1. Introduction

2. Laparoscopic Port Placement and Identification of Gallbladder

3. Lysis of Adhesions

4. Incision of Gallbladder Visceral Peritoneum and Exposure of the Infundibulum

5. Dissection of the Hepatocystic Triangle

6. Transition to Subtotal Cholecystectomy When Triangle of Safety Unable to be Visualized

7. Removal of Gallbladder Content

8. Transection of Gallbladder Wall

9. Removal of Internal Biliary Drainage Catheters, Inspection of Gallbladder, and Hemostasis

10. Identification and Ligation of Cystic Duct Orifice

11. Resection of Anterior Gallbladder Wall

12. Hemostasis of Remnant Posterior Gallbladder Wall, and Inspection of Ligated Cystic Duct

13. Removal of Specimen and Final Inspection

14. Drain Placement

15. Laparoscopic Port Removal and Closure

16. Post-op Remarks

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. 

<h4>CHAPTER 1</h4>

<p>Hi there. My name is Dr. Nicole Cherng.
I am a general surgeon at UMass Memorial Hospital
in Worcester, Massachusetts.
Today the case that I will be presenting
is a laparoscopic cholecystectomy
in a 60-something-year-old gentleman.
He has known alcoholic cirrhosis.
He presented many months ago with acute cholecystitis,
and at that time,
given his cirrhosis and his medical comorbidities,
it was deemed that he would be a better candidate
for endoscopic placement of transcystic stents.
This was done, and the patient did have good relief;
however, he then had clogging of the stents
and he had recurrent cholecystitis,
so he underwent an exchange of those stents
as well as the placement of a common bile duct stent.
He continued to have multiple admissions
with recurring cholecystitis,
and it was deemed that the transcystic stents were failing,
so it was decided that we would proceed
with a cholecystectomy
for definitive care with the higher risks,
and my plan for the operating room
would be a laparoscopic cholecystectomy
and also removal of the transcystic stents.</p>

<h4>CHAPTER 2</h4>

<p>Here, we enter the abdomen with a Veress needle
to obtain pneumoperitoneum.
Once I reach 15 mmHg,
I then place a 5-mm supraumbilical port.
An angled laparoscope, I use a 5-mm, 30-degree scope.
While I am placing the three other trocars
in the right upper quadrant,
it is immediately obvious the severely cirrhotic liver
that is visualized.
This is not surprising given the patient's history.
After placing all of my ports,
I then positioned the patient in reverse Trendelenburg
with the left side down.
Visualization of the right upper quadrant does show evidence
of the omental adhesions to the gallbladder.
Part of these omental adhesions easily come off
with positioning as well as gentle retraction.
I am able to visualize the gallbladder
and able to retract the fundus towards the right shoulder.</p>

<h4>CHAPTER 3</h4>

<p>I can tell that there are now some chronic adhesions
of the omentum to the wall of gallbladder.
These adhesions are generally evident
in someone who's had multiple episodes of biliary colic
or symptomatic cholelithiasis,
which this patient clearly had.
Given the appearance of the gallbladder,
I would deem this a picture more consistent
with chronic cholecystitis.
Retracting the fundus of the gallbladder
towards the right shoulder,
and then using the retraction of the omentum
down towards the pelvis,
I have good tension to take down these omental adhesions
with the hook electrocautery.
The duodenum now comes clearly into view.
I use short bursts of monopolar cautery
such that the thermal spread towards the duodenum
is minimal.
Now, with more of the gallbladder exposed,
I'm able to use a locking laparoscopic wavy retractor
to grasp the fundus of the gallbladder
and retract this towards the right shoulder.</p>

<h4>CHAPTER 4</h4>

<p>I continue to lyse the band of tissue
that is tethering the duodenum
to the infundibulum of the gallbladder.
I'm sure to stay closer to the gallbladder side
as the duodenum falls away.
I carry my dissection medially towards the liver
such that I can continue to expose the cholecystic triangle.
Here, you can tell that the patient's tissue
is very pliable and very inflamed.
It's very oozy.
This is not surprising given the patient's cirrhosis
and likely predisposing coagulopathy and thrombocytopenia.
I continue my dissection bed
towards the body of the gallbladder.
The peritoneum is incredibly thickened,
another common finding seen in chronic cholecystitis.
I do the same along the lateral aspect of the gallbladder,
taking down the peritoneum.
Here, I'm clearly staying high along the gallbladder.
I'm well above the sulcus.
At this point, in a more standard elective cholecystectomy,
after taking down the peritoneum
of the anterior and posterior portion of the infundibulum,
generally for most patients, we would have a sense
of where the cystic duct and the cystic artery lie,
and we would then proceed
to skeletonize those two structures.
However, here it's very evident
that this is incredibly inflamed and fused
and scarred in as well,
so I therefore then with good retraction of the infundibulum
in my left hand with the laparoscopic grasper,
I continue to use the hook electrocautery.
I continue to use the hook electrocautery
to take down the second layer
of incredibly thickened peritoneum
in hopes that it'll show me the critical structures.</p>

