SCIENTIFIC PAPER

Evaluation of Fundus-First Laparoscopic

Cholecystectomy
Amit Gupta, MBBS, Prem Narayan Agarwal, MS, Ravi Kant, MS, Vinod Malik, MS

ABSTRACT

INTRODUCTION

Objectives: Laparoscopic cholecystectomy is the gold

standard for gallbladder surgery. Cholecystectomy from
the fundus to the cystic duct may be advantageous when
cystic duct exposure becomes difficult due to adhesions
on Calots triangle. The aim of this study was to compare
conventional laparoscopic cholecystectomy with the fundus-first procedure and to evaluate whether the fundusfirst technique can prevent conversion in difficult cases.

Laparoscopic cholecystectomy today is regarded as the

gold standard for cholecystectomy. Dissection at Calots
triangle is sometimes difficult or not feasible because of
adhesions or anatomical abnormalities. The incidence of
bile duct injury is 0.5% to 3% compared with 0.1% to
0.5% in open cholecystectomy.1 Even today, the major
reasons for conversion to open surgery remain difficult
anatomy at Calots triangle and dense adhesions making
separation of the cystic duct from the common bile duct
(CBD) both difficult and dangerous. Cholecystectomy
using the opposite direction of dissection, from the fundus to the cystic duct, may be advantageous when cystic
duct exposure becomes difficult. The basis for the use of
the fundus-first approach in open surgery is well documented in the literature. In the Lahey Clinic, indications
were specified for the use of this approach2:

Methods: The study included 145 patients treated over

18 months. The inclusion criterion was the presence of
ultrasound proven gallstones. Patients were excluded
from the study if there was evidence of common bile
duct stones, a bilioenteric fistula, or carcinoma of the
gallbladder.
Results: The fundus-first approach was started in 45
patients; all procedures were completed laparoscopically. Conventional laparoscopic cholecystectomy was
begun in 100 patients. Twenty-seven of the 100 patients
were converted to fundus dissection (adhesions within
Calots triangle). Four of the 27 were further converted to
open surgery. One patient had a drop in blood pressure
on creation of pneumoperitoneum. Time taken for
severely inflammatory and noninflammatory cases was
significantly greater (P<0.05) in the fundus-first group.
The average hospital stay was 48 hours in both groups.
No major complications were observed.
Conclusion: The rate of conversion in the conventional
laparoscopic cholecystectomy group decreased from
18.75% (27/144) to 2.08% (3/144). The fundus-first technique has the potential to decrease conversion in difficult
cases.
Key Words: Fundus-first, Laparoscopic cholecystectomy.

1. In all cases in which a marked induration and thickening exists about the junction of the common and cystic duct and the common bile duct, and their relation
does not exist
2. All gallbladders possessing such thick walls that traction upon the ampulla or pelvis of the gallbladder necessary to expose the ducts would result in possible rupture of the structures and soiling from septic contents
3. Clear exposure of the cystic duct and the common
duct cannot be made out
Extending these very indications into the laparoscopic
arena, we believe that the rate of conversion can be
reduced using the fundus-first technique.
The aim of the study was to compare conventional
cholecystectomy with the fundus-first procedure and to
evaluate whether the fundus-first technique is useful in
preventing conversion in difficult cases.

METHODS
Department of Surgery, Maulana Azad Medical College, Delhi, India (all authors).
Address reprint requests to: Amit Gupta, L7 Ground floor, South Extension Part II,
New Delhi, 110049, Delhi, India. Telephone: 91 011 6255859, Fax: 091 011
26861966, E-mail: amitgupta76@hotmail.com
2004 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.

The study was carried out in a departmental unit of the

Department of Surgery, Maulana Azad Medical College,
over 18 months. Outpatients (145) presenting to the clinic with symptoms of chronic cholecystitis and ultrasound

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Evaluation of Fundus-First Laparoscopic Cholecystectomy, Gupta A et al.

proven gallstones were included. The cohort included 22

male patients. The age distribution of the group was 14
to 65 years with an average of 32 years. Forty-five
patients underwent fundus-first laparoscopic cholecystectomy. The inclusion criterion was the presence of ultrasound proven gallstones. Patients were excluded from
the study if there was evidence of CBD stones, a bilioenteric fistula, or carcinoma of the gallbladder.
The workup of the patients included a hemogram, alkaline phosphatase, serum amylase, blood sugar, blood
urea, urine examination, and a chest skiagram. All
patients underwent an ultrasonographic examination in
our own institution. The procedures were explained and
a written informed consent obtained.
Patients were randomly allotted to the 2 groups, and the
following parameters were studied: time taken for the
procedure (time from insertion of the first port to the
withdrawal of the last port); rate of conversion to either
procedure and to open procedure; injuries to viscera, viscus, and vessels; injury of the gallbladder leading to bile
and stone spillage; effect of bile spillage on hospital stay;
and distribution of severely inflamed cases in the 2
groups and rate of conversion in them.

