What is the role of subtotal cholecystectomy in managing severe gallbladder disease, particularly in patients with a history of multiple gallstone attacks, pancreatitis, or previous abdominal surgeries?

Subtotal Cholecystectomy: A Critical Bailout Procedure for Difficult Gallbladder Surgery

Subtotal cholecystectomy should be performed when the critical view of safety cannot be established during cholecystectomy, as this approach prevents bile duct injury while achieving morbidity rates comparable to total cholecystectomy in straightforward cases. 1, 2

Primary Indications

Subtotal cholecystectomy is indicated when anatomic structures in Calot's triangle cannot be safely identified due to: 1, 2

• Severe cholecystitis (72.1% of cases) with marked inflammation obscuring critical anatomy 1, 3
• Gallstones with liver cirrhosis and portal hypertension (18.2% of cases) where bleeding risk from the gallbladder bed is prohibitive 1, 4
• Empyema or perforated gallbladder (6.1% of cases) 1
• Dense adhesions, severe fibrosis, or distended gallbladder preventing safe dissection 5, 6

Technical Approach and Surgical Algorithm

Attempt laparoscopic cholecystectomy first with establishment of the critical view of safety as the primary goal. 2, 5 If the critical view cannot be safely achieved:

• Proceed to laparoscopic subtotal cholecystectomy (72.9% of cases can be completed laparoscopically) 1, 3
• Convert to open subtotal cholecystectomy if laparoscopic approach is not feasible (19% of cases) 1, 3
• Leave the posterior gallbladder wall attached to the liver to avoid excessive bleeding or bile duct injury 6, 4
• Secure the cystic duct from within the gallbladder using clips, sutures, or endoloop, or drain the gallbladder bed without isolating the cystic duct if anatomy is too hostile 6, 4

Safety Profile and Complication Management

Subtotal cholecystectomy demonstrates superior safety compared to forced total cholecystectomy in difficult cases:

• Bile duct injury rate is extremely low (0.08%) compared to 3.3% with forced total cholecystectomy in difficult cases 3, 7
• No bile duct injuries occurred in the subtotal cholecystectomy group versus four injuries in the total cholecystectomy group in matched cohorts 1
• Aggregate severe complications (bile duct injury, vascular injury, gastrointestinal injury) are significantly lower with subtotal cholecystectomy (0% vs 7.9%, P=0.036) 7

Expected Complications and Their Management

Bile leakage is the most common complication (18%) but is typically managed conservatively: 1, 3

• Abdominal drainage alone is often sufficient 1, 6
• Endoscopic retrograde cholangiopancreatography with biliary stenting for persistent leaks (required in 19-23% of subtotal cholecystectomy cases) 8
• Bile leaks occur primarily with the fenestration technique and are successfully managed endoscopically 8

Other complications include: 3, 6

• Postoperative hemorrhage (0.3%) 3
• Subhepatic collections (2.9%) 3
• Retained stones (3.1%) 3
• Reoperation rate (1.8%) 3
• 30-day mortality (0.4%) 3

Clinical Context and Timing

Early laparoscopic cholecystectomy within 7-10 days of symptom onset should be attempted first, with subtotal cholecystectomy serving as the bailout procedure when safe total cholecystectomy cannot be achieved. 1, 2, 5

Conversion to open surgery or subtotal cholecystectomy is not a failure but represents sound surgical judgment prioritizing patient safety over complete organ removal. 1, 2

Important Caveats

Multiple surgical techniques exist for subtotal cholecystectomy (fenestrating vs reconstituting), which may influence outcomes, particularly bile leak rates. 1, 8 The fenestrating technique leaves the gallbladder open to the peritoneal cavity and has higher bile leak rates, while the reconstituting technique closes the remnant. 8

Teaching hospitals have significantly increased their use of subtotal cholecystectomy (from 0.1% to 0.52% for open and 0.12% to 0.28% for laparoscopic approaches between 2003-2014), reflecting growing recognition of this technique's safety profile. 1, 5

The quality of evidence is moderate due to absence of prospective randomized trials, which are unlikely to be performed given ethical considerations. 1 However, the concordance of all available evidence, large global application, and important clinical impact on patient safety strongly support this recommendation. 1