Laparoscopic subtotal cholecystectomy in severe cholecystitis with unclear anatomy


  • Maged Rihan Department of General Surgery, Faculty of medicine, Cairo University, Egypt



Severe cholecystitis, Laparoscopic cholecystectomy, Laparoscopic subtotal cholecystectomy


Background: Aim of the study was to determine the differences between laparoscopic cholecystectomy and laparoscopic subtotal cholecystectomy as regards bile duct injury and post-operative complications rates in patients with severe cholecystitis and obscure anatomy.

Methods: We retrospectively reviewed the charts and postoperative outcomes of 293 patients with severe cholecystitis who underwent either laparoscopic cholecystectomy or laparoscopic subtotal cholecystectomy between September 2011 and January 2020. Patients with intraoperative altered anatomy which leaded to difficult dissection were defined as having severe cholecystitis.

Results: There were 304 cholecystectomies done for patients with severe cholecystitis. Of those, 203 underwent laparoscopic cholecystectomy (LC group), 90 underwent laparoscopic subtotal cholecystectomy (LSC group). There was no significant difference in male to female ratio, age, cases performed on an elective or emergency basis, hospital length of stay or initial operative findings. There were 5 patients with detected intraoperative biliary injury in LC group only. Postoperative bile leaks were significantly higher in the LSC (11.1%) than in the LC group (3.9%). Postoperative collections which needed percutaneous aspiration were also significantly higher in the LSC group (18.9%) than in the LC group (7.4%). Reoperation for collection was required in 8 patients in LC group and in 5 patients in LSC group. The rates of retained common bile duct stones, port site hernia, wound infections, and total complications were not significantly different between the two groups (28.1% v. 45.6%).

Conclusions: Our study demonstrated that laparoscopic subtotal cholecystectomy is a safe procedure which reduces the risk of bile duct injury and is comparable to laparoscopic cholecystectomy in patients with severe cholecystitis with unclear anatomy.


Begos DG, Modlin IM. Laparoscopic cholecystectomy: From gimmick to gold standard. J Clin Gastroenterol. 1994;19:325-30.

Blum CA, Adams DB. Who did the first laparoscopic cholecystectomy? J Minim Access Surg. 2011;7:165-8.

Kanakala V, Borowski DW, Pellen MG, Dronamraju SS, Woodcock SA. Risk factors in laparoscopic cholecystectomy: a multivariate analysis. Int J Surg. 2011;9:318-23.

Comitalo JB. Laparoscopic cholecystectomy and newer techniques of gallbladder removal. JSLS. 2012;16:406-12.

Gurusamy KS, Davidson C, Gluud C, Davidson BR. Early versus delayed laparoscopic cholecystectomy for people with acute cholecystitis. Cochrane Database Syst Rev. 2013;6:CD005440.

Kama NA, Doganay M, Dolapci M, Reis E, Atli M, Kologlu M. Risk factors resulting in conversion of laparoscopic cholecystectomy to open surgery. Surg Endosc. 2001;15:965–8.

Bingener CJ, Richards ML, Strodel WE, Schwesinger WH, Sirinek KR. Reasons for conversion from laparoscopic to open cholecystectomy: a 10- year review. J Gastrointest Surg. 2002;6:800-5.

Strasberg SM, Brunt LM. Rationale and use of the critical view of safety in laparoscopic cholecystectomy. J Am Coll Surg. 2010;211:132-8.

Strasberg SM, Pucci MJ, Brunt LM. Subtotal cholecystectomy “fenestrating” vs “reconstructing” subtypes and the prevention of bile duct injury: definition of the optimal procedure in difficult operative conditions. J Am Coll Surg. 2016;222:89-96.

Palanivelu C, Rangarajan M, Jategaonkar PA, Madankumar MV. Laparoscopic management of remnant cystic duct calculi: a retrospective study. Ann R Coll Surg Engl. 2009;91:25-9.

Katsohis C, Prousalidis J, Tzardinoglou E, Michalopoulos A, Fahandidis E, Apostolidis S, et al. Subtotal cholecystectomy. HPB Surg. 1996;9:133-6.

Lunevicius R. Laparoscopic subtotal cholecystectomy: a classification, which encompasses the variants, technical modalities, and extent of resection of the gallbladder. Ann R Coll Surg Engl. 2020;102(4):315-7.

Wolf AS, Nijsse BA, Sokal SM, Chang Y, Berger DL. Surgical outcomes of open cholecystectomy in the laparoscopic era. Am J Surg. 2009;197:781-4.

Henneman D, Costa DW, Vrouenraets BC, Wagensveld BA, Lagarde SM. Laparoscopic partial cholecystectomy for the difficult gallbladder: A systematic review. Surg Endosc. 2013;27:315-58.

Philips JA, Lawes DA, Cook AJ, Arulampalam TH, Zaborsky A, Menzies D, et al. The use of laparoscopic subtotal cholecystectomy for complicated cholelithiasis. Surg Endosc. 2008;22:1697-700.

Chowbey PK, Sharma A, Khullar R, Mann V, Baijal M, Vashistha A. Laparoscopic subtotal cholecystectomy: a review of 56 procedures. J Laparoendosc Adv Surg Tech. 2000;10:31-4.

Purzner RH, Ho KB, Al-Sukhni E, Jayaraman S. Safe laparoscopic subtotal cholecystectomy in the face of severe inflammation in the cystohepatic triangle: a retrospective review and proposed management strategy for the difficult gallbladder. Can J Surg. 2019;62(6):402-11.

Horiuchi A, Watanabe Y, Doi T, Sato K, Yukumi S, Yoshida M, et al. Delayed laparoscopic subtotal cholecystectomy in acute cholecystitis with severe fibrotic adhesions. Surg Endosc. 2008;22:2720-3.

Deziel DJ, Millikan KW, Economou SG, Doolas A, Ko ST, Airan MC. Complications of laparoscopic cholecystectomy: a national survey of 4,292 hospitals and an analysis of 77,604 cases. Am J Surg. 1993;165:9-14.

Strasberg SM. Error traps and vasculo-biliary injury in laparoscopic and open cholecystectomy. J Hepatobiliary Pancreat Surg. 2008;15:284-92.

Tornqvist B, Waage A, Zheng Z. Severity of acute cholecystitis and risk of iatrogenic bile duct injury during cholecystectomy, a population- based case-control study. World J Surg. 2016;40:1060-7.

Harilingam MR, Shrestha AK, Basu S. Laparoscopic modified subtotal cholecystectomy for difficult gall bladders: a single-centre experience. J Minim Access Surg. 2016;12(4):325-9.






Original Research Articles