What is the recommended technique for takedown of a cholecystohepatic fistula during definitive cholecystectomy in an elderly frail female patient?

Management of Cholecystohepatic Fistula Takedown

In an elderly frail female patient with cholecystohepatic fistula, perform laparoscopic or open subtotal cholecystectomy with careful dissection and primary closure of the hepatic defect, converting to open surgery if severe inflammation or bleeding occurs in Calot's triangle. 1

Surgical Approach Selection

Initial Approach

• Attempt laparoscopic cholecystectomy first unless absolute anesthetic contraindications or septic shock are present, even in elderly patients with complex fistulas 1
• Laparoscopic approach in elderly patients is safe and feasible with low complication rates (10% morbidity, 1% mortality) compared to open surgery (25% morbidity, 2% mortality) 2

When to Choose Subtotal Cholecystectomy

• Subtotal cholecystectomy is the preferred technique for cholecystohepatic fistula where advanced inflammation makes anatomy difficult to recognize and bile duct injury risk is high 1
• This approach is specifically recommended for "difficult gallbladder" scenarios including gangrenous gallbladder and severe inflammatory adhesions 1

Technical Steps for Fistula Takedown

Dissection Technique

• Maintain high index of suspicion for fistulous communication during dissection 3
• Carefully dissect the fistulous tract from the hepatic parenchyma using sharp dissection 4
• Use laparoscopic stapling techniques to divide the fistula while preventing bile leakage 3

Closure of Hepatic Defect

• Perform primary closure of the hepatic defect after fistula takedown 4, 5
• Ensure hemostasis from the liver parenchyma before closure 1

Conversion Criteria

Indications for Open Conversion

• Convert to open surgery if local severe inflammation, adhesions, or bleeding occurs in Calot's triangle 1
• Suspect bile duct injury warrants immediate conversion 1
• Predictors of conversion include fever, leukocytosis, elevated serum bilirubin, and extensive upper abdominal surgery history 1

Special Considerations for Elderly Frail Patients

Risk Assessment

• Evaluate patient frailty using frailty scores and surgical clinical scores 1
• Consider mortality rates for surgical versus conservative options, gallstone-related disease relapse rates, and age-related life expectancy 1

Alternative if Unfit for Surgery

• Percutaneous cholecystostomy can serve as bridge therapy in ASA III/IV patients, performance status 3-4, or septic shock 1, 6
• Use transhepatic route preferentially to reduce bile leak risk 6
• Remove catheter between 4-6 weeks after placement if cholangiogram demonstrates biliary tree patency 1

Common Pitfalls to Avoid

• Do not attempt standard cholecystectomy when anatomy is severely distorted by inflammation—this increases bile duct injury risk 1
• Do not delay conversion to open if bleeding or unclear anatomy develops during laparoscopic approach 1
• Do not assume age alone contraindicates surgery—cholecystectomy is preferred treatment even in elderly patients when medically fit 1
• Perform frozen section if gallbladder cancer is suspected, as 2% of fistula cases have concomitant malignancy 7