Accepted Manuscript

A Step-by-Step Guide to Laparoscopic Subtotal Fenestrating Cholecystectomy: A

Damage Control Approach to the Difficult Gallbladder

Sharmila Dissanaike, MD, FACS

PII: S1072-7515(16)30168-5
DOI: 10.1016/j.jamcollsurg.2016.05.006
Reference: ACS 8357

To appear in: Journal of the American College of Surgeons

Received Date: 21 March 2016

Revised Date: 9 May 2016
Accepted Date: 10 May 2016

Please cite this article as: Dissanaike S, A Step-by-Step Guide to Laparoscopic Subtotal Fenestrating
Cholecystectomy: A Damage Control Approach to the Difficult Gallbladder, Journal of the American
College of Surgeons (2016), doi: 10.1016/j.jamcollsurg.2016.05.006.

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A Step-by-Step Guide to Laparoscopic Subtotal Fenestrating Cholecystectomy: A Damage

Control Approach to the Difficult Gallbladder

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Sharmila Dissanaike, MD, FACS

Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX

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Correspondence address:
Sharmila Dissanaike, MD
Texas Tech University Health Sciences Center
Mailstop 8312

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3601 4th St
Lubbock, TX 79430
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806-928-9490
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Running head: Subtotal Cholecystectomy

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Damage control surgery is a concept pioneered in the field of trauma [1], but expanded over the

past decades to emergency general surgery as well. This paper describes a damage control

approach to cholecystectomy, one of the most common general surgical procedures, by using a

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laparoscopic subtotal fenestrating cholecystectomy in cases of severe inflammation discovered

intra-operatively in a patient admitted for acute cholecystitis [2].

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Cholecystectomy remains an operation with a significant incidence of complications despite it

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being one of the most commonly performed procedures in the US. It is widely acknowledged

that cases with dense inflammation may obscure the anatomy and increase the risk of major

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injury including common bile duct injury; several groups including the SAGES Safe
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cholecystectomy task force, have recently proposed approaches that reduce this risk [3].

The traditional paradigm has been that in cases deemed to be technically difficult, the default
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should be to convert to open surgery. This approach is derived from historic precedent in that

cholecystectomy morphed from an open operation to a predominantly laparoscopic procedure in

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a very short time. However, increasing concern at the lack of open cholecystectomy experience
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among recent and future general surgery graduates has called this algorithm into question [4]. In
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addition, there is evidence that conversion does not reduce rates of common bile duct injury,

especially among surgeons less familiar with the open approach [5]. Philosophically, the
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proposal that the fallback option in a difficult case be a procedure that the surgeon is much less
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familiar with is fundamentally unsound.

One salvage option that has been described in the literature is the partial or sub-total

cholecystectomy approach, both open and laparoscopic. A recent meta-analysis of over 30

articles and 1231 total cases of sub-total approaches showing an acceptably low morbidity and

mortality rate, with only one case of common or hepatic bile duct injury. The biggest drawback
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of this approach was the 18% rate of bile leak, which occurred primarily when the cystic stump

was left open. Interestingly, re-operation was necessary in only 1.8% of cases, with bile leaks

usually managed successfully non-operatively [6].While there have been many studies published

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on alternate surgical approaches to cholecystectomy, a drawback has been the inclusion of

varying methods under the banner of “sub-total” or “partial” cholecystectomy, thus rendering it

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difficult to draw conclusions about any given approach. Lack of consistency in nomenclature has

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further worsened the problem. Strasberg and colleagues recently attempted to clarify the

nomenclature by dividing the surgical approaches into fenestrating and reconstituting sub-types

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[2].
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This article describes one alternative to the traditional cholecystectomy, for use in situations

where there is dense fibrotic inflammation in the cystic triangle. The method described in this
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article is a version of laparoscopic fenestrating subtotal cholecystectomy. In my experience, the

procedure described is a definitive operation for the patient’s disease. While the technique
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described here is laparoscopic, a similar open procedure has been described in Zollinger’s Atlas
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of Surgical Operations [7], indicating recognition that converting to an open operation does not
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always allow for safe standard dissection.

Since this procedure is reserved only for cases in which dissection in the Triangle of Calot is
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deemed too unsafe to proceed, this is a limited case series of 15 patients. Patients in the current
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series were predominantly male, with a history of multiple episodes of cholecystitis prior to the

procedure. There were no complications. None of the patients have developed recurrent biliary

symptoms or required re-operation to my knowledge, with time since operation ranging from 6

months to 8 years.
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All patients underwent post-operative ERCP to speed the resolution of biliary drainage and thus

allow for faster drain removal based on author experience; a benefit of post-surgical ERCP has

not been consistently demonstrated in the literature. ERCP does carry a risk of pancreatitis,

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however none of the patients in this series suffered this complication. The JP drain was removed

prior to discharge, and the Malenkot drains was removed once bile output was minimal, with a

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median duration of 3.5 weeks and range of 5 days to 8 weeks. The patient who required 8 weeks

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of drainage was a gentleman with Down’s syndrome who had a large duodenal diverticulum,

precluding biliary stenting through ERCP. The Malenkot drain removal at 5 days was

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unfortunately inadvertent due to an error in communication within the healthcare team; however
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this patient did well and had no adverse sequelae from the premature removal.

Technique:
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The most important step is the decision to convert from a standard cholecystectomy technique to

a damage control approach, by identifying situations where attempts at further dissection in the
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cystic triangle, however careful, will be dangerous due to dense inflammation obscuring
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anatomic features, and increasing the risk of iatrogenic biliary or vascular injury. Once a decision
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to proceed with a damage control operation has been made, the anterior wall of the gallbladder is

incised near the dome in a clear safe zone using an ultrasonic dissector (Fig 1) or similar device.
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Cautery may be used but since hemostasis is essential for the safety of the operation, it is
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preferable to use a device that seals small vessels. Bile is evacuated using suction, and stones are

removed. The dome of the gallbladder is then removed using the hemostatic device.

