Difficult cholecystectomies: Procedures, prognosis and potential complications

Background: Complications from gallstone disease continue to cause patientmorbidity and mortality, although less frequently now. Complications of gallstonedisease are more likely to result in difficult cholecystectomies. A difficultcholecystectomy refers to a case in which exposure of the critical anatomy necessary toconduct a safe procedure is challenging as a result of acute inflammation, dense scarring,gallstone impaction, bleeding, liver pathology or hepatobiliary anatomy. These difficultlaparoscopic cholecystectomies demand advanced strategies to ensure safe operativeapproaches.Aim: To review the evidence-based advanced operative procedures for difficultlaparoscopic cholecystectomies, and outcomes of these approaches for difficult gallbladder problems.Methods: A review of literature databases of PubMed, MEDLINE, EMBASE, andSCOPUS was performed. Advanced operative approaches for difficult laparoscopiccholecystectomy and their outcomes in patients with gangrenous cholecystitis, inflamedmega-gall bladder, perforated gall bladder, a short or large cystic duct, Mirizzi syndromeand cholecystectomy in liver cirrhosis and portal hypertension are reviewed. Factorsinfluencing the decision to convert to open cholecystectomy are discussed.Results: From a review of 100 studies including 2 meta-analyses, 12 randomizedcontrolled trials (RCTs), and 86 prospective and retrospective studies, several differentoperative approaches for a difficult cholecystectomy were identified. They includefundus-first/dome down approach, ultrasonic dissection with or without fundus first or half-dome approach and subtotal/partial cholecystectomy. Another approach, the halfdome down approach, is also discussed. From the existing literature, the fundus-firstapproach, ultrasonic dissection and subtotal cholecystectomy have been found to reducethe rate of conversion of a laparoscopic to open cholecystectomy with no associatedincrease in the risk of injury to the liver, duodenum, colon or the biliary tree. They havebeen found to lower the complication rates.Ultrasonic dissection has been demonstrated to be safe and very valuable forbloodless dissection especially in acute cholecystitis, but a learning curve exists. There isalso a risk of thermal injury from instrument misuse. With these techniques, outcomessimilar to standard retrograde cholecystectomy for uncomplicated and acute cholecystitiscan be reached.Conclusion: Advanced operative approaches for difficult laparoscopiccholecystectomy should be considered prior to converting to open cholecystectomy. Insituation where it is still difficult to perform a safe laparoscopic cholecystectomy or thesurgeon is inexperienced, conversion to open cholecystectomy should be considered orthe patient referred to an experienced center.