SPECIAL ARTICLE

Subtotal Cholecystectomye“Fenestrating” vs
“Reconstituting” Subtypes and the Prevention of
Bile Duct Injury: Definition of the Optimal Procedure
in Difficult Operative Conditions
Steven M Strasberg, MD, FACS, Michael J Pucci, MD, FACS, L Michael Brunt, MD, FACS,
Daniel J Deziel, MD, FACS

Less than complete cholecystectomy has been advocated for difficult operative conditions for more than 100 years. These op-
erations are called partial or subtotal cholecystectomy, but the terms are poorly defined and do not stipulate whether a remnant
gallbladder is created. This article briefly reviews the history and development of the procedures and introduces new terms to
clarify the field. The term partial is discarded, and subtotal cholecystectomies are divided into “fenestrating” and “reconstitut-
ing” types. Subtotal reconstituting cholecystectomy closes off the lower end of the gallbladder, reducing the incidence of post-
operative fistula, but creates a remnant gallbladder, which may result in recurrence of symptomatic cholecystolithiasis. Subtotal
fenestrating cholecystectomy does not occlude the gallbladder, but may suture the cystic duct internally. It has a higher incidence
of postoperative biliary fistula, but does not appear to be associated with recurrent cholecystolithiasis. Laparoscopic subtotal
cholecystectomy has advantages but may require advanced laparoscopic skills. (J Am Coll Surg 2016;222:89e96.
2016
by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Laparoscopic cholecystectomy is a well-established proce- technique, in which the funnel-shaped infundibular-cystic

dure with clear benefits for patients over open cholecystec-
tomy. However, it is associated with an increased rate of
bile duct injury. Biliary injuries occur more commonly
when operations are made more difficult due to the pres-
ence of severe acute and/or chronic inflammation. Under
these conditions, secure ductal identification by the critical
view of safety (CVS) may be very challenging because CVS
requires clearing of the inflamed hepatocystic triangle in
order to demonstrate the cystic duct, cystic artery, and
the cystic plate. It is a rigorous method, but as we have pre-
viously stressed,1,2 this is actually one of the strengths of the
CVS method of identification. The infundibular
Disclosure Information: Nothing to disclose.
Disclosures outside the scope of this work: Dr Brunt receives research sup-
port grants from Gore and Karl Storz Endoscopy.
This article is a work product of the SAGES Safe Cholecystectomy Task
Force 2015.
Received July 28, 2015; Revised September 27, 2015; Accepted September
28, 2015.
From the Section of Hepato-Pancreato-Biliary Surgery (Strasberg) and the
Section of MIS Surgery (Brunt), Washington University in St Louis, St
Louis, MO; the Division of General Surgery, Thomas Jefferson University
Hospital, Philadelphia, PA (Pucci); and the Department of General Sur-
gery, Rush University Medical Center, Chicago, IL (Deziel).
Correspondence address: Steven M Strasberg, MD, FACS, Washington
University in Saint Louis, 4990 Children’s Place, Suite 1160, Box 8109,
Saint Louis, MO 63110. email: strasbergs@wustl.edu
duct junction is the rationale for identification, is much
easier to achieve than CVS. However, biliary inflammatory
fusion and contraction can make the common bile duct
resemble the cystic duct when this technique is used,3
and this increases the chance of biliary injury. The CVS
method protects against injury because when the CVS
has not been achieved after a reasonable trial of dissection,
the surgeon is more likely to realize that conditions are too
difficult to proceed in the usual manner and opt for a
different approach before a biliary injury occurs. It is
good that the CVS method prevents biliary injury, but if
there is to be an effective and safe method of dealing
with difficult gallbladders, it must include a safe and effec-
tive bail-out technique when CVS cannot be attained. By
safe we mean without bile duct injury and by effective we
mean without need for a second operation. Otherwise
the surgeon will be tempted to push on with a risky dissec-
tion in the hepatocystic triangle in order to avoid a second
procedure or perform a cholecystostomy, which will usu-
ally necessitate a second operation. Stated otherwise, it is
commendable when surgeons reach the decision that it is
unsafe to proceed with a total cholecystectomy, but obvi-
ously there should be a good way to finish the procedure
when its time “to get out of Dodge.”
