The gold standard for management of acute cholecystitis is surgical removal of the gallbladder, provided the patient is a good operative candidate. The incidence of common bile duct (CBD) injury during cholecystectomy ranges from 0.2% to       0.3%, which increases the risk of mortality. This devastating complication has prompted guidelines from the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) regarding the critical view of safety (CVS) to reduce the incidence of CBD injuries. When unable to achieve the CVS, the surgeon may turn to a subtotal cholecystectomy. These procedures are effective at controlling sepsis but increase the risk of bile leak and the need for secondary procedures [5]. 

Laparoscopic cholecystectomy (LC) for complicated acute cholecystitis (AC) cases is associated with a risk of vasculobiliary injuries (VBI) and requires advanced surgical skills. Even if LC is expected to be more useful than gallbladder (GB) drainage, performing it safely is rather challenging. The Tokyo Guidelines 2018 (TG18) indicate a clear strategy for such cases and recommend the use of bailout procedures and subtotal cholecystectomy as an optional approach to prevent VBI.9

The critical view of safety is accepted as a standard technique for safe and accurate LC with the prevention of common bile duct injury (3). However, chronic severe inflammation, dense adhesion in Calotʼstriangle and gangrenous gallbladder may disturb the identification of the critical view of safety. Laparoscopic subtotal cholecystectomy (LSC) has been reported as a safe and feasible alternative surgical procedure in such a difficult LC that has a potential risk of common bile duct injury [7]. 

If anatomy does not allow the surgeon to carry out a complete cholecystectomy, to avoid complications, subtotal cholecystectomy could be performed where a gallbladder wall remnant is left in the liver bed. This procedure can be performed in two types, fenestrated and reconstituted, based on the patient's characteristics and surgeon experience. The first one has a higher incidence of biller leak, and the last one has an increased risk of cholecystitis of the pouch. Subtotal cholecystectomy removes a portion of the gallbladder when the structures of Calot’s triangle cannot be identified, dissection between the gallbladder wall and liver bed cannot be accomplished, or the critical view of safety cannot be achieved. LSC is defined as a procedure where the cystic duct cannot be isolated, and ligation is done to a part of the gallbladder rim around the duct [1].

Patient 1 was a 32-year-old male with diabetes mellitus who arrived at the emergency room due to fever, abdominal pain, and colic-like symptoms, specifically in the right upper quadrant, of 7 days duration. Laboratory data has a leukocyte count of 17,000; the bilirubin level is normal. On USG, finding a dilated gallbladder, thickening gallbladder, and multiple stones of 0.9 cm. No dilatation of the CBD.

Patient 2 was a 54-year-old female who presented with epigastric pain radiating to the right upper quadrant for one week. The patient has diabetes mellitus. Laboratory results indicated leukocytosis of 9000, bilirubin normal, and consistent with the patient’s liver function tests being within the normal limits.  His physical examination showed palpable mass, Murphy sign, and USG findings that were consistent with acute cholecystitis, hydropic gallbladder, and stone in the gallbladder 1,4 cm. No dilatation of the CBD was present.

Patient 3 was a 61 -year-old female who presented with epigastric pain and fever for 10 days. The patient has chronic heart failure. Laboratory results indicated leukocytosis of 26.400, bilirubin normal, and consistent with the patient’s liver function tests being within the normal limits.  His physical examination showed palpable mass, Murphy sign, and USG findings that were consistent with acute cholecystitis, hydropic gallbladder, and stone in the gallbladder 2,3 cm.  No dilatation of the CBD was present.

All The patient was scheduled for a laparoscopic cholecystectomy (LC) with possible “bail out “procedure conversion or open cholecystectomy (OC).

Figure 1: Pictorial depiction of LSC patient 1.

Figure 2: Pictorial depiction of LSC patient 2.

Figure 3: Pictorial depiction of LSC patient 3.

Table 1: Clinical characteristics data 

The rationale of open conversion is to enable direct visualization and better manipulation in hope for achieving total cholecystectomy (TC) while avoiding bile duct injury.

However, open conversion does not always ensure better results. Surgery is dependent on the operator’s skill and experience\\\\\ thus some may find open procedure is equally, or even more challenging than laparoscopy. Especially on the advent of laparoscopy era where newer generations of surgeons that is better adapted in laparoscopic surgery. Wolf AS et al. found that patients who underwent open conversion suffered the most major complications (5,9%) compared to open only (4.4%) or laparoscopic only (1.2%) [8]. 

