Subtotal fenestrating cholecystectomy: Optimal ‘bailout’ for difficult cases

Subtotal fenestrating cholecystectomy with drain placement appears optimal, compared with the reconstituting procedure, for experienced surgeons seeking a “bailout” operation in both open and minimally invasive cholecystectomy where the critical view of safety (CVS) is not easily attainable, according to a report written on behalf of the SAGES Safe Cholecystectomy Task Force 2015.

The rise in laparoscopic cholecystectomy has been associated with an increase in the rate of bile duct injury, most commonly when secure ductal identification using CVS is not possible because of an inflamed hepatocystic triangle occluding the cystic duct, cystic artery, and cystic plate. In such cases, a safe and effective bailout technique (one not requiring a second operation) must be decided upon in preference to simply closing and proceeding to a later open procedure, according to Steven M. Strasberg, MD, of Washington University in Saint Louis and his colleagues (J Am Coll Surg. 2016;222:89-96).

In order to clarify the two most common and effective “partial cholecystectomy” procedures being performed, Dr. Strasburg and his colleagues have suggested the use of the term “subtotal” in place of “partial” and the terms “fenestrating” vs. “reconstituting,” to define whether there is an open or closed gallbladder remnant, respectively, after the procedure.

In subtotal fenestrating cholecystectomy, the free peritonealized portion of the gallbladder is excised, except for a tip at the lowest portion that acts as a shield to protect against inadvertently entering the hepatocystic triangle, according to the authors. There is no sealed lumen remaining, thus the cystic duct requires closure. The cystic duct may be closed from the inside with a purse-string suture. Attempts to ligate the cystic duct outside the gallbladder may injure the common bile duct and can potentially result in fistulas.

In subtotal reconstituting cholecystectomy, the free peritonealized portion of the gallbladder is excised, but the lowest portion of the gallbladder is closed with sutures or staples and reconstitutes an intact lumen in which stones may be re-formed, which can in turn require reoperation.

“Whether the subtotal cholecystectomy 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 gallbladder that is left attached to the liver,” according to the authors.

Subtotal fenestrating cholecystectomy is most likely done when an open approach is used, whereas subtotal reconstituting cholecystectomies are probably easier to do laparoscopically and are preferred by surgeons doing minimally invasive procedures, they said.

Despite the fact that there have been no head-to-head comparisons of fenestrating vs. reconstituting techniques, the authors said they prefer the fenestrating method, although the technique chosen may be based on the experience of the surgeon, they noted.

“The principle is that a subtotal fenestrating cholecystectomy is a standard operation that should be used liberally when surgeons encounter difficulty getting to the CVS,” the authors wrote. “We believe that clarification of the procedures and what they are called will help to choose which type of procedure to select, and it will also facilitate the performance of clinical studies in this area,“ they concluded.

The authors reported having no relevant financial disclosures.

A transcript of an interactive discussion of this paper and topic is available online (www.journalacs.org/RAS-ACS-discussion-2016).

[email protected]

Subtotal fenestrating cholecystectomy with drain placement appears optimal, compared with the reconstituting procedure, for experienced surgeons seeking a “bailout” operation in both open and minimally invasive cholecystectomy where the critical view of safety (CVS) is not easily attainable, according to a report written on behalf of the SAGES Safe Cholecystectomy Task Force 2015.

The rise in laparoscopic cholecystectomy has been associated with an increase in the rate of bile duct injury, most commonly when secure ductal identification using CVS is not possible because of an inflamed hepatocystic triangle occluding the cystic duct, cystic artery, and cystic plate. In such cases, a safe and effective bailout technique (one not requiring a second operation) must be decided upon in preference to simply closing and proceeding to a later open procedure, according to Steven M. Strasberg, MD, of Washington University in Saint Louis and his colleagues (J Am Coll Surg. 2016;222:89-96).

In order to clarify the two most common and effective “partial cholecystectomy” procedures being performed, Dr. Strasburg and his colleagues have suggested the use of the term “subtotal” in place of “partial” and the terms “fenestrating” vs. “reconstituting,” to define whether there is an open or closed gallbladder remnant, respectively, after the procedure.

In subtotal fenestrating cholecystectomy, the free peritonealized portion of the gallbladder is excised, except for a tip at the lowest portion that acts as a shield to protect against inadvertently entering the hepatocystic triangle, according to the authors. There is no sealed lumen remaining, thus the cystic duct requires closure. The cystic duct may be closed from the inside with a purse-string suture. Attempts to ligate the cystic duct outside the gallbladder may injure the common bile duct and can potentially result in fistulas.

