Medical Research: Emerging Concepts and Applications Vol. 5

Background & Objectives: Standard laparoscopic cholecystectomy (LC) requires the unambiguous identification of anatomical structures within Calot's triangle to establish the Critical View of Safety (CVS). In patients presenting with severe acute or chronic inflammation, empyema, gangrene, severe adhesions, or anatomical distortions, achieving the CVS can be technically precarious, substantially elevating the risk of major bile duct injury (BDI) and vascular trauma. Laparoscopic sub-total cholecystectomy (LSTC) serves as a crucial operative bailout strategy that obviates the need for open conversion while preventing major biliary tree trauma. This study evaluated the feasibility, clinical outcomes, safety profile, and associated morbidity of LSTC in difficult gallbladder cases.

Methods: A hospital-based prospective observational study was conducted at the Department of General Surgery, Citizens Specialty Hospital, Hyderabad, India, over an 18-month period between September 2020 and March 2022. Out of a total cohort of 672 patients scheduled for laparoscopic cholecystectomy, 30 consecutive patients who underwent LSTC due to intraoperative technical difficulties were enrolled after obtaining informed consent. Detailed clinical characteristics, baseline comorbidities, surgical indications, intraoperative metrics, structural reasons for the difficult gallbladder, postoperative complications, length of hospital stay, and short-to-medium-term outcomes were systematically recorded and analysed.

Results: The overall incidence of LSTC in the studied cohort was 4.46% (30/672). The mean age of the patient cohort was 58.2 ± 12.1 years, with a slight male predilection (53.3%, n=16). Primary clinical indications for intervention were acute calculus cholecystitis (73.3%, n=22), gallbladder empyema (20.0%, n=6), and perforated/gangrenous gallbladder (6.7%, n=2). Prior ERCP with biliary stenting was documented in 16.7% (n=5) of patients. The primary intraoperative trigger for performing LSTC was a "frozen Calot's triangle" (56.7%, n=17), followed by a severely thickened, fibrotic gallbladder adherent to the liver bed (23.3%, n=7), dense visceral/omental adhesions (13.3%, n=4), and gangrenous/perforated tissue with pericholecystic abscess (6.7%, n=2). The mean operative duration was 59.5 ± 19.1 minutes. Conversion to open surgery was successfully avoided in 100% of cases (0% open conversion rate). One case of minor intraoperative bile duct injury (3.3%) occurred and was successfully managed with primary intraoperative laparoscopic repair. Postoperative complications were predominantly minor, including mild abdominal pain (16.7%, n=5) and transient pyrexia (6.7%, n=2), with no incidence of persistent postoperative bile leakage or abdominal distension. The majority of patients (83.3%, n=25) were safely discharged on postoperative day 2. Follow-up evaluation demonstrated symptom resolution in most patients, with a retained stump calculus reported in 1 patient (3.3%), who was managed conservatively, and no reoperations.

Conclusion: Laparoscopic sub-total cholecystectomy is a highly feasible, safe, and robust bailout manoeuvre. It effectively prevents iatrogenic bile duct injury, eliminates the morbidity associated with open conversion, shortens postoperative recovery time, and optimises outcomes in complex hepatobiliary pathology.