Laparoscopic Subtotal Cholecystectomy (LSC)
For Difficult Cases of Acute Cholecystitis in Rural Area (A Serial Case)
Introduction: The gold standard for management of acute cholecystitis is surgical removal of the gallbladder, provided the patient is a good operative candidate. The critical view of safety is accepted as a standard technique for safe and accurate LC with the prevention of common bile duct injury. 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. Presentation of case: Three patients (2 females, 1 male) who underwent LSC were reported. Intraoperatively, adhesions were found between the gallbladder, omentum, and duodenum. Adhesiolysis was performed. The operative technique starts with the dissection of the gallbladder peritoneal surface distal (anterior) to Hartmann’s pouch. Visualization of the Callot triangle was unobtainable; thus, safe dissection was not feasible. We could not perform the critical view of safety: severe inflammation and fibrosis in all patients. We made an incision in the GB wall. The gallbladder was opened at the infundibulum and neck region circumferentially. Removal of the gallstone and all content, then identification of the cystic duct orifice from the inner lumen of the GB. After making a stump on the Hartmann pouch, irrigation and suction removed residual bile and residual stone from the infundibulum GB. We resected the GB wall, considering the suture line, and left a minimum remnant of the GB wall of the neck near the cystic duct to be sutured using an absorbable 3–0 barbed suture (V-Loc 3.0) all-layer continuous suture. We placed a closed drainage tube next to the stump. Discussion: Laparoscopy Subtotal chole cystectomy 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.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. Conclusion: 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.