<h4>CHAPTER 5</h4>

<p>I do the similar move
on the lateral backside of the gallbladder.
At this point, the interface of the infundibulum
to the cystic duct is not fully clear to me.
Here on the posterior lateral side of the gallbladder,
I take down the second layer of very thickened peritoneum
in hopes to better define the edge of the infundibulum.
As you can see, it's very thickened in well.
It appears to be clear through the hook.
It feels thicker tissue than I expect,
and so I stopped there
and moved to another part of the gallbladder.
I continue on the lateral backside,
staying high along the gallbladder
to find the gallbladder edge.
I carry this dissection straight back towards the liver bed.
When I flip the gallbladder back towards the front,
it's very evident to me that there's clearly a hole
within the body of the gallbladder
just above the level of the infundibulum.
At this point, what is going through my head
is now at the hole within the gallbladder,
I am committed to having to move forward.
I know that at the minimum
I will need to do some form of subtotal cholecystectomy.
So what is critical for me now
is to find the cystic duct and cystic artery.
I go back and forth between the hook electrocautery
as well as the suction irrigator as a blunt dissector.
Here along the backside of the gallbladder
I have a sense based off of haptic feedback
as well as visualization,
that I am coming down to the level
of the edge of the infundibulum of the gallbladder.
And I continue to sweep bluntly
this very thickened peritoneum off of it
to further expose it.
Within the hole of the gallbladder that I made,
I visualize the plastic transcystic transpapillary stents
that were previously placed.</p>

<h4>CHAPTER 6</h4>

<p>Pigmented gallstones are suctioned out as well.
Here I find the edge of the infundibulum of the gallbladder.
And at this point, I deemed
that within the cholecystic triangle it will not be feasible
for me to skeletonize the critical view of safety.
I therefore elect
that I will do a subtotal fenestrating cholecystectomy.
In order to do so, I know that I need to develop the window
between the gallbladder and the liver plate.
I therefore transition along the body of the gallbladder
to stay safe to find this window.
Here, I am bluntly dissecting the posterior wall
of the gallbladder off of the peritoneal edge.
I transitioned to the lateral backside of the gallbladder
in hopes to find that same plane and connect the two.
With the gallbladder more decompressed,
now that the hole in the gallbladder is made,
I do think I have better retraction with my left hand
to find that same plane so that I can meet the two.

</p><h4>CHAPTER 7</h4>

However, now the retraction of the gallbladder
and the amount of force that has been placed
and thinned out the gallbladder wall,
I have created a hole
in the backside of the gallbladder as well.
Once again, the transpapillary plastic stent is visualized,
as well as multiple pigmented gallstones
are now coming out of the gallbladder.
I know that both holes
are within the body of the gallbladder,
given that I see the stent as well as multiple gallstones.
My dissection is - the holes are also well above the area of the dissection,
and so I do not think that at this point
that any danger has been done.
As I try to develop a plane
between the posterior wall of the gallbladder
from the liver plate,
I continue to cause a fair amount of shear injury
to the wall of the gallbladder,
such that it continues to become - that hole becomes wider.

<h4>CHAPTER 8</h4>

So at this point, I elect
that instead I'll just connect those two holes,
which means transecting the anterior wall
of the gallbladder.
I'm high up, well above the dissection bed,
well away from the cystic duct, cystic artery,
as well as the common bile duct.<p></p>

<h4>CHAPTER 9</h4>

<p>Now you can see that the body of the gallbladder
has been essentially transected, about 80% of it.
The two previously placed transpapillary transcystic ducts
stents are visualized.
I remove both of those,
as they're clearly obstructing my view,
and we no longer need them.
These are plastic stents.
They're very small and they're safe to come out.
I also clean out and suction out
and remove the multiple pigmented black stones seen.
My goal at this point is to identify the cystic duct orifice
and suture that off with plans for a drain.
The patient had a preoperative common bile duct stent
placed as well.
I will often have the advanced gastroenterologist
place the common bile duct stent
before these very difficult gallbladders
who've had multiple interventions
such as either transpapillary cystic duct stents,
or percutaneous cholecystostomy tube placements,
because I know that these oftentimes
cause significant chronic inflammation and scarring,
and therefore will pose a fairly difficult gallbladder,
and the patients are counseled
that oftentimes the subtotal cholecystectomy
is more likely than not to be performed,
and so by placing the common bile duct stent
before the surgery,
I know that therefore I can minimize
the amount of bile leakage
if anything does occur, postoperatively.
Here, I continue to clean out multiple pigmented stones,
and just achieving hemostasis here
before we move on with our subtotal cholecystectomy.
Clearly, we can see where the catheter is sitting
within the cystic duct orifice.
This is where I'll plan to stitch the cystic duct orifice.</p>

