Performing the McElmoyle Shield in Fenestrating Subtotal Cholecystectomy
I cannot provide specific procedural steps for the "McElmoyle shield" technique as this term does not appear in the available surgical literature or guidelines on subtotal cholecystectomy. The evidence provided does not describe a technique called the "McElmoyle shield" in the context of fenestrating subtotal cholecystectomy. 1, 2
What the Evidence Does Support: Fenestrating Subtotal Cholecystectomy Technique
The fenestrating approach to subtotal cholecystectomy involves leaving the posterior gallbladder wall attached to the liver bed and leaving the gallbladder remnant open (not closed), which is performed when the critical view of safety cannot be achieved. 2, 3, 4
Standard Fenestrating Technique Steps:
Remove the anterior and lateral walls of the gallbladder while leaving the posterior wall adherent to the liver bed, avoiding dangerous dissection in Calot's triangle 5
Secure the cystic duct from within the gallbladder lumen using a purse-string suture technique at its origin, which eliminates the need for hazardous dissection in the hepatocystic triangle 5
Leave the gallbladder remnant open (fenestrated) rather than closing it, which defines this as fenestrating rather than reconstituting subtotal cholecystectomy 4, 6
Control bleeding from the remaining gallbladder edge using running sutures after each stage of piecemeal gallbladder excision 5
Place an abdominal drain in 85% of cases, with 28% of patients discharged with the drain in place 3
Critical Caveats About Fenestrating Technique:
Bile leakage occurs in 19.6-25.8% of fenestrating cases, significantly higher than reconstituting subtotal cholecystectomy (OR 0.29 for reconstituting vs fenestrating; p=0.0002) 4, 7, 6
Postoperative ERCP is required more frequently with fenestrating technique (22.6% vs lower rates with reconstituting; OR 0.32; p=0.001) 7, 6
Bile leaks are managed successfully with abdominal drainage alone or in combination with endoscopic biliary stenting 1, 3, 7
The fenestrating approach is most commonly indicated in severe cholecystitis (72.1% of cases), gallstones with cirrhosis/portal hypertension (18.2%), and empyema or perforated gallbladder (6.1%) 1, 2
If You Are Seeking a Specific Named Technique:
If "McElmoyle shield" refers to a specific modification or protective maneuver during fenestrating subtotal cholecystectomy, this technique is not documented in current major guidelines or recent surgical literature. You may need to consult the original source describing this technique or clarify the terminology with colleagues familiar with this specific approach.