Which is better, fenestrating or reconstituting technique, in subtotal cholecystectomy for a patient with severe gallbladder disease or a history of multiple gallstone attacks?

Fenestrating vs Reconstituting Subtotal Cholecystectomy

The reconstituting technique is superior to the fenestrating technique for subtotal cholecystectomy in patients with severe gallbladder disease, as it significantly reduces bile leak rates while achieving comparable long-term outcomes. 1, 2

Key Outcome Differences

Bile Leak Risk

• Reconstituting technique has significantly lower bile leak rates (7% vs 18%, p < 0.022), representing a 2.5-fold reduction in odds compared to fenestrating approach 1, 3
• The fenestrating technique is associated with higher bile leak incidence (OR: 2.47, p = 0.007) across multiple studies 1
• Despite higher leak rates with fenestrating technique, most bile leaks resolve without intervention or with postoperative ERCP, showing no significant difference in ultimate resolution between techniques 1

Postoperative Interventions

• Fenestrating technique requires more frequent postoperative ERCP (14.4% vs 6.6%, p < 0.001) 4
• Sensitivity analysis confirms increased ERCP rates with fenestrating approach (OR 0.32; 95% CI 0.16-0.64; p = 0.001) 2
• Reoperation rates are higher with fenestrating technique (3.5% vs 1.3%, p < 0.001) 4

Perioperative Complications

• Reconstituting technique demonstrates lower rates of:
  • Open conversion (4.6% vs 10.2%, p < 0.001) 4
  • Subhepatic/subphrenic collections (1.4% vs 5.8%, p < 0.001) 4
  • Superficial surgical site infections (1.5% vs 3.2%, p = 0.0303) 4
  • Retained stones (4.1% vs 6.7%, p = 0.0253) 4

Long-Term Outcomes

Recurrent Biliary Events

• Fenestrating technique paradoxically shows lower long-term recurrence of biliary events (9% vs 18%, p < 0.022) after median 6-year follow-up 3
• Reconstituting technique trends toward more severe recurrent biliary disease requiring intervention 5
• Completion cholecystectomy is performed more frequently after fenestrating technique (9% vs 4%, p < 0.022) 3

Critical Safety Outcomes

• Both techniques are equivalent for preventing bile duct injury (no significant difference, RD: -0.02, p = 0.16) 1
• No difference in readmission rates between techniques 2
• Overall reintervention rates are comparable (32% fenestrating vs 26% reconstituting, p = 0.211) 3

Clinical Decision Algorithm

Primary recommendation: Use reconstituting technique when feasible 4

Choose Reconstituting When:

• Anatomy allows safe closure of the gallbladder remnant 4
• Minimizing immediate postoperative complications is priority 1, 2
• Reducing need for postoperative ERCP is important 4
• Patient has limited access to endoscopic services 2

Consider Fenestrating When:

• Severe inflammation prevents safe closure of remnant 3
• Tissue quality is too poor for secure suturing 4
• Risk of incorporating bile duct into closure is present 3
• Surgical expertise favors this approach 4

Management of Bile Leaks

For Fenestrating Technique (Higher Risk):

• Routine drain placement is essential to detect and manage bile leaks 1
• Delayed drain removal based on output characteristics 1
• Low threshold for postoperative ERCP in selected cases 1
• Most leaks resolve with conservative management (drainage alone or with endoscopic therapy) 1

Important Caveats

Both techniques are complementary bailout procedures when critical view of safety cannot be achieved 6, 4

• The choice between techniques should be guided by intraoperative findings, particularly tissue quality and degree of inflammation 4, 3
• Surgical expertise and familiarity with each technique impacts outcomes 4
• Neither technique should be considered a failure—both represent sound surgical judgment prioritizing patient safety over complete organ removal 7
• The higher immediate bile leak rate with fenestrating technique is offset by easier management and potentially better long-term outcomes 1, 3

Quality of Life

• Both techniques achieve comparable quality of life outcomes at long-term follow-up 3
• No significant difference in patient-reported outcomes between approaches 3