Paradoxically, 2 of the most useful “bail out” proceduresd
partial cholecystectomy and subtotal cholecystectomydare

ª 2016 by the American College of Surgeons. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jamcollsurg.2015.09.019

All rights reserved. 89 ISSN 1072-7515/16
90 Strasberg et al Subtotal Fenestrating Cholecystectomy
Figure 1. Endoscopic retrograde cholangio-pancreatograms (ERCP)
in 2 patients who had subtotal reconstituting cholecystectomies
and became symptomatic again. Gallbladder remnants were iden-
tified by ERCP as enlarged areas at the end of the cystic duct. Right
figure inset shows that stones had reformed or were retained.
not clear and well-defined operations. Even the terms par-
tial and subtotal are imprecise because they fail to encom-
pass an essential element in these operations, which is
whether a functional remnant gallbladder may result as
a consequence of performing these procedures. In 1966,
Bodvall and Overgaard4 defined “gallbladder remnant”
as a wider part of the free end of the cystic duct that gives
the appearance of a diminutive gallbladder.4 Today,
remnant gallbladders may be diagnosed by ERCP
(Fig. 1), magnetic resonance cholangiopancreatography
Figure 2. Magnetic resonance image (MRCP) of remnant gall-
bladder (GB).
J Am Coll Surg
Figure 3. Transabdominal ultrasound of a patient who had a cho-
lecystectomy nearly four years before developing recurrent biliary
colic. A small remnant gallbladder with a retained or reformed stone
was identified (solid arrow) with acoustic shadow (dashed arrow).
(MRCP) (Fig. 2), or by ultrasound (Fig. 3). The func-
tional remnant gallbladder may communicate with the
remainder of the biliary tree just as the parent gallbladder
does. Stones can form or be retained within these rem-
nants and may cause recurrent biliary colic and all of
the usual complications of cholecystolithiasis.The poten-
tial consequences of leaving a gallbladder remnant are
well known. Bodvall and Overgaard4 attributed the first
report of clinically significant complications of gallbladder
remnants after cholecystectomy to Florken in 1912,5 and
summarized literature to 1966. The subject was reviewed
again in 2009 by Pernice and Andreoli.6 A brief summary
of the literature, which is mostly composed of small case
series or case reports, is that gallbladder remnants may
become symptomatic and require excision in a second
operation at any time from shortly after the initial opera-
tion to many years later. The latter is an important point
because most publications dealing with the outcomes of
less than complete cholecystectomy have short patient
follow-up times and therefore, may underestimate the
consequences of leaving a gallbladder remnant. Further-
more, operations to remove remnant gallbladders may
be difficult, so procedures that do not result in remnant
gallbladders are more desirable than those that do (Fig. 4).
Excellent recent systemic reviews of outcomes of proce-
dures reported in papers under the terms partial or subtotal
cholecystectomy by Henneman and colleagues7 and Elshaer
and associates8 are available. The purpose of this paper is
Vol. 222, No. 1, January 2016
Figure 4. Intraoperative photograph at conclusion of laparoscopic
dissection to free a remnant gallbladder (GB) in a patient who had
become symptomatic after a previous subtotal cholecystectomy.
to clarify the procedures that have been described under the
terms partial and subtotal cholecystectomy in respect to
whether they are associated with a potentially functional
remnant gallbladder and then to propose new terms that
more appropriately depict what is actually done in these
procedures. We believe that clarification of the procedures
and what they are called will help surgeons choose what
type of procedure to select and will also facilitate clinical
studies in this area. Based upon referrals to our centers
we strongly suspect that many surgeons still believe that
no good option between cholecystostomy and total chole-
cystectomy is available and that anything less than a com-
plete cholecystectomy may result the need for as second
procedure. As noted earlier, this belief may encourage the
surgeon to push on with dissection in the hepatocystic
triangle when there is danger in doing so, or to do a chol-
ecystostomy when a more satisfactory procedure is availa-
bleeone that will take care of the patient’s problem in a
single operation. Part of the lack of awareness of options
seems to be the confusing terminology. An effective, reli-
able, standard, widely known, and accepted operation
needs to be available when the CVS cannot be achieved.
