Overview
Definition:
Subtotal cholecystectomy is a surgical procedure where only a portion of the gallbladder is removed, typically leaving a part of the gallbladder and the cystic duct stump in situ
This technique is usually employed in cases of severe inflammation, dense adhesions, or unclear anatomy where complete removal poses significant risks to adjacent structures like the common bile duct
The remaining portion may be marsupialized or drained.
Epidemiology:
Subtotal cholecystectomy is an uncommon variant of cholecystectomy, performed in less than 1% of all cholecystectomies, primarily when standard cholecystectomy is deemed technically challenging
Its incidence is higher in patients with complicated gallstone disease, prior abdominal surgery, and acute inflammatory conditions.
Clinical Significance:
This procedure is a crucial alternative for surgeons facing difficult gallbladders, preventing potential bile duct injuries
Understanding its indications, techniques, and complications is vital for surgical residents to safely manage complex cases and prepare for board examinations where such scenarios are tested.
Indications
Absolute Indications:
Dense pericholecystic inflammation with severe edema
Intraoperative bleeding that obscures critical structures
Extensive adhesions making dissection of the gallbladder bed unsafe
Suspected malignancy within the gallbladder wall where a radical resection might be complicated by unclear margins.
Relative Indications:
Previous abdominal surgeries leading to significant adhesions around the gallbladder
Intraoperative suspicion of a difficult cystic duct or common bile duct anatomy
Inexperienced surgeon encountering an exceptionally challenging dissection
Presence of a gallbladder polyp > 1 cm where conservative management is considered.
Contraindications:
Clear visualization of the cystic duct and common bile duct is possible
Absence of significant inflammation or adhesions
Ability to perform a safe dissection of the gallbladder bed
Suspicion of gallbladder cancer requiring radical resection.
Preoperative Preparation
Patient Assessment:
Thorough history focusing on previous abdominal surgeries, comorbidities, and current symptoms
Detailed physical examination, noting abdominal tenderness and masses
Assessment of nutritional status and coagulation profile.
Investigations:
Complete blood count to assess for infection and anemia
Liver function tests to evaluate biliary obstruction or liver damage
Ultrasound abdomen to confirm gallstones, gallbladder wall thickening, and assess biliary tree dilatation
CT scan or MRI/MRCP may be used for complex cases to delineate anatomy and extent of inflammation.
Informed Consent:
Detailed explanation of the procedure, including the rationale for subtotal cholecystectomy, potential risks such as retained stones, biliary leak, or stump dehiscence, and the possibility of conversion to total cholecystectomy or further surgical intervention
Discussing the benefits of avoiding bile duct injury.
Procedure Steps
Access And Exposure:
Laparoscopic or open approach as determined preoperatively
Careful dissection to expose the triangle of Calot
Careful retraction of the liver to improve visualization of the gallbladder and cystic duct area.
Cystic Duct Management:
If the cystic duct can be safely identified and ligated, it is done so
If not, the stump is often oversewn or secured with clips, leaving a portion of the gallbladder attached to the liver bed and the cystic duct stump.
Gallbladder Resection:
The fundus and body of the gallbladder are resected, leaving the inferior portion attached to the gallbladder bed
The remaining portion is often trimmed to create a neat stump.
Hemorrhage Control And Drainage:
Meticulous hemostasis is achieved in the gallbladder bed
A drain is usually placed in the gallbladder bed and brought out through a separate stab incision to monitor for bile leak or bleeding
The remaining gallbladder stump may be marsupialized to the skin or closed depending on the technique and surgeon preference.
Wound Closure:
Abdominal wall layers are closed in the usual manner for either laparoscopic or open surgery
The drain site is secured.
Postoperative Care
Pain Management:
Adequate analgesia is crucial
Multimodal pain management including IV or oral analgesics and patient-controlled analgesia if required
Early mobilization to prevent deep vein thrombosis and pulmonary complications.
Drain Management:
The drain output is monitored closely for volume, color, and consistency
Bile-stained or bloody output warrants prompt investigation
The drain is typically removed when output is minimal and non-bilious.
Antibiotics:
Prophylactic antibiotics are usually continued postoperatively, guided by intraoperative findings and local protocols
Broad-spectrum antibiotics are used if infection is suspected.
Nutritional Support:
Diet is advanced as tolerated, starting with clear liquids and progressing to a regular diet
Patients are advised to avoid fatty foods initially due to potential malabsorption or altered bile flow.
Monitoring For Complications:
Close monitoring for signs of bile leak (e.g., fever, abdominal pain, drain output, jaundice), bleeding, wound infection, or retained stones.
Complications
Early Complications:
Bile leak from the cystic duct stump or gallbladder bed
can manifest as peritonitis or abscess formation
Bleeding from the gallbladder bed or cystic artery stump
Retained gallstones within the stump or common bile duct
Postcholecystectomy syndrome due to retained stones or altered bile dynamics.
Late Complications:
Biliary strictures at the stump or common bile duct
Gallbladder stump mucocele formation
Incisional hernias
Chronic abdominal pain
Cholangitis if retained stones are present.
Prevention Strategies:
Meticulous surgical technique, careful identification of anatomy, secure ligation or oversewing of the cystic duct stump, placement of a drain in the gallbladder bed, and careful hemostasis
Judicious use of intraoperative cholangiography if anatomy is unclear
Close postoperative monitoring and prompt management of any deviations from the norm.
Key Points
Exam Focus:
Indications for subtotal cholecystectomy, especially in cases of severe inflammation or difficult anatomy
Management of the cystic duct stump
Common complications like bile leak and retained stones
The role of intraoperative cholangiography
Distinction between subtotal and total cholecystectomy.
Clinical Pearls:
Always prioritize patient safety over complete gallbladder removal when anatomy is obscured
Consider subtotal cholecystectomy as a safe option to prevent bile duct injury
A well-placed drain is crucial for early detection of complications
Postoperative ultrasound can be useful for evaluating unexplained symptoms.
Common Mistakes:
Attempting complete cholecystectomy in compromised situations leading to injury
Inadequate management of the cystic duct stump
Not placing a drain in the gallbladder bed
Delayed diagnosis and management of bile leak
Ignoring symptoms of retained stones.