If cholecystectomy, either open or laparoscopic, appears hazardous because of severe inflammation, if the gallbladder is partially buried in the liver, or if structures in the cystic duct region cannot be safely identified, a subtotal cholecystectomy may be the safest course of action. Subtotal cholecystectomy, also known as partial cholecystectomy, also should be strongly considered for patients with cirrhosis and portal hypertension because attempts to remove the back wall of the gallbladder will result in significant hemorrhage that can be extremely difficult to control.
In subtotal cholecystectomy, the infundibulum of the gallbladder is left in situ in order to prevent inadvertent bile duct injury in the setting of severe inflammation. The back wall of the gallbladder can be left attached to the liver or removed partially or completely along with the peritoneal side of the gallbladder wall. Nevertheless, two different types of subtotal cholecystectomies have been described based on management of the cystic duct. In fenestrated subtotal cholecystectomy, the infundibulum is left open, though the cystic duct can be closed internally. In reconstituted subtotal cholecystectomy, the infundibulum is closed, typically with 3-0 absorbable sutures. Whereas the reconstituted type has a lower incidence of biliary leak, it is associated with a higher incidence of recurrent symptoms of cholelithiasis.
In the presence of acute cholecystitis, preoperative treatment depends on the severity and duration of the attack. Early operation is indicated in patients seen within 48 hours of the onset, as soon as fluid balance and antibiotic coverage have been established. Anticipating the degree or severity of inflammation is helpful for patient counseling, ensuring the necessary assistance and expertise, and considering alternative therapeutic strategies. Radiographic findings, laboratory values, clinical signs (e.g., fever, tenderness, and/or tachycardia), patient comorbidities (e.g., diabetes mellitus), and duration of symptoms may all suggest the severity of inflammation that might be anticipated. Percutaneous cholecystostomy may be considered for patients with anticipated severe cholecystitis or for those who are too ill to tolerate surgery. These patients may undergo interval cholecystectomy in 6 weeks.
The patient is placed in the usual position for gallbladder surgery (see Chapter 74). If local anesthesia is used, the position may be modified slightly to make the patient more comfortable.
The skin is prepared in the usual manner. Then a time-out is performed.
Incision and exposure are carried out as shown in Chapter 74.
Subtotal cholecystectomy can be performed in either an open or laparoscopic fashion. Given the severity of inflammation that is typically present when subtotal cholecystectomy is considered, the open approach is more common and ...