The CVS is only 1 part of COSIC (culture of safety in cho-
lecystectomy),1,9 and a reliable bail-out operation is another
key component of safety. These operations may also be
helpful when cholecystectomy is difficult due to associated
hepatic cirrhosis.10
A BRIEF HISTORY OF OPERATIONS IN WHICH
ONLY A PART OF THE GALLBLADDER IS
REMOVED
In 1898, Hans Kehr11 operated on a 27-year-old woman
with acute cholecystitis, intending to extirpate the
Strasberg et al Subtotal Fenestrating Cholecystectomy 91
gallbladder. Due to difficult conditions, he removed the
gallbladder such that “the hardened posterior wall and
the part of the bladder lying next to the cystic duct
remained.” He sewed the remaining gallbladder over on
itself, with a strip of gauze as a drain. This seems to be
the first description of a modification of cholecystectomy
due to difficult operative conditions in which the intent
was to remove as much of the gallbladder as possible
without dissecting the inflamed hepatocystic triangle.
The idea was to deal with the gallbladder problem in 1
operation while avoiding the risk of a major biliary or
vascular injury. The next development of subtotal chole-
cystectomy occurred not because of the problem of the
difficult gallbladder, but due to the problem of postoper-
ative bile leakage and bleeding from the liver bed after
routine elective total cholecystectomy. Pribram,12,13 from
Berlin, described a technique in which the gallbladder
was bivalved along its longitudinal axis, stones were
removed, and then thermal ablation of both portions of
the gallbladder wall was performed. The technique con-
sisted of a deep destruction of the wall down to the serosa.
The preserved flaps of serosa were folded and sutured
together to reperitonealize the liver bed. Pribram did
not perform any anatomic resection in these cases, nor
did he use this method to avoid dissection in the region
of the cystic duct in the difficult gallbladder. In fact, he
recommended ligation and division of the cystic duct
and the cystic artery external to the gallbladder, as in total
cholecystectomy. Variations on Pribram’s technique,
which included actual removal of the free portion of the
gallbladder wall and ablation of the remaining portion
attached to the liver, were recommended by Thorek14 in
Chicago and by Bailey and Love15,16 in London. A free
graft of omentum or falciform ligament was sutured
over the remnant gallbladder on the liver. As did Pribram,
however, these surgeons also divided the cystic duct and
artery.
The idea of less than complete cholecystectomy for the
specific purpose of dealing with difficult operative condi-
tions during cholecystectomy was advanced by Estes,17 of
Bethlehem, PA, in 1938. In an operation for gangrenous
cholecystitis on 25 patients, which he termed partial cho-
lecystectomy, the gallbladder was incised longitudinally and
the wall of the gallbladder was excised up to the point that
it was attached to the liver. The part attached to the liver
itself was left behind and the free cut edge of the gall-
bladder was oversewn. The remaining mucosa was treated
with iodine. Estes specifically stated that the cystic duct
was not sutured or ligated and that no part of the gall-
bladder was sutured together to produce a closed cystic
structure, ie, a gallbladder remnant.17 Recovery was
92 Strasberg et al Subtotal Fenestrating Cholecystectomy
generally quite smooth and there were no persistent bile
fistulas. Arthur Lerner,18 of Winnipeg, in 1950 and Wil-
liam McElmoyle,19 of Victoria, British Columbia, in
1954 described variations of this technique, intended
specifically for difficult cholecystectomies and again
without producing a closed cystic structure. Lerner
described 2 cases of “partial cholecystectomy” in which
he resected the free wall of the gallbladder down to the
cystic duct. He noted that the cystic artery would be
cut within or on the wall of the gallbladder as one
trimmed the inferior aspect of the gallbladder wall
near the cystic duct and recommended oversewing the
wall at that point to occlude the vessel. McElmoyle19
described and illustrated, in a singularly clear fashion,
the principles and technique of this operation when per-
formed specifically for the prevention of bile duct or
vascular injury during a difficult cholecystectomy. No
attempt is made to dissect the cystic duct or artery
when inflammation obscures the neck of the gallbladder.