<h4>CHAPTER 10</h4>

<p>Here, the cystic duct orifice is visualized.
In order for me to place an adequate stitch,
I would need adequate exposure, so I actually elect
to place an additional 5-mm trocar
along the right lateral abdomen.
That's where you see the additional blunt grasper
holding the cuff of the infundibulum of the gallbladder,
such that I could easily visualize the cystic duct orifice
and then have two hands
to be able to place a stitch laparoscopically.
Here, I've chosen to use a 3-0 PDS suture.
Oftentimes, I'll use some form of an absorbable suture,
either a 3-0 PDS or a 3-0 Vicryl
to ligate the cystic duct orifice.
Depending on the angle, I either place a figure-of-8 stitch
or I'll do interrupteds.
While this part is tedious
because the ports are often not set up for sewing,
I do think it's important.
With a common bile duct stent in place,
any sort of a bile leak will most likely slow with time
as this area scars down.
However, I do think that this helps
to prevent the spillage of bile
and speed up that process for the patients,
and does provide a level of reassurance as well.
So here, I've placed a figure-of-8 stitch with a 3-0 Vicryl.
No bile is seen exiting the cystic duct orifice
after the stitch is placed.
It should be noted
that it was only very minimal bile even before.
To complete the subtotal cholecystectomy,
the remainder of the fundus
in the body of the gallbladder is removed,
and any remainder of the back wall of the gallbladder
that stays on is generally fulgurated
with the hook electrocautery to prevent a future mucocele.</p>

<h4>CHAPTER 11</h4>

<p>I also fulgurate the remaining infundibulum mucosa
of the gallbladder.
Here, the anterior wall of the gallbladder
is being taken down in a top down approach.</p>

<h4>CHAPTER 12</h4>

<p>That portion of the gallbladder
is ultimately sent off to pathology, and for this patient
it did show acute-on-chronic cholecystitis.
Here, we see some more significant bleeding
along the edge of the posterior peritoneum.
This is likely a branch of the cystic artery,
and I therefore then use clips to achieve hemostasis.
Once again, the overall ooziness of the patient
is not surprising given his liver cirrhosis
and baseline coagulopathy.
And while the bleeding looks fairly impressive on the video,
the actual estimated blood loss in this case
was less than 100, and he did not require any transfusions.
Here, we use the hook electrocautery to fulgurate the mucosa
of the posterior wall of the gallbladder.
I reexamined the area of dissection
as well as the placement of the stitch.
No bilious output from the cystic duct orifice
is really appreciated.
Once everything is cleaned up and I remove the specimen
as well as any visualized gallstones seen,
I planned to place a 19 French JP within the dissection bed.</p>

<h4>CHAPTER 13</h4>

<p>Postoperatively, the patient did stay overnight
in the hospital.
From a liver cirrhosis standpoint,
he had no hepatic decompensation and actually did very well.
His drain was a minimal serosanguineous output,
and he was ultimately discharged home on post-op day 1.
The drain was removed on post-op day 5,
as he had no bilious output
and only minimal serous output thereafter.
Final inspection of the gallbladder fossa
shows good hemostasis.</p>

<h4>CHAPTER 14</h4>

<p>Here, in the last steps of the case,
we see the placement of the 19th French JP
that sits in the gallbladder fossa.
This ultimately sits within the gallbladder fossa,
as well as under the right lobe of the liver bed.
I think this case brings up a few good points:
one, that laparoscopic cholecystectomy is safe
in patients with cirrhosis;
secondly, that while we have come far
with our advanced endoscopy techniques,
in that transpapillary stents do play a role -
they often do lead to a fair amount of scarring
and inflammation of the gallbladder,
should a surgeon choose to proceed
with a definitive cholecystectomy.
And lastly,
that for a subtotal fenestrating cholecystectomy,
I think technically having an additional port
helps with any suturing
and ligating of the cystic duct orifice,
and either preoperatively or soon postoperatively,
placement of a common bile duct stent
can help with any form of a bile leak
and accelerate its healing process.
Placement of a few pieces of Surgicel
within the gallbladder fossa, just given how oozy it was.</p>

<h4>CHAPTER 15</h4>

<p>[No Dialogue.]</p>

<h4>CHAPTER 16</h4>

<p>In the case that you just saw,
we did a laparoscopic subtotal fenestrating cholecystectomy.
In this case, you were able to see
that the gallbladder was severely chronically inflamed
and had a very thickened gallbladder wall.
Given this, it was unsafe to proceed
with trying to skeletonize
the traditional critical view of safety,
and at one point, given how thick the wall was,
I did end up entering the gallbladder.
So at that point,
my plan for the operating room did have to change,
and I could see the two transcystic stents,
which I did remove.
I did at that point then open up the gallbladder
to identify the cystic duct orifice.
I think it's important to identify
that during that and how difficult that dissection was,
I did place an additional port
to help with retraction and assistance,
which was very helpful for me in this case.
And I did place a stitch at the cystic duct orifice.
He already has a common bile duct stent in place,
so I knew that that would also help
with the bilious drainage.
And then I took off the anterior wall of the gallbladder.
I then also cauterized the back wall,
the posterior wall of the gallbladder
that I intentionally left in place
to prevent a future mucocele.
And then I placed the JP drain at the end of the case
to help with any bilious drainage that I can monitor,
and also, you know,
just given how contaminated the field was
to also help with that.</p>


Watch this full-length, narrated surgical video of a laparoscopic fenestrating cholecystectomy performed by Dr. Nicole Cherng at UMass Memorial Medical Center.

UMass Memorial Medical Center