LSC is recommended to avoid the intraoperative bile duct injury when severe inflammation and fibrous change of Calotʼs triangle is observed in cases of acute cholecystitis. LSC is secure surgical procedure for cases of technically difficult laparoscopic total cholecystectomy because no dissection is performed near the common bile duct. Subtotal cholecystectomy is divided into two categories, fenestrating and reconstituting subtotal cholecystectomy, according to the method of processing at neck of the gallbladder. In the present study, our choice for the subtotal cholecystectomy was reconstituting method in all cases.8 

The indication for LSC in our study was inflammatory changes in the form of frozen calot’s triangle and obliterated cystic plate. Frozen calot’s triangle refers to severe inflammation present in the calot’s triangle. Structures present in the calots triangle, i.e., the cystic artery and cystic duct could not be visualized separately or could not be identified at all. 

Hence the calot’s triangle is said to be frozen. The cystic plate is a thin fibrofatty layer between the liver bed and gallbladder in the gallbladder fossa region. Due to the severe inflammation, there are chances that this layer may be wiped out, which is referred to as an obliterated cystic plate. In such cases, dissection in this plane will cause bleeding from the liver surface. The frozen calot’s triangle and obliterated cystic plate are purely intraoperative findings [3]. 

Laparoscopic cholecystectomy remains the gold standard for management of acute cholecystitis. In cases where this is not possible and attempts at subtotal cholecystectomy via a reconstituting or fenestrated method may be necessary, careful consideration must be given to the patient's overall health and the potential for complications. Surgeons should weigh the benefits of these alternative approaches against the risks to ensure optimal outcomes

1. Haldeniya, Kulbhushan, et al. "Laparoscopic Subtotal Cholecystectomy in Difficult Gallbladder: Our Experience in a Tertiary Care Center." Annals of Hepatobiliary Pancreatic Surgery, vol. 28, 2024, pp. 214–219. https://doi.org/10.14701/ahbps.23-168.

2. Muñoz, Braulio R., and Carlos D. Gutiérrez. "Acute Cholecystitis in a Post-Operated Patient of Subtotal Laparoscopic Cholecystectomy: Case Report." International Surgery Journal. https://dx.doi.org/10.18203/2349-2902.isj20241397.

3. Segal, Michael S. "Case Report: Modified Laparoscopic Subtotal Cholecystectomy: An Alternative Approach to the 'Difficult Gallbladder'." American Journal of Case Reports. http://www.amjcaserep.com/abstract/index/idArt/900646.

4. Stellon, Michael A., Cullen J. Fleming, and John E. Scarborough. "Subtotal Cholecystectomy with Omental Pedicle Plug for the Challenging Gallbladder: A Case Report and Review of the Literature." Clinical Case Reports, vol. 12, 2024, e8757. https://doi.org/10.1002/ccr3.8757.

5. Kimura, Jiro, et al. "Laparoscopic Subtotal Cholecystectomy for Mirizzi Syndrome: A Case Report." International Journal of Surgery Case Reports, vol. 55, 2019, pp. 32–34.

6. Kuroki, Tamotsu, et al. "Results of Laparoscopic Subtotal Cholecystectomy by Laparoscopic Linear Stapler in Difficult Cases with Severe Cholecystitis." Acta Medica Nagasakiensia, vol. 63, 2020, pp. 55–59.

7. Supita, Caroline, et al. "The Outcome of Laparoscopic Subtotal Cholecystectomy in Difficult Cases – A Case Series." International Journal of Surgery Case Reports, vol. 41, 2017, pp. 311–314. https://doi.org/10.1016/j.ijscr.2017.10.054.

8. Fujiwara, Sho, et al. "Laparoscopic Subtotal Cholecystectomy for Difficult Cases of Acute Cholecystitis: A Simple Technique Using Barbed Sutures." Surgical Case Reports, vol. 6, 2020, Article ID 238. https://doi.org/10.1186/s40792-020-01026-1.

9. Khan, Hosni Mubarak, et al. "Laparoscopic Subtotal Cholecystectomy: A Safe Approach in Difficult Cholecystectomy." International Surgery Journal, vol. 6, no. 5, May 2019, pp. 1767–1771. https://doi.org/10.18203/2349-2902.isj20191904.