The gallbladder is opened and the redundant portions
excised. The cystic duct and the portions of the body,
neck, and infundibulum lying above and to the left
side are left in situ as a “shield to the vulnerable struc-
tures.” The cystic duct is not closed; its mucosa is ablated
and a drain is placed. McElmoyle19 reported 23 cases
with excellent results and no biliary fistula. What Estes,
Lerner, and McElmoyle all recognized was that a portion
of the gallbladder wall should intentionally be left
behind as a buffer between the edge of the dissection
on the gallbladder and the dangerous hepatocystic trian-
gle.19 This was the “shield” of McElmoyle, which fulfils a
main principle of safety: to stay 1 step away from danger.
McElmoyle’s description was particularly eloquent.
Bornman and Terblanche20 clearly described and illus-
trated a similar operation 30 years later using the name
subtotal cholecystectomy, but gave the option of internal
suture of the cystic duct or external suture over a probe
advanced into the cystic duct from within the
gallbladder.
While these authors were describing their techniques,
others were presenting a modification in which the lowest
portion of the gallbladder was resutured. This step was
done to avoid biliary fistula but may also result in the cre-
ation of a remnant gallbladder. Maingot,21 who contrib-
uted much to the performance of biliary surgery, and
Grey Turner,22 who recognized the seriousness of biliary
injury, suggested a similar approach in 1936 and 1944,
respectively, which they dubbed partial cholecystectomy.
Note that the terms partial and subtotal were used in
some cases to describe the same operation, and in neither
case did the terms indicate whether a remnant gallbladder
was produced.
J Am Coll Surg
MEANING OF PARTIAL AND SUBTOTAL
CHOLECYSTECTOMY AND INTRODUCTION OF
FENESTRATING AND RECONSTITUTING AS
MODIFYING TERMS
Partial in surgical terminology literally means removal of
a part of an organ. It is quantitatively a vague term that
can mean removal of a small or large part of the organ.
Subtotal means removal of almost all of an organ. It is
less vague as to extent. Normally, a partial resection is
less than a subtotal resection, as in the terms partial gas-
trectomy and subtotal gastrectomy. However, a review of
the literature showed that in regard to the gallbladder,
some authors use the term partial to describe a near total
excision7,18,21,23-26; others use the term subtotal to describe
the same extent of resection.8,10,20,27-30 It is a source of
confusion that 2 terms are used for the same procedure.
Furthermore, neither term indicates whether a gallbladder
remnant is produced as a result of the procedure. The lack
of nomenclature relating to gallbladder remnants is also a
source of confusion, so much so that recent review articles
on this subject have subclassified subtotal cholecystec-
tomies7 or pointed out the variations.8 Therefore, 2 ad-
justments to terminology are required, the first to deal
with the overlapping terms partial and subtotal, and the
second to introduce words that will indicate whether a
particular technique leaves a remnant gallbladder or not.
As a starting point, it is suggested that the term subtotal
should be preferred over the term partial to designate
the extent of this resection because subtotal is clearly
more accurate than partial. If only the top half or less
of the gallbladder is removed, which is not what is being
discussed in this article, the term fundectomy would seem
appropriate. In that way, the term partial cholecystectomy
could be completely eliminated in reference to excision
of the gallbladder. Secondly, to designate whether or
not a remnant gallbladder is produced by the procedure,
it is proposed that that the modifiers fenestrating (no gall-
bladder remnant produced [Fig. 5]) and reconstituting
(gallbladder remnant produced [Fig. 6]) be introduced
to describe these operations. Therefore, 2 types of subtotal
cholecystectomies would be recognized, namely, subtotal
fenestrating cholecystectomy and subtotal reconstituting
cholecystectomy.