In subtotal reconstituting cholecystectomy, the free peritonealized portion of the gallbladder is excised, but the lowest portion of the gallbladder is closed with sutures or staples and reconstitutes an intact lumen in which stones may be re-formed, which can in turn require reoperation.

“Whether the subtotal cholecystectomy 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 gallbladder that is left attached to the liver,” according to the authors.

Subtotal fenestrating cholecystectomy is most likely done when an open approach is used, whereas subtotal reconstituting cholecystectomies are probably easier to do laparoscopically and are preferred by surgeons doing minimally invasive procedures, they said.

Despite the fact that there have been no head-to-head comparisons of fenestrating vs. reconstituting techniques, the authors said they prefer the fenestrating method, although the technique chosen may be based on the experience of the surgeon, they noted.

“The principle is that a subtotal fenestrating cholecystectomy is a standard operation that should be used liberally when surgeons encounter difficulty getting to the CVS,” the authors wrote. “We believe that clarification of the procedures and what they are called will help to choose which type of procedure to select, and it will also facilitate the performance of clinical studies in this area,“ they concluded.

The authors reported having no relevant financial disclosures.

A transcript of an interactive discussion of this paper and topic is available online (www.journalacs.org/RAS-ACS-discussion-2016).

[email protected]

Subtotal fenestrating cholecystectomy with drain placement appears optimal, compared with the reconstituting procedure, for experienced surgeons seeking a “bailout” operation in both open and minimally invasive cholecystectomy where the critical view of safety (CVS) is not easily attainable, according to a report written on behalf of the SAGES Safe Cholecystectomy Task Force 2015.

The rise in laparoscopic cholecystectomy has been associated with an increase in the rate of bile duct injury, most commonly when secure ductal identification using CVS is not possible because of an inflamed hepatocystic triangle occluding the cystic duct, cystic artery, and cystic plate. In such cases, a safe and effective bailout technique (one not requiring a second operation) must be decided upon in preference to simply closing and proceeding to a later open procedure, according to Steven M. Strasberg, MD, of Washington University in Saint Louis and his colleagues (J Am Coll Surg. 2016;222:89-96).

In order to clarify the two most common and effective “partial cholecystectomy” procedures being performed, Dr. Strasburg and his colleagues have suggested the use of the term “subtotal” in place of “partial” and the terms “fenestrating” vs. “reconstituting,” to define whether there is an open or closed gallbladder remnant, respectively, after the procedure.

In subtotal fenestrating cholecystectomy, the free peritonealized portion of the gallbladder is excised, except for a tip at the lowest portion that acts as a shield to protect against inadvertently entering the hepatocystic triangle, according to the authors. There is no sealed lumen remaining, thus the cystic duct requires closure. The cystic duct may be closed from the inside with a purse-string suture. Attempts to ligate the cystic duct outside the gallbladder may injure the common bile duct and can potentially result in fistulas.

In subtotal reconstituting cholecystectomy, the free peritonealized portion of the gallbladder is excised, but the lowest portion of the gallbladder is closed with sutures or staples and reconstitutes an intact lumen in which stones may be re-formed, which can in turn require reoperation.

“Whether the subtotal cholecystectomy 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 gallbladder that is left attached to the liver,” according to the authors.

Subtotal fenestrating cholecystectomy is most likely done when an open approach is used, whereas subtotal reconstituting cholecystectomies are probably easier to do laparoscopically and are preferred by surgeons doing minimally invasive procedures, they said.

Despite the fact that there have been no head-to-head comparisons of fenestrating vs. reconstituting techniques, the authors said they prefer the fenestrating method, although the technique chosen may be based on the experience of the surgeon, they noted.

“The principle is that a subtotal fenestrating cholecystectomy is a standard operation that should be used liberally when surgeons encounter difficulty getting to the CVS,” the authors wrote. “We believe that clarification of the procedures and what they are called will help to choose which type of procedure to select, and it will also facilitate the performance of clinical studies in this area,“ they concluded.

The authors reported having no relevant financial disclosures.

A transcript of an interactive discussion of this paper and topic is available online (www.journalacs.org/RAS-ACS-discussion-2016).

[email protected]