What are the alternatives for reconstruction after completion cholecystectomy (surgical removal of the gallbladder) following subtotal fenestrating cholecystectomy (partial removal of the gallbladder) in a setting of difficult anatomy?

From the Guidelines

Completion cholecystectomy after subtotal fenestrating cholecystectomy is recommended when residual gallbladder tissue causes persistent symptoms or complications, with the preferred approach being laparoscopic completion cholecystectomy when feasible, as supported by the 2020 World Society of Emergency Surgery guidelines 1.

Key Considerations

• The decision to perform completion cholecystectomy should be based on the presence of persistent symptoms or complications, rather than routine completion, as the morbidity rates of subtotal cholecystectomy are comparable to those of total cholecystectomy in straightforward cases 1.
• For reconstruction in difficult anatomy, several options exist, including primary closure of the bile duct, choledochoduodenostomy, Roux-en-Y hepaticojejunostomy, or biliary stenting, with the choice of approach depending on the extent of damage and the patient's overall condition 1.
• Timing of reoperation is crucial, with early reoperation (within 72 hours) potentially easier due to less inflammation, while delayed completion (after 6-12 weeks) allows inflammation to subside, as highlighted in the 2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy 1.

Technical Considerations

• Preoperative imaging with MRCP or ERCP is essential to clarify biliary anatomy and guide the surgical approach, as emphasized in the 2021 WSES guidelines 1.
• Intraoperative cholangiography and careful dissection starting from normal anatomy are key technical considerations to prevent bile duct injury and ensure a successful outcome, as supported by the 2020 World Society of Emergency Surgery guidelines 1.
• The use of adjuncts such as IOC, ICG-C, or intraoperative ultrasound may be helpful in identifying biliary structures and preventing bile duct injuries, but their routine use is not significantly associated with a lower risk of BDIs, as reported in a recent survey involving 3411 surgeons 1.

From the Research

Alternatives for Reconstruction in Setting of Difficult Anatomy

In cases where completion cholecystectomy is required after subtotal fenestrating cholecystectomy, several alternatives for reconstruction can be considered. The choice of technique depends on various factors, including the patient's anatomy, the surgeon's expertise, and the specific challenges posed by the case.

Techniques for Subtotal Cholecystectomy

Two main techniques for subtotal cholecystectomy are:

• Fenestrating subtotal cholecystectomy: This technique involves removing a portion of the gallbladder and leaving a remnant in place 2, 3, 4.
• Reconstituting subtotal cholecystectomy: This technique involves reconstructing the gallbladder remnant to create a functional gallbladder 2, 3, 4.

Outcomes of Fenestrating and Reconstituting Subtotal Cholecystectomy

Studies have compared the outcomes of fenestrating and reconstituting subtotal cholecystectomy, including:

• Bile leak: Fenestrating subtotal cholecystectomy is associated with a higher rate of bile leak compared to reconstituting subtotal cholecystectomy 2, 3, 4.
• Reoperation: There is no significant difference in the rate of reoperation between the two techniques 2, 3, 4.
• Completion cholecystectomy: The rate of completion cholecystectomy is similar between the two techniques 2, 3, 4.

Considerations for Completion Cholecystectomy

Completion cholecystectomy is a complex operation that carries significant morbidity, even when performed using minimally invasive techniques 5. The decision to perform completion cholecystectomy should be based on individual patient factors, including the presence of recurrent or persistent biliary symptoms, and the size of the gallbladder remnant 5.

Factors Influencing the Choice of Technique

The choice of technique for subtotal cholecystectomy and completion cholecystectomy depends on various factors, including:

• Intraoperative conditions: The surgeon's expertise and the specific challenges posed by the case can influence the choice of technique 6, 2, 3.
• Patient anatomy: The size and location of the gallbladder remnant can affect the choice of technique 5.
• Surgeon's preference: The surgeon's preference and experience with a particular technique can also influence the choice of technique 6, 2, 3.