JK SCIENCE

ORIGINALARTICLE

A Profile of Fundus First Laparoscopic Cholecystectomy

Kailash Singh, Bharti D Thaker*, S. L. Kachroo

Abstract
Fundus first laparoscopic cholecystectomy is becoming an option with experienced laparoscopic surgeons
to deal with difficult anatomy at Calot's triangle and thereby reducing the conversion rate and rate of
complications. Fundus first laparoscopic cholecystectomy was done in 40 patients between three year.
There were 26 female & 14 male patients with mean age of 36 years (range 29-64). Reasons for opting
for fundus first method were: dense adhesions at Calot's trianglein 26 patients, stones in Hartmann's
pouch with short cystic duct 8 , small contracted gall bladder in 4 and Mirizzi's syndrome in 2 patients.
Mean operating time was 96 minutes (range 80-135 mts). 3 Patients were converted to open cholecystectomy
because of obscure anatomy, intraoperative hemorrhage and CBD injury. The Patient with CBD injury
was managed by hepaticojejunostomy. 5 Patients developed postoperative biliary fistula and one Patient
had prolonged ileus. Out of the 5 Patients 2 were managed with percutaneous drainage and the biliary leak
stopped and 3 Patients required ERCP and stenting. The Patient with ileus was managed conservatively
and was discharged on the 6th day. The average hospital stay was 4 days. Fundus first laparoscopic
cholecystectomy offers the surgeon the same safety and versatility during laparoscopic cholecystectomy
that it confers during open cholecystectomy. It is a viable and a safe option in the hands of an experienced
laparoscopic surgeon and it helps in reducing the conversion rate and may also decrease the risk of injury
to biliary system.

Key Words
Fundus First, laparoscopic Cholecystectomy

Introduction
Since the time Philipe Mouret in 1987 in France
performed the first laparoscopic Cholecystectomy (LC)
on a human patient, (1) we have come a long way &
today laparoscopic choleystectomy has become the gold
standard for gall bladder surgery.(2,3) Over the last
decade, many expert laparoscopic surgeons prefer to do
laparoscopic choleystectomy even in patients with
significant periductal inflammation due to acute
choleystitis or chronic, fibrotic, contracted 'burnt-out' gall
bladders. It is important to identify the structures at the
Calot's triangle at the time of cystic duct isolation. In the
case where a stone is incarcerated in the neck of the gall
bladder or where cystic duct is very short with firm
adhesions around it, the operative anatomy of the bilary
tree may not always be clear. In such cases, the incidence
of vasculobiliary injury is very common in laparoscopic
cholecystectomy than in conventional open surgery. The
incidence of bile duct injury is 0.5% to 0.9% in LC as
compared to 0.1% to 0.4% in open cholecystectomy.(4,5)
In this respect the Fundus first laparoscopic
cholecystectomy is considered as an alternative method
to decrease vasculobiliary injuries and reduce conversion
rate.(6) Further conversion to open choleystectomy leads
to the loss of advantages of this minimally invasive
procedure and significantly increases the length of hospital
stay as well as its cost.(7)
Therefore it was proposed to take up this retrospective
study of Fundus first laparoscopic cholecystectomy in
Patients with obscure anatomy at the calot's triangle with
a view to evaluate its indications and clinical out come.
Material and Methods
The study was carried out in a single surgical unit of

From the PG Deptt. of General Surgery & *Pathology, Govt. Medical College, Jammu J&K
Correspondence to : Dr.Kailash Singh, Lecturer Deptt. of Surgery GMC Jammu J&K - India

