Merseyside laparoscopic cholecystectomy course, Royal Liverpool Academy.

1. LESS-THAN-TOTAL
LAPAROSCOPIC CHOLECYSTECTOMY:
HOW I DO ITATAINTREE
Raimundas Lunevicius
Consultant Surgeon & Honorary Senior Lecturer
Emergency, Trauma, Biliary, Hernia Surgery
Aintree University Hospital NHS Foundation Trust, Liverpool, England
13th July 2018
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2. Total or Less-Than-Total?
What would you think?
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3. Total or Less-Than-Total?
What would you think?
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Perforated
Perforated
Acute inflammatory mass partially detached
Gn: Zone of Hartmann’s pouch

4. Laparoscopic subtotal cholecystectomy:
aim to achieve best quality of S-TC
PRINCIPLES
To remove as much of gallbladder wall as you can
To remove all calculi from the remnant of gallbladder
To ablate mucosa of hepatic wall of the gallbladder
To close the stump of the gallbladder, when safe
Challenges / specific populations 4

5. Variants of sub-total cholecystectomy
• Circular subtotal excision
• Removal of peritoneal wall, just
• Fundectomy
• Other
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6. Types of completion of sub-total
cholecystectomy
• Reconstituting
• Fenestrating
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7. Variants of sub-total cholecystectomy
• Circular subtotal excision: most common
• A range of techniques
• One aim:
• to remove as much tissues (and calculi) as
possible
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8. Detach surrounding tissues/organs and identify Hartmann’s pouch
Insert large gallbladder retrieval bag, if you would plan to incise
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Perforated
Perforated
Acute inflammatory mass partially detached
Gn: Zone of Hartmann’s pouch

9. Exposure is the key
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Hartmann’s pouch exposed more but not fully
S4BS5

10. Retrieval bag is in
Incise gallbladder transversally
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Hartmann’s pouch

11. Remove all gallstones
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12. Retrieval bag place laterally (or above the liver)
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Hartmann’s pouch
Peritoneal wall
Gallstones

13. Complete excision of peritoneal wall
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Hartmann’s pouch
Peritoneal wall
Mucosa of hepatic wall
Large gallstone in the
neck of gallbladder

14. Inspect the remnant of gallbladder well
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Large gallstone in the
neck of gallbladder
S5 S4B
Omentum
Mucosa

15. Remove all calculi from the remnant of
gallbladder
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Large gallstone from the
neck of gallbladder removed

16. Remove all calculi from the remnant of gallbladder: it was
deep proximal portion (Gn), as predicted before S-TC
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Large gallstone from the
neck of gallbladder removed

17. Another case:
peritoneal + hepatic walls as two components
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Cystic plate
Hepatic wall
Peritoneal wall
Gn

18. Another case: Commonest variant of laparoscopic S-TC
circular 80-90% S-TC, reconstituting type.
Example: postoperative specimen & 350 gallstones
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19. Another case: Peritoneal (anterior) wall excision JUST,
and removal of 10 gallstones from intrahepatic
gallbladder
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20. Summary points: for sub-total LC
• Do it
• when you can’t achieve sufficient WOS
• for true intrahepatic G
• for solid inflammatory pericholecystic mass when fundus is visible or
exposable (fundectomy)
• for subhepatic abscess (not all)
• A few variants / sub-variants: know them
• Much more difficult than total LC
• Performing this surgery, provide the best quality of it
• Circular excision is the best option (when possible)
• Two types of completion of sub-total LC:
• reconstituting and fenestrating
• NB! Morbidity associated with S-TC is significant
• Laparoscopic STC is the alternative to open surgery. WHY?
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21. Practice summary since the moment of my first laparoscopic
less-than-total cholecystectomy:
setting – EGS: EMERGENCY or DELAYED OPERATIONS
12/2013 2014 2015 2016 2017 07/2018 Total
Open cholecystectomy 0 0 0 0 0 0 0
Laparoscopic cholecystectomy 1 27 84 94 57 52 315
Conversion rate 0 0 0 0 0 0 0
Bile duct injury rate: Strasberg A, B, C, D, E 0 0 0 0 0 0 0
Stomach or small bowel injury rate 0 0 0 0 0 0 0
Colon injury rate 0 0 0 0 0 0 0
Major haemorrhage & haemotrasfusion 0 0 0 0 0 0 0
Diaphragm injury rate 0 0 0 0 0 0 0
Abandoned planned cholecystectomy 0 0 0 0 2 0 2 (0.6%)
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Abandoned planned cholecystectomies: follow up: one patient was recognized as unfit for open
surgery and discharged from HB clinic, and one patient underwent elective subcostal laparotomy,
incision of the fundus of the gallbladder, removal of gallstones, closure of fundus as
cholecystoduodenal and cholecystocolonic fistulae were highly probable (under HB Team)