SUBTOTAL CHOLECYSTECTOMY AND THE
CYSTIC DUCT
As noted in the historical section, the cystic duct and ar-
tery were sometimes ligated external to the gallbladder
when a less than complete cholecystectomy was per-
formed early in the development of cholecystectomy.
But as emphasized by McElmoyle19 and others,17,18 this
Vol. 222, No. 1, January 2016 Strasberg et al Subtotal Fenestrating Cholecystectomy 93

Figure 5. Subtotal fenestrating cholecystectomy. (A) The free, peritonealized portion of the
gallbladder has been excised except for a lip at the lowest portion of the gallbladder. This acts as
a shield to protect against inadvertently entering the hepatocystic triangle (“Shield” of McEl-
moyle). The portion of the gallbladder adherent to the liver has been left in situ. Stones have
been extracted. The cut edge of the gallbladder may be oversewn. The mucosa is usually ab-
lated. The cystic duct may be closed from the inside with a purse-string suture (inset). The cystic
duct may be very short, and attempts to ligate the cystic duct outside the gallbladder may result
in injury to the common bile duct. (B) As in Figure 5A, except a portion of the gallbladder adherent
to the liver has been excised.

method is undesirable when a subtotal operation is per-
formed in the presence of difficult operative conditions.
In fact, to do so, the surgeon must use the infundibular
technique to display the cystic duct. As explained earlier,
this method of identification may be unreliable in the
presence of severe inflammation. Under these conditions,
occlusion of the cystic duct should be attempted only
from the interior of the gallbladder by a purse-string
suture, as described in 1 method by Bornman and
Terblanche.20 The suggested alternative method of
advancing a probe into the cystic duct from the interior
of the gallbladder to identify and ligate the cystic duct

Figure 6. Subtotal reconstituting cholecystectomy. (A) The free, peritonealized portion of the
gallbladder has been excised. The portion of the gallbladder adherent to the liver may be left situ
as in Figure 5A or partially excised as shown here. The lowest portion of the gallbladder is closed
with sutures or staples, reconstituting an intact lumen in which stones may reform. (B) As in
Figure 6A, except that only the lowest part of the gallbladder remains. As in Figure 6A, this is
closed, reconstituting an intact lumen in which stones may reform. Whether the subtotal cho-
lecystectomy is “fenestrating” or “reconstituting” depends on whether the lowest part of the
gallbladder is left open (fenestrating) or closed (reconstituting) and not on the amount of gall-
bladder that is left attached to the liver.
94 Strasberg et al Subtotal Fenestrating Cholecystectomy
external to the gallbladder20 has the potential danger of
advancing the probe into the common bile duct and
mistakenly ligating that duct instead of the cystic duct.
This would be prone to occur when the cystic duct
is very short, as may happen when it is effaced by a
large stone.
SUBTOTAL FENESTRATING CHOLECYSTECTOMY
AND SUBTOTAL RECONSTITUTING
CHOLECYSTECTOMY: ADVANTAGES,
DISADVANTAGES
Subtotal fenestrating cholecystectomy has the advantage
that a remnant gallbladder is much less likely to result
than if the lumen of the gallbladder is re-established at
Hartmann’s pouch, as in the reconstituting technique. If
an ERCP were done immediately after a subtotal reconsti-
tuting cholecystectomy, an area at the end of the cystic
duct wider than the cystic duct would be present and
the criterion of Bodvall and Overgaard4 for the existence
of a gallbladder remnant would be fulfilled. Although
closing over Hartmann’s pouch results in a gallbladder
remnant, it was found, as might be expected, to reduce
the incidence of postoperative bile fistula in the reviews
of subtotal cholecystectomy by Henneman and col-
leagues7 and Elshaer and associates.8 However, although
bile fistula was more common with the fenestrating tech-
nique, these fistulas seem to resolve spontaneously in most
cases.8 Those that do not may be associated with retained
common bile duct stones and relieved endoscopically.
