The difficult laparoscopic cholecystectomy: a narrative review

Abstract

Background/purpose: Laparoscopic cholecystectomy is one of the most commonly performed general surgical procedures. Difficult laparoscopic cholecystectomy is associated with increased operative time, hospital stay, complication rates, open conversion, treatment costs, and mortality. This study aimed to provide a comprehensive literature review on difficult laparoscopic cholecystectomy.

Methods: A literature search was conducted for articles published in English up to June 2024 using common databases including PubMed/MIDLINE, Web of Science, Google Scholar, and ScienceDirect. Keywords included "safe laparoscopic cholecystectomy", "difficult laparoscopic cholecystectomy", "acute cholecystitis", "prevention of bile duct injuries", "intraoperative cholangiography," "bailout procedure," and "subtotal cholecystectomy". Only clinical trials, systematic reviews/meta-analyses, and review articles were included. Studies involving children, robotic cholecystectomy, single incision laparoscopic cholecystectomy, open cholecystectomy, and cholecystectomy for indications other than gallstone disease were excluded.

Results/discussion: Emergency laparoscopic cholecystectomy for acute cholecystitis is ideally performed within 72 h of symptom onset, with a maximum window of 7-10 days. Intraoperative cholangiography can help clarify unclear biliary anatomy and detect bile duct injuries. In the "impossible gallbladder", laparoscopic cholecystostomy or gallbladder aspiration may be considered. When dissection of Calot's triangle is deemed hazardous or impossible, the fundus-first approach allows for completion of the procedure with either total cholecystectomy or subtotal cholecystectomy. Subtotal cholecystectomy is effective in preventing bile duct injuries, can be performed laparoscopically, and is currently the best available bailout approach for difficult laparoscopic cholecystectomy.

Conclusion: Difficult laparoscopic cholecystectomy is a common clinical scenario that requires a judicious approach by experienced surgeons in appropriate settings. When difficult laparoscopic cholecystectomy is encountered, various bailout strategies are available. Currently, subtotal cholecystectomy is likely the most effective bailout approach.

Keywords: Acute cholecystitis; Bailout procedure; Bile duct injuries; Difficult laparoscopic cholecystectomy; Intraoperative cholangiography; Safe laparoscopic cholecystectomy; Subtotal cholecystectomy.

Fig. 1

PRISMA study selection flow chart

Fig. 2

A flow-chart for the approach to a DLC DLC: difficult laparoscopic cholecystectomy, DeLC: delayed laparoscopic cholecystectomy, PTC: percutaneous transhepatic cholecystostomy, LC: laparoscopic cholecystectomy, GB: gallbladder, BSAFE B: bile duct, base of segment 4, S: Rouviere’s sulcus, segment 4, A: hepatic artery, F: umbilical fissure, E: enteric structures, R4U: Rouviere’s sulcus, 4 base of segment 4, U umbilical fissure, CVS: critical view of safety, IOC: intraoperative cholangiogram, ICG: Indocyanine green, CD: cystic duct, CA: cystic artery, SC: subtotal cholecystectomy