OPERATIVE PROCEDURE
Fundus-First Laparoscopic Cholecystectomy (FFLC)
After insertion of the standard 4 ports, the gallbladder is
retracted at the fundus and dissected from the liver fossa
to create a space to insert the triflange liver retractor. With
the retractor in position, the gallbladder is now easily dissected off the liver bed till it hangs at the junction of the
cystic duct with the CBD. At this stage, the gallbladder is
divided between clips of Endoloops. In certain situations
in very severely inflamed cases, the EndoGIA stapler
(Ethicon, Somerville, NJ) is used.
Conventional Laparoscopic Cholecystectomy (CLC)
The gallbladder is dissected at Calots triangle to divide
the cystic duct and artery between clips. The organ is
then dissected off the liver bed.

RESULTS
The study group comprised 145 patients; 22 of these
were males. Forty-five patients underwent fundus-first
laparoscopic cholecystectomy. Of these 45 patients, 22
256

had severely inflamed gallbladders. Of the 99 patients in

the conventional group, 36 had severely inflamed gallbladders. (1 patient was converted to an open procedure
due to a sudden fall in blood pressure on creation of
pneumoperitoneum.)
Time Taken
The time taken during FFLC for noninflamed cases was
significantly greater than that in CLC. The converse
occurs in cases where inflammation was present. The
time taken during surgery on noninflammatory cases was
50.211.4 minutes and 60.9518.1 minutes for the conventional laparoscopic cholecystectomy and fundus-first
laparoscopic cholecystectomy group, respectively. The
same procedures performed on the severely inflamed
group took 104.818.6 minutes and 89.814.05 minutes,
respectively. The results are significant at 95% interval
limits.
None of the patients who underwent the fundus-first
method required conversion either to the cystic duct
method or to an open procedure (Table 1). However, 27
patients in the CLC group required conversion to the
FFLC method. Of these, 3 were further converted to an
open procedure. One patient had a small duodenal perforation during the procedure and had dense adhesions.
She was opened and cholecystectomy along with repair
of duodenal perforation was performed. The other 2
were converted due to dense adhesions.
One patient was excluded from the study because she
had severe hypotension on creation of pneumoperitoneum. The procedure was immediately terminated and
an open procedure performed satisfactorily.
Injuries
One patient had a small duodenal perforation, caused
during separation of the gallbladder from the duodenum
in the CLC group. Due to dense adhesions and fear of
injury, she was converted to an open procedure. The
rent was repaired and a cholecystectomy performed.
Injuries of the Gallbladder Leading to Bile Spillage
The incidence of gallbladder injury was greater in the
conventional group (Table 2). The difference was significant at 95% interval limits. In both groups, the incidence of injury was greater in the severely inflamed
group.

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Effect of Gallbladder Injury and Bile Spillage on

Hospital Stay
The duration of postoperative hospital stay was not
affected by bile leakage from gallbladder injury (with
injury, 28 of 144 patients, 2 days; without injury 118 of
144 patients, 1.9 days). The small difference shown is not
statistically significant. However, the first group did
receive antibiotics for a longer period (3 days versus 1
day for the second group).

DISCUSSION
Laparoscopic cholecystectomy today is regarded as the
gold standard for cholecystectomy. The chief causes for
the increased rate of conversion to open surgery has
been nonvisualization of anatomy at Calots triangle due
to dense adhesions.1,3-5
During the study, hook scissors and dissectors were
used. We did not have the benefit of a Harmonic scalpel.
The obvious advantage of fundus-first laparoscopic
cholecystectomy is evident in the above study by simple

Table 1.
Conversion Rate
Fundus-First Laparoscopic Cholecystectomy
With cholecystitis
0/22
Without cholecystitis

0/23

Conventional Laparoscopic Cholecystectomy

With cholecystitis
23/36 converted to FFLC;
3 further converted to open
Without cholecystitis

4/62 converted to FFL

*1 patient in Conventional Laparoscopic Cholecystectomy group

excluded because her blood pressure fell immediately on creation of pneumoperitoneum; the anesthetist did not allow further continuation of the process.