Vol. 17 No. 1, Jan - Mrach 2015 www.jkscience.org 43

 JK SCIENCE
the post graduate Deptt. of Surgery, Govt. Medical
College, Jammu, over a period of 3years. A retrospective
record of 40 patients initially taken for conventional
laparoscopic cholecystectomy but due to difficult anatomy
at the Calot's triangl were done by using fundus first
dissection method was kept and results analysed. The
inlucsion criteria for taking patient for LC was the
presence of ultrasound proven gallstones. Patients were
excluded from the study if there was evidence of common
bile duct stones, a bilio-entric fistula, or evidence of
carcinoma of the gall bladder and patients not fit for
general anaesthesia.The procedure was explained to the
patients & written informed consent obtained.The patients
age ranged from 29-64 years (mean 36years); 26 were
females and 14 were males. Standard laparoscopic set
was used. In all patients 4 trocars were used and the
initial dissection done by the same technique as is done in
conventional LC as described in the literature.(1-3)
However after the initial dissection, it was found that
dissection at the Calot's triangle was difficult due to dense
adhesions (26 cases), stones in Hartmann's pouch with
short cystic duct (8 cases), small contracted gall bladder
(4 cases) and Mirizzi's syndrome (2 cases). Therefore, it
was decided to complete laparoscopic cholecystectomy
by fundus first dissection. 30 degree telescope was used
in all the Patients. In 13 patients the liver could not be
retracted safely using a simple grasping instrument so a
closed grasper (7 cases) or suction canula (6 cases) was
used. None of the patients required an additional port.
The Fundus first laparoscopic cholecystectomy was
carried out with dissection of the lateral attachement of
the gall bladder liver junction, followed by dissection of
the superior border of gall bladder-liver junction and then
the medial border was dissected. Dissection of the triangle
of the Calot's was done at the end. Sharp dissection using
electro cautery was used initially however near the neck
of the gall bladder blunt or hydrodissection was used.
While doing dissection of the gallbladder from the liver,
hemostasis of the liver bed was maintained. Once lower
end of gall bladder was reached, it was milked with
atraumtic forceps to prevent residual stones in the stump
or migration of stones into CBD, intracorporal knots were
used to ligate the stump in 3 cases, transfixation of stump
with 2-0 polyglactin on needle was done in 25 cases and
endolooping of stump could be carried out in 12 cases.
Frequent use of irrigation and suction was must to keep
the area clear. In 5 cases there was spillage of the stones
and endobag (Finger glove) was used to retrieve them
and extensive wash with saline was given. After removal
of gall bladder a drain was kept in the morisson'spouch.
44 www.jkscience.org
Patients were put on third generation cephalosporins in
addition to usual post-operative treatment.
Results
Of the 40 patients 26 (65%) were women and 14
(35%) were men. The mean age of the patients was 36
years (range 29-64 years). Reasons for doing Fundus
first laparoscopic cholecystectomy was difficult dissection
of the Calot's triangle due to dense adhesions (26 cases),
stone in Hartmann's pouch with short cystic duct (8 cases),
small contracted gall bladder (4 cases) and Mirizzi's
syndrome (2 cases). The mean operating time was 96
mts (range 80-135 mts). 3 Patients were converted to
open cholecystectomy because of obscure anatomy,
intraoperative hemorrhage and CBD injury. The Patient
with CBD injury was managed by hepaticojejunostomy.
5 Patients developed postoperative biliary fistula and one
Patient had prolonged ileus. Out of these 5 Patients 2
were managed with percutaneous drainage and the biliary
leak stopped on the 8th and 12th day. 3 Patients required
ERCP and stenting, the drain output in these Patients
became nil on the 10th,12th and 15th day. In all these 5
Patients check ultrasonography was done to see any intra-
abdominal collection, once there was no collection the
drain was removed. The Patient with ileus was managed
conservatively and was discharged on the 6th day. In 5
cases, there was spillage of stones while removing gall
bladder and endo bag ( finger glove) was used to retrieve
them. The average hospital stay was 4 days (range 1-15
days ). There was no mortality. Histopathology showed;
chronic cholecystitis in 34, xanthogranulomatous
Cholecystitis in 4 and acute necrotizing cholecystitis in 2
gall bladder specimen. (Fig 1)
Discussion
After its introduction in 1987, laparoscopic
cholecystectomy (LC) gained widespread acceptance and
became the new gold standard for management of gall
stone disease. During early learning phase there were
reports of increased bile duct injuries,(8) however with
Surgeons gaining experience it came down considerably.
During LC when there is difficult anatomy at the
calot'striangle,dissection by conventional technique
increases the risk of bile duct injuries.(9) In such situations
the fundus first dissection method is recognized as a safe
technique and it minimizes the risk of injuries to the biliary
structures. (10-12) In addition several authors have
reported that Fundus first laparoscopic cholecystectomy
helps to avoid conversion to open surgery. The magnified
view at laparoscopy is a big advantage. Conversion leads
to the loss of advantages of minimal access surgery and
significantly increases the length of hospital stay as well
