Laparoscopic Subtotal Fenestrating Cholecystectomy in a Cirrhotic Patient

In patients with difficult gallbladders due to anatomy prohibiting a clear critical view of safety, a subtotal cholecystectomy can be considered as a safer alternative to a total cholecystectomy.^1, 2, 5 Subtotal cholecystectomies can be divided into “reconstituting” or “fenestrating.” Subtotal reconstituting cholecystectomies include closing off the lower end of the gallbladder to create a remnant gallbladder, while subtotal fenestrating cholecystectomies do not occlude the gallbladder and instead may involve suturing the cystic duct.¹ The most common indication for subtotal fenestrating cholecystectomy is inflammation in the hepatocystic triangle, and subtotal fenestrating cholecystectomy has proven to be useful specifically for patients with a history of cirrhosis.^{1, 2, 6, 7} 

This case report describes the performance of a subtotal fenestrating cholecystectomy for the management of acute on chronic cholecystitis in a patient with cirrhosis initially managed with transcystic stent placement endoscopically. Management of this patient’s omental adhesions to the gallbladder required alterations to typical surgical technique, which will be described in this report. Additionally, we will discuss the indications for subtotal fenestrating cholecystectomy and the benefit of this technique to specific patient populations presenting with acute on chronic cholecystitis. 

Minimally invasive surgery; subtotal cholecystectomy; cirrhosis; acute on chronic cholecystitis. 

Patients with symptomatic cholelithiasis or calculous cholecystitis typically present with colicky right upper quadrant pain and are eligible for an elective cholecystectomy. Patients with a history of cirrhosis (especially patients qualifying as Child-Pugh category B or C) have a high risk of complications from laparoscopic cholecystectomy. Therefore, patients with cirrhosis may be candidates for alternative procedures such as advanced endoscopy interventions including transcystic stent placement. One recent study showed transcystic stent placement had a 97% clinical success rate in treating recurrent cholecystitis in cirrhotic patients.¹ However, this procedure does carry the risk of the stent becoming obstructed. In the aforementioned study, 15% of patients had adverse events at some point in their recovery, with pancreatitis and cholangitis from recurrent obstruction of the biliary ducts being the most common events.¹ If stenting fails, patients with challenging anatomy such as inflammation in the hepatocystic triangle may benefit from a subtotal fenestrating cholecystectomy.¹ Subtotal cholecystectomy does pose a risk of recurrent cholelithiasis and cholecystitis in the remaining gallbladder tissue requiring completion cholecystectomy; however, this risk is small if the residual gallbladder remnant is less than 2.5 cm. The risks of subtotal fenestrating cholecystectomy in cirrhotic patients generally outweigh the benefits in patients due to their anatomy and physiology creating dangers in routine total laparoscopic cholecystectomy.^2, 8

Here we present the case of a 62-year-old male who presented to the emergency department for right upper quadrant pain in the setting of recurrent acute cholecystitis status post transcystic duct stent placement 6 months prior to this admission. The patient had a past medical history of recurrent cholelithiasis and cholecystitis, biliary strictures, prior alcohol use disorder, end stage liver disease, hypertension, and deep venous thrombosis. The patient’s surgical history also includes inguinal hernia repair, bilateral cataract removal, knee arthroplasty, and shoulder repair surgery. He does not smoke tobacco products and smokes marijuana daily. His last alcoholic drink was in 2020.

His American Society of Anesthesiologist score (ASA) was 3. His preoperative complete blood count and basic metabolic panel were within normal limits with the exception of a blood glucose level of 144 and a platelet count of 108,000. His MELD score was 9 and his Child-Pugh score was 5 (Child class A).

The patient described severe, waxing and waning, sharp pain in the right upper quadrant of his abdomen. He had tenderness to palpation over the right upper quadrant, but a negative Murphy’s sign. He did not appear jaundiced and did not have ascites. All other physical exam findings were within normal limits. His BMI was 22.93.

The patient underwent right upper quadrant ultrasound during his evaluation. Ultrasound findings were notable for liver enlargement with cirrhotic morphology and coarsened echotexture. The gallbladder had circumferential wall thickening and contained multiple gallstones. There was a small amount of simple appearing pericholecystic fluid at the gallbladder tip. No sonographic Murphy’s sign was elicited. The common hepatic duct measured 0.3 cm.

Symptomatic cholelithiasis or biliary colic causing acute cholecystitis is treated with a minimally invasive cholecystectomy. In patients where standard total cholecystectomy may be contraindicated due to anatomy which obscures the critical view of safety, a subtotal cholecystectomy may be performed. Less than complete cholecystectomies have been described as early as 1938. These operations were originally termed subtotal or partial cholecystectomies, with the two terms being used interchangeably.¹ In order to decrease confusion surrounding terms, it was proposed in 2016 to refer to all cholecystectomies that were less than complete cholecystectomies as subtotal cholecystectomies. Additionally, subtotal cholecystectomies were categorized into fenestrating and reconstituting types.¹ Subtotal cholecystectomies still do not have a separate CPT code, which may lead to difficulties when conducting retrospective chart reviews. Further research surrounding subtotal cholecystectomies and stronger coding standardization for these procedures is needed.¹ Current research suggests that the rate of total cholecystectomies to subtotal cholecystectomies is approximately 13:1.⁹

The patient had previously undergone several ERCP procedures with transcystic stent placement but still had recurrent pain from cholecystitis due to stent clogging, indicating the need for cholecystectomy. History of ERCP is not associated independently with the need for subtotal cholecystectomy versus a total cholecystectomy. However, history of cirrhosis and other preoperative morbidities causing inflammation of the hepatocystic triangle is associated with the need for a subtotal cholecystectomy over a total cholecystectomy.¹⁰