Table 3.
Injuries of the Gallbladder Leading to Bile Spillage
Fundus-First Laparoscopic Cholecystectomy
With cholecystitis
19/36
Without cholecystitis

3/63

Conventional Laparoscopic Cholecystectomy

With cholecystitis
5/22
Without cholecystitis

1/23

observation of the reduction in conversion to the open

procedure. None of the patients started by the fundusfirst laparoscopic cholecystectomy technique required
conversion to either cystic duct dissection or the open
procedure. On the other hand, 27 of the 98 patients who
started with the conventional laparoscopic cholecystectomy method required conversion. Twenty-three of these
27 were of the severely inflamed group. All of these
patients were first treated with the fundus dissection
method. Only 3 of these patients required conversion to
an open procedure, the rest being completed laparoscopically. Conversions were required in the severely
inflamed group only. Thus, the rate of conversion in the
conventional laparoscopic cholecystectomy group has
decreased from 18.75% (27/144) to 2.08% (3/144). One
patient (hypertensive and asthmatic) was excluded
because she had to be converted to an open procedure;
as soon as pneumoperitoneum was created, she experienced sudden hypotension.
The time taken during surgery on noninflammatory cases
was 50.211.4 minutes and 60.9518.1 minutes for the
conventional laparoscopic cholecystectomy and fundusfirst laparoscopic cholecystectomy group, respectively.
The same procedures performed on the severely
inflamed group took 104.818.6 minutes and 89.814.05
minutes, respectively. This indicates that in the noninflammatory group, fundus-first laparoscopic cholecystectomy technique does not add much; it is in the severely
inflamed cases that the technique really adds to the
armamentarium of the surgeon.
During the study, 1 injury occurred during dissection of
a severely inflamed gallbladder to the duodenum. A pinhead perforation occurred, which was repaired after conversion to open surgery.
Twenty-eight of 144 patients had injury to the gallbladder and subsequent bile leakage and stone spillage. The
incidence was higher in the severely inflamed cases and
in the conventional laparoscopic cholecystectomy group.
The difference is statistically significant within 95% interval limits. This figure compares favorably with that of
other studies, some of which have reported up to a 33%
injury rate.6,7
The bile spillage did not increase the hospitalization rate,
the patients being discharged on an average of 2 days.
This group was however given a good saline wash
laparoscopically and antibiotics for a period of 3 days on

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Evaluation of Fundus-First Laparoscopic Cholecystectomy, Gupta A et al.

a prophylactic basis. No complication has occurred in the

follow-up of these patients.
No patient required blood transfusion, and no injury to
the CBD has been reported.

CONCLUSION
It is thus evident that the technique of fundus-first laparoscopic cholecystectomy is a very useful one. It has a role
in the management of severely inflamed patients and
brings down the rate of conversion. It has provided us
with the safety and confidence to tackle difficult cases
more than is afforded with the open arena.

3. Matsuda M, Oneder K, Kato K, et al. Laparoscopic cholecystectomy from fundus downward. Surg Laparosc Endosc.
1994;4:373-374.
4. Uyama I, Iida S, Ogiwara K, et al. Laparoscopic retrograde
cholecystectomy (from fundus downward) facilitated by lifting
the liver bed up to the diaphragm for inflammatory gallbladder.
Surg Laparosc Endosc. 1995;9:203-206.
5. Martin I, Dexter S, Marton J, et al. Fundus first laparoscopic
cholecystectomy. Surg Laparosc Endosc. 1995;9:203-206.
6. Raj PK, Castillo G, Urban L. Laparoscopic cholecystectomy:
fundus first approach. J Laparoendosc Adv Surg Tech A.
2001;11(2):95-100.

References:

7. Underwood RA, Soper NJ. Laparoscopic cholecystectomy

and choledocholithotomy. In: Blumgart LH, Fond Y, eds. Surgery
of Liver and Biliary Tract. Vol 1. 3rd ed. Oxford: Oxford
University Press; 1994:1209-1241.

1. Kato K, Kasai S, Matsuda M, et al. A new technique for

laparoscopic cholecystectomy: an analysis of 81 cases.
Endoscopy. 1996;28:356-359.

Acknowledgments: We thank Dr Vishal Gupta, Dr Rajat Saxena,

Dr Jai Bikhchandani, Dr Ajai Yadav, and Dr Vivek Gupta for their
contributions to this study.

2. Lahey F. Cholecystectomy. Surg Clin North Am. 1976;56(3):

547-557.

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