The remaining anterior wall is then incised superior-inferior, followed by lateral incisions above

the infundibulum, (Fig 2) so that the gallbladder may be opened like a book. This dissection is

kept above the infundibulum and aided by the visualization of both interior and exterior aspects
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of the gallbladder simultaneously, in order to maintain safety and not injure structures that may

be adhered closely. An angled laparoscope (I use a 45° scope) is always used to improve this

visualization. The walls are incised medially and laterally to the junction with the liver, and the

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“leaflets’ of the gallbladder wall then removed completely. The cystic artery or its branches (it

has usually bifurcated at this level) are easily controlled using the ultrasonic dissector. Only the

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posterior wall of the gallbladder completely adherent to the fossa – the cystic plate – is left.

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At this point there should be approximately 1- 2cm of anterior gallbladder wall left as a rim

above the infundibulum. Using careful dissection and the view from both interior and exterior,

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this is trimmed to no more than 1cm above the cystic duct, which can often be visualized from
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the internal aspect through the angled laparoscope. On occasion it is possible to suture ligate the

cystic duct from the inside of remnant infundibulum, but usually the inflammation renders this
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difficult. If the internal orifice of the cystic duct cannot be visualized, an instrument such as a

dissector or grasper can be inserted into the remaining infundibulum to assess the depth by
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palpation, and the infundibulum trimmed to 1cm from the tip of the instrument that is pushed
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against the bottom of the infundibulum (i.e. where the cystic duct orifice would be) (Fig 3).
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Finally the mucosal surface of the remnant posterior wall of the gallbladder is cauterized.

A drain (I usually use a 20Fr Malenkot) is placed at the infundibulum directly above the cystic
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duct, and brought through the skin at the laparoscopic port site directly above. A #10 flat
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Jackson-Pratt drain is left in the gallbladder fossa and brought out through the lateral port site

(Fig 4).

This technique is being described here not because it represents a new technologic advance or a

particularly intricate procedure; rather, it is evident that there is a need for a safe approach to the

difficult gallbladder that is accessible to every surgeon with basic laparoscopic skills in the
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middle of the night, requiring neither special equipment, advanced hepatobiliary training nor

many years of experience. Since there is a paucity of literature that carefully details such an

approach in a step-by-step fashion, it is hoped that this description and the accompanying

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illustrations will serve such a purpose.

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References:

1: Rotondo MF, Schwab CW, McGonigal MD, et al. “Damage control”: an approach for

improved survival in exsanguinating penetrating abdominal injury. J Trauma 1993;35:375–382.

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discussion 382–383.

2. Strasberg SM, Pucci MJ, Brunt LM, Deziel DJ. Subtotal cholecystectomy – fenestrating vs

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reconstituting subtypes and the prevention of bile duct injury: definition of the optimal procedure

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in difficult operative conditions. J Am Coll Surg 2016;222:89-96.

3. Strasberg SM. A teaching program for the "culture of safety in cholecystectomy" and

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avoidance of bile duct injury. J Am Coll Surg 2013;217:751. doi:
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10.1016/j.jamcollsurg.2013.05.001. Epub 2013 May 23. PubMed PMID: 23707046.

4. McCoy AC1, Gasevic E, Szlabick RE, et al. Are open abdominal procedures a thing of the
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past? An analysis of graduating general surgery residents' case logs from 2000 to 2011. J Surg

Educ 2013;70:683-689.
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5. Booij KA, de Reuver PR, Nijsse B, et al. Insufficient safety measures reported in operation
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notes of complicated laparoscopic cholecystectomies. Surgery 2014;155:384-389.

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doi:10.1016/j.surg.2013.10.010. Epub 2013 Oct 12. PubMed PMID: 24439739.

6. Elshaer M, Gravante G, Thomas K, et al. Subtotal cholecystectomy for "difficult

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gallbladders": systematic review and meta-analysis. JAMA Surg 2015;150:159-168. doi:

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10.1001/jamasurg.2014.1219. Review. PubMed PMID: 25548894.

7. Zollinger RM Jr, Zollinger RM Snr. Zollinger’s Atlas of Surgical Operations, eighth edition

McGraw-Hill 2003 pp 204-205

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Figure Legends

Figure 1. Initial incision into the gallbladder wall is made using a hemostatic device near the

dome of the gallbladder, in order to minimize potential injury to vital structure. (© 2016 Kaitlin

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Lindsay, printed with permission.)

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Figure 2. Incision is then extended superiorly and inferiorly, followed by lateral extension to the

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liver, in order to remove the anterior and lateral walls of the gallbladder safely. Concomitant

visualization of both external and internal gallbladder anatomy helps prevent injury during this

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process. (© 2016 Kaitlin Lindsay, printed with permission.)
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Figure 3. The remaining infundibulum is then assessed for depth, and trimmed to 1 cm above the
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cystic duct orifice. The posterior wall of the gallbladder is left undisturbed throughout the

procedure, to prevent iatrogenic right hepatic duct, common bile duct or hepatic artery injury
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caused by dense fibrotic adhesions between these structures and the gallbladder wall, which can
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occur with inferior retraction of the gallbladder in severe inflammation. (© 2016 Kaitlin Lindsay,
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printed with permission.)

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Figure 4: A drain is placed within the cusp of the remaining infundibulum, with a separate drain
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near the gallbladder fossa. This step is especially important if the cystic duct orifice has not been

visualized and ligated. (© 2016 Kaitlin Lindsay, printed with permission.)

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