Laparoscopic Subtotal Cholecystectomy for Difficult Acute Calculous Cholecystitis

Background: When the critical view of safety (CVS) can't be obtained during dissection of Calot’s triangle in difficult gallbladder, conversion to open surgery or other “damage control” alternatives as cholecystostomy and subtotal cholecystectomy are recommended to prevent bile duct injury. Materials and methods: The medical records of all patients presented with acute calculous cholecystitis (ACC) during the study period were retrospectively reviewed and analyzed. Results: Laparoscopic cholecystectomy (LC) was attempted in 71 difficult gallbladders out of 379 patients presenting with ACC. In 6 patients (8.5%), conversion to open surgery or laparoscopic cholecystostomy was performed. Laparoscopic subtotal cholecystectomy (LSC) with dissection and control of the cystic duct was performed for the remaining 65 patients (91.5%) including 50 females (77%) and 15 males (23%) with a mean age of 42.35±12.4 years. The mean operative blood loss was 45.28±18.6 CC and the mean operative time was 96.3±24.19 minutes. There were no operative complications or mortality. The mean hospital stay was 28±17.8 hours. There was no postoperative jaundice, bile leak, intra-abdominal collections or mortality. Conclusion: When surgery is indicated for difficult ACC, LSC with control of the cystic duct is safe with excellent outcomes. However, if the CVS can’t be achieved due to obscured anatomy at Calot’s triangle, conversion to open surgery or cholecystostomy must be performed to prevent bile duct injury.