Vol. 17 No. 1, Jan - March 2015
 JK SCIENCE
the post graduate Deptt. of Surgery, Govt. Medical
College, Jammu, over a period of 3years. A retrospective
record of 40 patients initially taken for conventional
laparoscopic cholecystectomy but due to difficult anatomy
at the Calot's triangl were done by using fundus first
dissection method was kept and results analysed. The
inlucsion criteria for taking patient for LC was the
presence of ultrasound proven gallstones. Patients were
excluded from the study if there was evidence of common
bile duct stones, a bilio-entric fistula, or evidence of
carcinoma of the gall bladder and patients not fit for
general anaesthesia.The procedure was explained to the
patients & written informed consent obtained.The patients
age ranged from 29-64 years (mean 36years); 26 were
females and 14 were males. Standard laparoscopic set
was used. In all patients 4 trocars were used and the
initial dissection done by the same technique as is done in
conventional LC as described in the literature.(1-3)
However after the initial dissection, it was found that
dissection at the Calot's triangle was difficult due to dense
adhesions (26 cases), stones in Hartmann's pouch with
short cystic duct (8 cases), small contracted gall bladder
(4 cases) and Mirizzi's syndrome (2 cases). Therefore, it
was decided to complete laparoscopic cholecystectomy
by fundus first dissection. 30 degree telescope was used
in all the Patients. In 13 patients the liver could not be
retracted safely using a simple grasping instrument so a
closed grasper (7 cases) or suction canula (6 cases) was
used. None of the patients required an additional port.
The Fundus first laparoscopic cholecystectomy was
carried out with dissection of the lateral attachement of
the gall bladder liver junction, followed by dissection of
the superior border of gall bladder-liver junction and then
the medial border was dissected. Dissection of the triangle
of the Calot's was done at the end. Sharp dissection using
electro cautery was used initially however near the neck
of the gall bladder blunt or hydrodissection was used.
While doing dissection of the gallbladder from the liver,
hemostasis of the liver bed was maintained. Once lower
end of gall bladder was reached, it was milked with
atraumtic forceps to prevent residual stones in the stump
or migration of stones into CBD, intracorporal knots were
used to ligate the stump in 3 cases, transfixation of stump
with 2-0 polyglactin on needle was done in 25 cases and
endolooping of stump could be carried out in 12 cases.
Frequent use of irrigation and suction was must to keep
the area clear. In 5 cases there was spillage of the stones
and endobag (Finger glove) was used to retrieve them
and extensive wash with saline was given. After removal
of gall bladder a drain was kept in the morisson'spouch.
44 www.jkscience.org
Patients were put on third generation cephalosporins in
addition to usual post-operative treatment.
Results
Of the 40 patients 26 (65%) were women and 14
(35%) were men. The mean age of the patients was 36
years (range 29-64 years). Reasons for doing Fundus
first laparoscopic cholecystectomy was difficult dissection
of the Calot's triangle due to dense adhesions (26 cases),
stone in Hartmann's pouch with short cystic duct (8 cases),
small contracted gall bladder (4 cases) and Mirizzi's
syndrome (2 cases). The mean operating time was 96
mts (range 80-135 mts). 3 Patients were converted to
open cholecystectomy because of obscure anatomy,
intraoperative hemorrhage and CBD injury. The Patient
with CBD injury was managed by hepaticojejunostomy.
5 Patients developed postoperative biliary fistula and one
Patient had prolonged ileus. Out of these 5 Patients 2
were managed with percutaneous drainage and the biliary
leak stopped on the 8th and 12th day. 3 Patients required
ERCP and stenting, the drain output in these Patients
became nil on the 10th,12th and 15th day. In all these 5
Patients check ultrasonography was done to see any intra-
abdominal collection, once there was no collection the
drain was removed. The Patient with ileus was managed
conservatively and was discharged on the 6th day. In 5
cases, there was spillage of stones while removing gall
bladder and endo bag ( finger glove) was used to retrieve
them. The average hospital stay was 4 days (range 1-15
days ). There was no mortality. Histopathology showed;
chronic cholecystitis in 34, xanthogranulomatous
Cholecystitis in 4 and acute necrotizing cholecystitis in 2
gall bladder specimen. (Fig 1)
Discussion
After its introduction in 1987, laparoscopic
cholecystectomy (LC) gained widespread acceptance and
became the new gold standard for management of gall
stone disease. During early learning phase there were
reports of increased bile duct injuries,(8) however with
Surgeons gaining experience it came down considerably.
During LC when there is difficult anatomy at the
calot'striangle,dissection by conventional technique
increases the risk of bile duct injuries.(9) In such situations
the fundus first dissection method is recognized as a safe
technique and it minimizes the risk of injuries to the biliary
structures. (10-12) In addition several authors have
reported that Fundus first laparoscopic cholecystectomy
helps to avoid conversion to open surgery. The magnified
view at laparoscopy is a big advantage. Conversion leads
to the loss of advantages of minimal access surgery and
significantly increases the length of hospital stay as well
Vol. 17 No. 1, Jan - March 2015
 JK SCIENCE