Based on presently available information, it would seem
that the fenestrating type of subtotal cholecystectomy
would be preferable, but knowledge in this area is very
incomplete. There certainly have been no head-to-head
comparisons of fenestrating vs reconstituting techniques.
Furthermore, the extent to which Hartmann’s pouch is
resected is probably quite variable, and the effect of leav-
ing different size remnants on the chance of developing
subsequent symptoms is unknown. In fact, there is no
good information regarding the incidence of symptomatic
gallbladder remnants after subtotal reconstituting or sub-
total fenestrating cholecystectomies. A recent meta-
analysis discussed this issue,8 but articles on the subject
rarely provide long-term follow-up of patients, and gall-
bladder remnants may become symptomatic years after
subtotal cholecystectomy, so good data on this topic are
lacking. Possibly, there is a watershed in the reconstituting
subtotal cholecystectomy procedure in which so little of
the gallbladder lumen is left that it is equivalent to
occluding the lumen of the cystic duct from within the
gallbladder. If so, it must be an occlusion very close to
the cystic duct because some symptomatic gallbladder
J Am Coll Surg
remnants that required excision at a second procedure
had an internal diameter of only about 1 cm. Clearly,
many important aspects of the outcomes of these opera-
tions will not be known until large studies involving small
and large hospitals are available. This will not be possible
using administrative databases because for now, subtotal
cholecystectomy does not have its own CPT code.
The modern technique for performing these operations
is straightforward (Figs. 5 and 6). The gallbladder is
opened along its long axis and emptied of stones,
including removal of stones in the lumen of the gall-
bladder neck and cystic duct if possible. Also, consider-
ation may be given to attempting imaging either via
cholangiography through the lumen of the gallbladder
or with intraoperative ultrasound. In either the fenestrat-
ing or reconstituting type of procedure, the portion of the
gallbladder adherent to the liver is usually left in situ and
ablated. The latter may be done with electrocautery, argon
beam, or saline-linked radiofrequency ablation. Alterna-
tively, some or all of the gallbladder attached to the liver
may be removed (Figs. 5 and 6). When this is done, the
gallbladder wall and cystic plate may be removed down
to bare liver, as shown in the diagrams, or the cystic plate
may be left in situ. The cut edge of the gallbladder
adherent to the liver may be oversewn with a continuous
suture. In some cases, the gallbladder will be gangrenous.
If so, the gangrenous portion should be excised without
extending the extent of the subtotal resection. In the fen-
estrating procedure, the very bottom of the gallbladder
lumen remains open to the peritoneal cavity. There will
be a “lip” or “shield” of gallbladder (Fig. 5), where the
cystic artery branches come onto the gallbladder and these
will be transected at that point. Oversewing the cut edge
of the gallbladder here may be necessary, although when
inflammation is severe, these vessels are sometimes throm-
bosed. The cystic duct may be sutured from the inside us-
ing fine sutures, although this is often not possible. The
area should be carefully drained with 1 or 2 closed suction
drains, depending on the extent of the contamination. In
the reconstituting type, the lip is usually somewhat larger
and the lumen is closed by various means including su-
tures and staplers8 (Fig. 6). Note again that the procedures
are not distinguished by the amount of gallbladder left
adherent to the liver, but by whether or not a closed
remnant gallbladder is created.
LAPAROSCOPIC VS OPEN SUBTOTAL
CHOLECYSTECTOMY
Based on the meta-analysis of Elshaer and coworkers,8 it
seems that a subtotal fenestrating cholecystectomy is
more likely to be done when an open approach is used.
Vol. 222, No. 1, January 2016 Strasberg et al
Paradoxically, in their data, bile leaks were more common
after a laparoscopic procedure. Possibly, this is due to the
improved ability to suture the cystic duct orifice when the
procedure is done open. The ideal procedure in circum-
stances when the CVS cannot be achieved would have
several attributes, including the following:
1. Does not leave a remnant gallbladder that will become
symptomatic and require a later operation.
2. Has low morbidity due to bile fistula. If a fistula occurs
it should resolve spontaneously over a short period.
