From the Guidelines
Completion cholecystectomy after subtotal fenestrating cholecystectomy is recommended to be performed as an early laparoscopic cholecystectomy (ELC) within 7 days of hospital admission and within 10 days of onset of symptoms, as it appears to be superior to delayed laparoscopic cholecystectomy (DLC) or intermediate laparoscopic cholecystectomy (ILC) in terms of reducing hospital stay and time to return to work 1.
Key Considerations
- The decision to perform completion cholecystectomy should be based on the patient's overall health, symptoms, and risk factors for complications, with a focus on minimizing morbidity, mortality, and improving quality of life.
- ELC is considered the recommended treatment for patients who are fit to undergo surgery, as it has been shown to reduce the total hospital stay by about 4 days compared to DLC, and about 5 days compared to ILC 1.
- The procedure should be attempted only by experienced surgeons, and referral to centers with high surgical expertise should be considered if adequate surgical expertise is not available 1.
Procedure Details
- Preoperative imaging with ultrasound, CT, or MRI is essential to assess the remnant gallbladder anatomy and identify any complications.
- Patients should undergo standard preoperative preparation including fasting for 8 hours, antibiotic prophylaxis, and thromboprophylaxis if indicated.
- The completion procedure involves removing the remaining gallbladder tissue, including the cystic duct stump and any residual gallbladder wall, and can be performed laparoscopically in most cases.
Potential Complications
- Leaving gallbladder remnants can lead to persistent symptoms, stone formation, inflammation, or rarely, malignant transformation.
- Patients with confirmed gallbladder cancer may require more extensive surgery, including liver resection and lymphadenectomy, as part of the completion procedure.
Evidence Summary
- A Cochrane review published in 2013 concluded that ELC for acute cholecystitis seems safe and may shorten the total hospital stay 1.
- An update of the literature searches performed for the 2020 World Society of Emergency Surgery guidelines identified 16 trials comparing ELC, DLC, and ILC, with consistent evidence showing that ELC is superior to either ILC or DLC in terms of reducing hospital stay and time to return to work 1.
From the Research
Completion Cholecystectomy after Subtotal Fenestrating Cholecystectomy
- The need for completion cholecystectomy after subtotal fenestrating cholecystectomy is a significant consideration in the management of difficult gallbladders 2, 3, 4.
- A study published in 2017 found that completion cholecystectomy was performed significantly more often in patients after fenestrating subtotal cholecystectomy (9% vs 4%; p < 0.022) 2.
- In contrast, a 2023 study reported that subtotal fenestrating cholecystectomy is a safe and effective approach to the difficult gallbladder, with no major vascular injuries occurring in the subgroup of patients who underwent this procedure 5.
- A 2024 systematic review and meta-analysis found no difference between fenestrating and reconstituting laparoscopic subtotal cholecystectomy regarding the rates of completion of cholecystectomy 4.
- A 2025 study reported a long-term completion cholecystectomy rate of 0.9% after subtotal cholecystectomy, with no notable difference in postoperative or quality of life outcomes between subtotal cholecystectomy subtypes 3.
Factors Influencing Completion Cholecystectomy
- The choice of technique for subtotal cholecystectomy, either fenestrating or reconstituting, depends on intraoperative conditions and is associated with specific complications 2, 3, 4.
- Cystic duct closure during fenestrating subtotal cholecystectomy is associated with improved postoperative outcomes, including a decreased rate of bile leak 3.
- Laparoscopic completion of subtotal cholecystectomy is also associated with improved postoperative outcomes, including fewer postoperative bile leaks, wound complications, and a decreased length of stay 3.