Difficult Gallbladder

1. Carlos A. Córdova Velázquez
Residente de segundo año de Cirugía General
Centro Médico Nacional “La Raza”
Texcoco, Estado México a 11 de Mayo de 2021
Safe cholecystecomy
JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS
Difficult Gallbladder

2. Dissanaike S, A Step-by-Step Guide to Laparoscopic Subtotal Fenestrating Cholecystectomy: A Damage Control Approach to the Difficult Gallbladder, Journal of the American College of
Surgeons (2016), doi: 10.1016/j.jamcollsurg.2016.05.006.
Safe Cholecystectomy

3. Dissanaike S, A Step-by-Step Guide to Laparoscopic Subtotal Fenestrating Cholecystectomy: A Damage Control Approach to the Difficult Gallbladder, Journal of the American College of
Surgeons (2016), doi: 10.1016/j.jamcollsurg.2016.05.006.
Safe Cholecystectomy
This paper describes a damage control approach to cholecystectomy, one of the most common general surgical procedures,
by using a laparoscopic subtotal fenestrating cholecystectomy in cases of severe inflammation discovered intra-operatively
in a patient admitted for acute cholecystitis.
Strasberg and colleagues recently attempted to clarify the nomenclature by dividing the surgical approaches into
fenestrating and reconstituting sub-types.
This article describes one alternative to the traditional cholecystectomy, for use in situations where there is dense fibrotic
inflammation in the cystic triangle.

4. Dissanaike S, A Step-by-Step Guide to Laparoscopic Subtotal Fenestrating Cholecystectomy: A Damage Control Approach to the Difficult Gallbladder, Journal of the American College of
Surgeons (2016), doi: 10.1016/j.jamcollsurg.2016.05.006.
Safe Cholecystectomy
The most important step is the decision to convert from a standard cholecystectomy technique to a damage control approach, by
identifying situations where attempts at further dissection in the cystic triangle, however careful, will be dangerous due to dense
inflammation obscuring anatomic features, and increasing the risk of iatrogenic biliary or vascular injury.
The Parkland Grading Scale for Cholecystitis (PGS)

5. Dissanaike S, A Step-by-Step Guide to Laparoscopic Subtotal Fenestrating Cholecystectomy: A Damage Control Approach to the Difficult Gallbladder, Journal of the American College of
Surgeons (2016), doi: 10.1016/j.jamcollsurg.2016.05.006.
Safe Cholecystectomy

6. Kohn JF et al., Long-term outcomes after subtotal reconstituting cholecystectomy: A retrospective case series, The American Journal of
Surgery, https://doi.org/10.1016/j.amjsurg.2020.01.030
Safe Cholecystectomy
In situations where inflammation, adhesions, or obscured anatomy make
dissecting the triangle of Calot difficult or impossible, subtotal
reconstituting cholecystectomy has been proposed as a safe option to
complete the procedure without risking an injury to the common bile duct
or other critical structures in the area.

7. Dissanaike S, A Step-by-Step Guide to Laparoscopic Subtotal Fenestrating Cholecystectomy: A Damage Control Approach to the Difficult Gallbladder, Journal of the American College of
Surgeons (2016), doi: 10.1016/j.jamcollsurg.2016.05.006.
Safe Cholecystectomy
Fig. 2. Subtotal reconstituting cholecystectomy. Retaining the bottom portion of
the gallbladder avoids dissection within the hepatocystic triangle. The remaining
portion of the gallbladder is closed with sutures or staples, forming a new
reconstituted gallbladder lumen. The posterior wall may be retained or removed.
The existence of a closed remnant at the end of the procedure differentiates
reconstituting from fenestrating cholecystectomy.

8. Dissanaike S, A Step-by-Step Guide to Laparoscopic Subtotal Fenestrating Cholecystectomy: A Damage Control Approach to the Difficult Gallbladder, Journal of the American College of
Surgeons (2016), doi: 10.1016/j.jamcollsurg.2016.05.006.
Safe Cholecystectomy
Fig. 1. Subtotal fenestrating cholecystectomy. By not excising the lowest
portion of the gallbladder, accidental damage to the hepatocystic triangle
during dissection is avoided. The cystic duct may be closed from the inside
(inset). The posterior wall of the gallbladder may be fully retained or mostly
removed.

9. Dissanaike S, A Step-by-Step Guide to Laparoscopic Subtotal Fenestrating Cholecystectomy: A Damage Control Approach to the Difficult Gallbladder, Journal of the American College of
Surgeons (2016), doi: 10.1016/j.jamcollsurg.2016.05.006.
Safe Cholecystectomy
Figure 1. Initial incision into the gallbladder wall is made using a
hemostatic device near the dome of the gallbladder, in order to
minimize potential injury to vital structure.
Figure 2.Incision is then extended superiorly and inferiorly, followed by
lateral extension to the liver, in order to remove the anterior and lateral
walls of the gallbladder safely. Concomitant visualization of both external
and internal gallbladder anatomy helps prevent injury during this process.

10. Dissanaike S, A Step-by-Step Guide to Laparoscopic Subtotal Fenestrating Cholecystectomy: A Damage Control Approach to the Difficult Gallbladder, Journal of the American College of
Surgeons (2016), doi: 10.1016/j.jamcollsurg.2016.05.006.
Safe Cholecystectomy
Figure 3. The remaining infundibulum is then assessed for depth, and trimmed to 1
cm above the cystic duct orifice. The posterior wall of the gallbladder is left
undisturbed throughout the procedure, to prevent iatrogenic right hepatic duct,
common bile duct or hepatic artery injury caused by dense fibrotic adhesions
between these structures and the gallbladder wall, which can occur with inferior
retraction of the gallbladder in severe inflammation.
Figure 4: A drain is placed within the cusp of the remaining infundibulum, with
a separate drain near the gallbladder fossa. This step is especially important if
the cystic duct orifice has not been visualized and ligated.

11. Dissanaike S, A Step-by-Step Guide to Laparoscopic Subtotal Fenestrating Cholecystectomy: A Damage Control Approach to the Difficult Gallbladder, Journal of the American College of
Surgeons (2016), doi: 10.1016/j.jamcollsurg.2016.05.006.
Safe Cholecystectomy
A drain (I usually use a 20Fr Malenkot) is placed at the infundibulum
directly above the cystic duct, and brought through the skin at the
laparoscopic port site directly above. A #10 flat Jackson-Pratt drain is left in
the gallbladder fossa and brought out through the lateral port site

12. GRACIAS