In one study, nearly 20% of subtotal cholecystectomies had postoperative complications including bile duct leakage. However, patients undergoing subtotal cholecystectomies have higher preoperative morbidity than patients undergoing total cholecystectomy, which may confound this statistic.¹¹ In one prospective study, all 71 patients who underwent subtotal cholecystectomy had no complications at 1 year post-op.⁷ Subtotal cholecystectomies theoretically pose the risk of retained stones necessitating subsequent total cholecystectomy. However, one recent study showed all patients requiring repeat completion cholecystectomy after subtotal cholecystectomy had residual gallbladder remnants greater than the recommended size.⁸ The need for a completion cholecystectomy after a subtotal cholecystectomy is not an ideal outcome. However, in case reports where completion cholecystectomy was subsequently required, the patient was ultimately able to achieve complete resolution of symptoms. Therefore, in patients where total cholecystectomy is initially contraindicated it is reasonable to begin with a subtotal cholecystectomy.¹²

Some studies have shown an increased rate of retained stones and bile leaks in fenestrated subtotal cholecystectomies when compared to reconstituting subtotal cholecystectomies.^5,9 However, contrasting research has shown no difference between rates of complications from reconstituting subtotal cholecystectomies and fenestrating cholecystectomies.¹¹ Ultimately, the decision to conduct a fenestrating versus reconstructive subtotal cholecystectomy should be up to surgeon preference as there is no consensus on significant differences in postoperative complications.²

Elective cholecystectomy was recommended for this patient due to his recurrent cholecystitis and the ineffective management of his symptoms with transpapillary cystic duct stents. Subtotal cholecystectomy is the safest option for patients with cirrhosis if a critical view of safety cannot be achieved. In this case, a fenestrating subtotal cholecystectomy was performed over a reconstituting approach due to surgeon preference.  A laparoscopic approach was chosen due to surgeon preference and in concordance with recent data which suggests converting to open cholecystectomy instead of proceeding with laparoscopic subtotal cholecystectomy had significantly higher rates of severe complications.³

Here we discuss the case of a 57-year-old male who presented with acute on chronic calculous cholecystitis in the setting of multiple failed transpapillary cystic duct stenting and a past medical history significant for alcoholic cirrhosis. The patient underwent a laparoscopic fenestrating subtotal cholecystectomy with removal of previously placed cystic duct stents.

For laparoscopic subtotal cholecystectomies, trocar placement is crucial for success so that instruments have adequate reach and the surgeon is able to discern appropriate exposure. For this patient, 5-mm ports were placed in the supraumbilical, right midclavicular line, and right lateral quadrant. An 11-mm port was placed in the epigastrium. Upon exposure of the gallbladder, omental adhesions to the gallbladder were slowly and carefully removed with hook electrocautery. Ultrasonic energy is an option in place of monopolar electrocautery in laparoscopic cholecystectomy, but recent studies do not advocate strongly for either approach and so monopolar electrocautery was chosen based on cost efficiency and surgeon preference.⁴ Many patients with recurrent cholecystitis will have a thickened gallbladder wall due to chronic inflammation. This was the case with our patient, and the thickened gallbladder wall was entered about one-third of the way down the gallbladder body, and the anterior wall of the gallbladder was therefore transected to fully expose the lumen of the gallbladder and visualization of the cystic duct orifice. Pigmented stones were removed completely from the gallbladder lumen. The two previously placed cystic duct stents that were across the cystic duct were removed and the cystic duct orifice was visualized. Subsequently, the surgeon placed a figure-of-eight stitch with 3-0 PDS to occlude the cystic duct orifice. In order to place the stitch with appropriate visualization, an additional 5-mm trocar was placed to aid in retraction and exposure of the cystic duct orifice. Following this stitch, the anterior wall of the gallbladder was removed to the level of the fundus, and this portion of the gallbladder and the stents were removed in a 10-mm Endo Catch bag. The posterior wall of the gallbladder was subsequently cauterized to prevent formation of a future mucocele. The fossa was then irrigated to clear debris from the dissected area. The surgeon elected to leave a 19 French JP within gallbladder fossa.

The operation lasted approximately 2 hours and was well tolerated. There was an estimated blood loss of 10 cc. Postoperatively, the patient’s pain was well controlled and his JP drain output remained serosanguinous. His liver function tests were within normal limits and no evidence of hepatic decompensation was identified clinically. The patient had a prothrombin time within normal limits at baseline and therefore did not require preoperative vitamin K or fresh frozen plasma products. He did have chronic thrombocytopenia (108,000); however, he did not receive any platelet transfusion. His albumin remained within normal limits and did not require albumin as part of resuscitation during his hospital stay. He was kept adequately hydrated by 30 mL/hour infusion of lactated ringer’s solution preoperatively and 100 mL/hour infusion of lactated ringer’s solution postoperatively with mindful consideration to stop IVF once adequate PO intake as achieved. He was discharged home on postoperative day 1. Following the procedure, his JP drain was removed on postoperative day 5 given its low serous output.

This laparoscopic subtotal fenestrating cholecystectomy was performed using Olympus laparoscopic tools including laparoscopic grasping forceps and electrocautery tools. The surgical field was visualized by an Olympus high-resolution video endoscopy system including two high-resolution color monitors. A 19 French JP catheter was left within the gallbladder fossa.

Nothing to disclose.