Table.1 Demographical Detail Table.3. Histopathology Findings (n=40)

Total n=40
Women 26 (65%) Chronic cholecystitis 34(85%)
Men 14 (35%)
Mean age of the patients 36 years Xanthogranulomatous Cholecystitis 4 (10%)
Range of the Age 29-64 years
Mean operating time was 96 mts Acute necrotizing cholecystitis in 2(5%)
Conversion Rate (7.5%) Fig.1 Histopathology Showing Xanthogranulomatous
Converted to open cholecystectomy 3 Cholecystitis HNE (40x10)
Complication Rate (20%)
Intraoperative hemorrhage 1
CBD injury 1
Postoperative biliary fistula 5
Prolonged ileus 1
Table 1 Distribution of Cases According To Indications of
Fundus First Dissection
Dense Adhesions At Calot’s 26
Hartmans Pouch Stones 08
With Short Wide Cystic Duct
Small Contracted Gall Bladder 04 Post-operative complication rate in our study was
Mirizzi"S Syndrome 02 16.2% (6/37). This is more as copared to a postoperative
Total 40 complication rate of 0% by Barham M, (14) 3% (1/33)
as cost.(7) In our study 3 Patients (7.5%) were converted by Huang SM et al. (20) and 3.5% (2/57) by Martin IG
to open cholecystectomy due to obscure anatomy, et al. (6) According to the literature postoperative biliary
intraoperative hemorrhage and CBD injury. This is more leak may be minorarising from a small accessory bile
as compared to 0% conversion rate by Kelly MD,(13) duct it is clinically insignificant and should be treated with
Barham M (14) and 2.7% by Wang YC et al (15) but percutaneous drainage. (21) On the other hand, a major
less than 14.8% by Gupta et al (16) and 20% by Tuveri leak due to injury to a main duct or retained stones in the
et al. (17) CBD may result in biliary fistula, peritonitis, or bilioma.
The mean operating time in this study was 96 minutes (22,23) In such cases ERCP helps in diagnosis and
(range 80-135mts). This compares favourably with Martin management. We had only 5 case of postoperative biliary
IG et al. (6) (90 mts with a range of 35-240 mts.), fistula in our study. 5 Patients developed postoperative
Mahmud S et al. (18) (125 mts with a range of 50-230 biliary fistula and one Patient had prolonged ileus. Out of
mts.) and Tuveri M et al.(17) (65 mts with a range of 40- the 5 Patients, 2 were managed with percutaneous
170 mts.). It is our observation that the operarting time drainage and the biliary leak stopped on the 8th and 12th
decreases as the experience of the surgeon to deal with day. 3 Patients required ERCP and stenting, the drain
difficult anatomy at the calot's triangle increases. output in these Patients became nil on the 10th,12th and
The mean duration of hospital stay was 4 days (range 15th day. In all these 5 Patients check ultrasonography
1 to 15 days). This hospitalization compares favourably was done to see any intra-abdominal collection, once there
with 3.5 days by Lirici et al. (19) and 2.2 days by Kelly was no collection the drain was removed and the Patient
MD (13) The longer duration of hospital stay as compared discharged. The Patient with ileus was managed
to conventional laparoscopic chlecystectomy can be conservatively and was discharged on the 6th post-
explained by the fact that most of the gall bladders had operative day.
adhesions at the calot's triangle and dissection left a large The indications for doing fundus first dissection in our
area of raw surface and oozing, so drain had to be kept study were dense adhesios (24 cases), stones in the
in the for a longer time in morrison's pouch to evacuate Hartmann's pouch with short cystic duct (8cases), small
postoperative fluid or blood. Seconly the six Patients with contracted gall bladder (4 cases) and Mirizzi's syndrome
complications had longer stay, the longest being 15 days. (2cases). In the study by Turcu F et al.(24) the indications

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 JK SCIENCE
were dense adhesions (14 cases), large hartmann's 8.
stones(10 cases), short dilated cystic duct (3 cases) and
mirizzi's syndrome (3 cases). Similarly the indications in
9.
the study by Kelly MD (13) were contracted gallbladder
(7 cases) and mirizzi's syndrome (2 cases). Some authors
have recommended the routine use of Fundus first
laparoscopic cholecystectomy rather than reseving it for 10.
difficult cases. (25, 26) In our view, it should not be
routine procedure as surgeons are not trained routinely 11.
for this method. Moreover, harmonic scalpel as
recommended by these authors is not available in every
setup and fundus first dissection is complex and requires 12.
more experience in technique and suturing. We
13.
reccomend fundus first laparoscopic cholecystectomy
only in difficult cases with definite indications as observed 14.
in our study.
Conclusion
Fundus first laparoscopic cholecystectomy is a safe 15.
and viable option in the management of difficult
laparoscopic cholecystectomy with definite indications
and should not be routine procedure because of technical
difficulties. The use of standard trocars as used in 16.
conventional laparoscopic cholecystectomy, experienced
laparoscopic surgeon and magnified view during surgery
offer the flexibility in approach. Management of stump 17.
does not require endostapler essentially as it can be
managed by suturing . Fundus first laparoscopic
cholecystectomy minimizes the risk of damage to the
structures in and around calot's triangle. It decreases the 18.
rate of conversion thereby giving the patient the benefits
of laparoscopic surgery and also reduces the rate of bile
duct injuries and other associated injuries The procedure 19.
should be performed by experienced laparoscopic
surgeon and conversion to open surgery is still an option
and should not be deemed a failure.
20.
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