:
Bile leak from the cystic duct stump or gallbladder remnant
Postoperative hemorrhage
Infection (wound infection, intra-abdominal abscess)
Injury to the common bile duct or adjacent structures
Retained stones in the common bile duct
Post-cholecystectomy syndrome.
Late Complications:
Biliary stricture
Formation of bile duct stones
Gallbladder remnant stones
Recurrent cholangitis
Hernia at port sites
Adhesions.
Prevention Strategies:
Meticulous surgical technique with careful identification of anatomical structures
Secure ligation or clipping of the cystic duct
Use of intraoperative cholangiography if uncertainty exists
Prompt diagnosis and management of bile leaks or infections
Careful closure of port sites to prevent hernias.
Prognosis
Factors Affecting Prognosis:
The presence and severity of inflammation, extent of adhesions, presence of comorbidities, and the technical difficulty of the procedure
Early recognition and management of complications are critical.
Outcomes:
In most cases, subtotal cholecystectomy successfully resolves symptoms of cholecystitis and allows for recovery
Long-term outcomes are generally good, although a small percentage of patients may experience recurrent symptoms due to the retained gallbladder remnant or bile duct issues.
Follow Up:
Postoperative follow-up appointments are scheduled to monitor for complications and assess recovery
Patients are advised to report any new or worsening symptoms, such as abdominal pain, fever, or jaundice
Imaging may be performed if indicated.
Key Points
Exam Focus:
Subtotal cholecystectomy is a salvage procedure for difficult cholecystectomies, prioritizing patient safety over complete removal
Key indications include severe inflammation and dense adhesions making cystic duct identification hazardous
Fenestration aids drainage and prevents remnant distension.
Clinical Pearls:
When faced with unclear anatomy in Calot's triangle during laparoscopic cholecystectomy, do not hesitate to convert to open or consider a subtotal approach
Secure ligation of the cystic duct stump, even if short, is paramount to prevent bile leak
Consider a drain if there is any concern for bile spillage.
Common Mistakes:
Attempting aggressive dissection in a severely inflamed gallbladder leading to bile duct injury
Inadequate ligation of the cystic duct stump, resulting in bile leak
Failing to fenestrate or adequately drain the remnant gallbladder, leading to retained bile and potential infection.