3. Can be done laparoscopically.
4. Can be done by a general surgeon without additional
fellowship training in hepato-pancreato-biliary or
minimally invasive surgery.
These attributes are, in some cases, in tension with
each other. Subtotal fenestrating cholecystectomies are
understandably less likely to leave a functional gall-
bladder remnant, which might require a second proce-
dure, but are more likely than subtotal reconstituting
cholecystectomies to result in fistulas. Subtotal reconsti-
tuting cholecystectomies are probably easier to do lapa-
roscopically and seem to be favored by minimally
invasive surgeons, but result in the remnant gallbladder
problem.8 Laparoscopic subtotal cholecystectomy pro-
vides the advantages of minimally invasive surgery, but
general surgeons, who do most cholecystectomies in
the US, may not have the skills to do these procedures
laparoscopically.
CONCLUSIONS
Which technique is best may vary with the experience of
the surgeon. For a surgeon experienced in minimally inva-
sive techniques, a subtotal fenestrating cholecystectomy
with drain placement would seem to best fulfill the listed
aims. However, for many surgeons, the safest approach
will be to do an open procedure of the same type. The
key principle, however, should not be lost in the details
of the technique. That principle is that a subtotal fenes-
trating cholecystectomy is a standard operation that
should be used liberally when surgeons encounter diffi-
culty in getting to the CVS. We believe that clarification
of the procedures and what they are called will help sur-
geons choose what type of procedure to select, and it
will also facilitate the performance clinical studies in
this area.
Author Contributions
Study conception and design: Strasberg, Pucci, Brunt,
Deziel
Acquisition of data: Strasberg, Pucci, Brunt, Deziel
Subtotal Fenestrating Cholecystectomy 95
Analysis and interpretation of data: Strasberg, Pucci,
Brunt, Deziel
Drafting of manuscript: Strasberg, Pucci, Brunt, Deziel
Critical revision: Strasberg, Pucci, Brunt, Deziel
Acknowledgment: The authors gratefully acknowledge the
contribution made to this manuscript by Jennifer Brum-
baugh, MA, Webmaster and Medical Illustrator, Depart-
ment of Surgery, Thomas Jefferson University, who
produced Figures 5 and 6. The editors are also grateful to
Dr Martin Hertl, MD, FACS, Rush University Medical
Center, for translation of reference 12.
REFERENCES
1. Strasberg SM. Biliary injury in laparoscopic surgery: part 2.
Changing the culture of cholecystectomy. J Am Coll Surg
2005;201:604e611.
2. Strasberg SM, Brunt LM. Rationale and use of the critical view
of safety in laparoscopic cholecystectomy. J Am Coll Surg
2010;211:132e138.
3. Strasberg SM, Eagon CJ, Drebin JA. The “hidden cystic duct”
syndrome and the infundibular technique of laparoscopic chol-
ecystectomyethe danger of the false infundibulum. J Am Coll
Surg 2000;191:661e667.
4. Bodvall B, Overgaard B. Cystic duct remnant after cholecys-
tectomy: incidence studied by cholegraphy in 500 cases, and
significance in 103 reoperations. Ann Surg 1966;163:
382e390.
5. Floreken H. Gallenblasenregeneration mit Steinrecidive nach
Cholecystectomie. Deutch Z Chir 1912;13:604e606.
6. Pernice LM, Andreoli F. Laparoscopic treatment of stone
recurrence in a gallbladder remnant: report of an additional
case and literature review. J Gastroint Surg 2009;13:
2084e2091.
7. Henneman D, da Costa DW, Vrouenraets BC, et al. Laparo-
scopic partial cholecystectomy for the difficult gallbladder: a
systematic review. Surg Endosc 2013;27:351e358.
8. Elshaer M, Gravante G, Thomas K, et al. Subtotal cholecystec-
tomy for “difficult gallbladders”: systematic review and meta-
analysis. JAMA Surg 2015;150:159e168.
9. Strasberg SM. A teaching program for the “culture of safety in
cholecystectomy” and avoidance of bile duct injury. J Am Coll
Surg 2013;217:751.
10. Palanivelu C, Rajan PS, Jani K, et al. Laparoscopic cholecys-
tectomy in cirrhotic patients: the role of subtotal cholecystec-
tomy and its variants. J Am Coll Surg 2006;203:145e151.
11. Kehr H. Introduction to the Differential Diagnosis of the
Separate Forms of Gallstone Disease: Based upon His Own
Experience Gained from 433 Laparotomies for Gallstones.
Philedelphia: P Blakiston’s Son and Co; 1901.
12. Pribram BO. Mukoklase und drainagelose Gallenchirurgie.
Zentralbl Chir 1928;55:773e779.
13. Pribram BO. The electrosurgical operation in gall-bladder dis-
eases: results of 13 years’ experience. Lancet 1939;234:
927e929.
14. Thorek M. Electrosurgical obliteration of gallbladder without
drainage: a means of reducing mortality. Am J Surg 1936;32:
417e434.
96 Strasberg et al Subtotal Fenestrating Cholecystectomy
15. Baily H, Love RJM. Electrosurgical obliteration of the gall-
bladder without drainage: Thoreks’ operation. Brit Med J
1939;30:682e683. 25.
16. Love RJM. Diathermy dissection of the gall-bladder. Brit Med
J 1947;5:11e13.
17. Estes WL. Acute gangrenous cholecystitis and the use of partial
cholecystectomy in its treatment. Am J Surg 1938;40: 26.
197e204.
18. Lerner AI. Partial cholecystectomy. Can Med Assn J 1950;63: 27.
54e56.
19. McElmoyle WA. Cholecystectomy: a method for the difficult
gall-bladder. Lancet 1954;26:1320e1323.
20. Bornman PC, Terblanche J. Subtotal cholecystectomy: for the 28.
difficult gallbladder in portal hypertension and cholecystitis.
Surgery 1985;98:1e6.
21. Maingot R. Postgraduate Surgery, Vol 1. New York: D. Apple- 29.
ton-Century; 1936:678e679.
22. Gray Turner G. Injuries to the main bile-ducts. Lancet 1944;
13:621e622.
23. Schein M. Partial cholecystectomy in the emergency treatment 30.
of acute cholecystitis in the compromised patient. J Royal Coll
Surg Edin 1991;36:295e297.
24. Subramaniasivam N, Ananthakrishnan N, Kate V, et al. Partial
cholecystectomy in elective and emergency gall bladder surgery
J Am Coll Surg
in the high risk patientsea viable and safe option in the era of
laparoscopic surgery. Tropical Gastroenterol 1996;17:49e52.
Soleimani M, Mehrabi A, Mood ZA, et al. Partial cholecystec-
tomy as a safe and viable option in the emergency treatment of
complex acute cholecystitis: a case series and review of the liter-
ature. Am Surg 2007;73:498e507.
Ibrarullah MD, Kacker LK, Sikora SS, et al. Partial cholecys-
tectomyesafe and effective. HPB Surg 1993;7:61e65.
Kuwabara J, Watanabe Y, Kameoka K, et al. Usefulness of
laparoscopic subtotal cholecystectomy with operative cholangi-
ography for severe cholecystitis. Surg Today 2014;44:
462e465.
Singh K, Matta H, Nain PS, et al. Modification of laparo-
scopic subtotal cholecystectomy. Surgical Endosc 2011;25:
2760.
Singhal T, Balakrishnan S, Hussain A, et al. Laparoscopic sub-
total cholecystectomy: initial experience with laparoscopic
management of difficult cholecystitis. Surgeon J Royal Coll
of Surg Edin & Ireland 2009;7:263e268.
Chaudery M, Hunjan T, Beggs A, Nehra D. Pitfalls in the
use of laparoscopic staplers to perform subtotal cholecystec-
tomy. BMJ Case Rep 2013. Available at: http://casereports.
bmj.com/content/2013/bcr-2013-009047.abstract. Accessed
October 19, 2015.