Abandoned Cholecystectomy: A Single—Center Retrospective Cross-Sectional Cohort Study,2013

Abstract

Introduction:

Abandoned cholecystectomy (AbC) is a rarely studied bailout procedure in gallbladder surgery. This study aimed to estimate the annual utilization rates of AbC, provide AbC-specific clinical outcome data, and discuss AbC-related themes in a broader context.

Materials and Methods:

This retrospective cross-sectional study was conducted at a university hospital and comprised patients who underwent AbC between 2013 and 2023. The final follow-up was conducted on January 31, 2024. The dataset was investigated using exploratory data analysis.

Results:

In total, 20 female and 17 male patients (mean age, 62.5 years) underwent AbC. The mean AbC rate in the elective surgery setting was 1%. A chronic pericholecystic inflammatory mass was the most common cause of AbC (n = 22; 59.5%). The 30-day postoperative outcomes included a prolonged length of hospital stay (median, 2), readmission rate of 18.9% (four emergencies; three planned), second surgical procedure rate of 13.5% (two emergencies; three planned), and iatrogenic injury rate of 5.4% (2 patients). Long-term outcomes included six emergency admissions with acute biliopancreatic events (16.7%). Fifteen patients underwent elective secondary gallbladder surgeries, including 11 total cholecystectomies, three subtotal cholecystectomies (20%), and one cholecystolithotomy with tube cholecystostomy.

Conclusions:

AbC is preventable in most cases. Adherence to guidelines for managing acute calculous cholecystitis is the key. The decision to convert laparoscopic surgery to open or bail out by abandoning cholecystectomy when other options for damage control and limitation surgery are infeasible should be made early to avoid the burden associated with laparoscopic surgery to expose the gallbladder.

Introduction

For over 30 years, it has been well-known that laparoscopic cholecystectomy (LC), the complete excision of the gallbladder by conventional definition, is the standard treatment for benign symptomatic or complicated gallbladder diseases in patients who are fit for surgery.¹ However, it is now accepted that when encountering hostile surgical conditions and unfavorable circumstances, alternative lower-risk surgical procedures should be considered to eliminate the risk of injury associated with conventional LC.^2–4 Furthermore, preoperative shared decision-making for critical scenarios is paramount in surgical practice, symbiotically related to clinical ethics, acknowledging the importance of the relationships within which the patient is held.^5–7

Severe pericholecystic inflammatory changes leading to maximal grades of cholecystectomy difficulty,^8–10 atypical variants of biliary anatomy,¹¹ advanced liver disease,^2,12 and suspected malignancy of the gallbladder¹³ are intraoperative conditions that warrant immediate decisions regarding the safest surgical approach in patients who consent to cholecystectomy. The surrounding circumstances related to internal human factors also substantially influence decision-making in surgical practice.^14,15

Three broad terms—damage control, prevention, or limitation,¹⁶ surgical rescue,¹⁷ and surgical bailout¹⁸—encompass four alternative gallbladder surgical procedures: subtotal (partial) cholecystectomy (STC), tube cholecystostomy, cholecystolithotomy, and abandoned cholecystectomy (AbC), verbalized as aborted or attempted cholecystectomy. The latter surgical procedure, AbC, remains uncoded, uncharacterized, and undefined.^19,20 No AbC was identified in a recently published nationwide study of 1,234,319 gallbladder surgeries performed in England between 2000 and 2019.²¹

Electronic bibliographic databases provided one full-text article²² and two abstracts^23,24 with limited data on the clinical outcomes of 43,²² 5,²³ and 4²⁴ patients who underwent a second gallbladder surgery following AbC. Of these, most patients were referred to hepatobiliary surgery units from other healthcare facilities.²² This made the characterization and evaluation of the clinical trends and patterns arising from an analysis of primary cohorts of patients to whom cholecystectomy was abandoned unachievable.

This study primarily aimed to determine the annual utilization rates of AbC in a single surgical center. Second, the study also sought to characterize a cohort of patients who underwent AbC. Third, AbC-specific 30-day and >30-day clinical outcomes were evaluated. Fourth, the perioperative and long-term clinical outcomes of elective secondary gallbladder surgeries were reported.

Materials and Methods

Design, registration, and adherence

This retrospective single-center surgical cohort study was conducted at a university hospital. The Institutional Clinical Audit Management Board reviewed and approved this study (registration number 12025). The study complies with the guidelines for strengthening the reporting of cohort, cross-sectional, and case-control studies in surgery—STROCSS 2024—statement.²⁵ Study data within this report are provided according to the Findable, Accessible, Interoperable, and Reusable principles.²⁶ The supplement provides additional details on the methods, results, and discussion.

Patients, period, and definition

Patients who underwent AbC between January 1, 2013, and December 31, 2023, were adult individuals (≥18 years) listed for LC for symptomatic or complicated cholecystolithiasis. A cholecystectomy was defined as abandoned when a decision was made and actualized to discontinue the surgical procedure at any time point after the induction of general anesthesia, regardless of whether a surgical incision or incisions were performed.

Identification of patients

In consultation with a leading specialist from the hospital’s Division of Finance, eight OPCS-4 codes¹⁹ used to encode AbC were identified: T413, T415, T423, T439, T309, T343, X598, and S421. Professionals from the Digital Intelligence Unit of the Trust conducted further searches. These eight codes were cross-linked with the International Statistical Classification of Diseases and Related Health Problems 10th revision codes for gallbladder diseases of inflammatory nature, gallstones, and peritoneal adhesions: K800, K801, K802, K805, K810, K811, K660, and K565. An information search to identify patients with AbC was conducted twice: in February 2023 and January 2024.

One hundred potential cases were identified. Reviewing patients’ anesthesia charts and operation notes stored in the hospital electronic systems revealed 28 AbCs. In addition, nine cases were identified during preparatory work for other studies.^14,15,27 All operations were performed by consultant surgeons with extensive experience in biliary surgery. Patients operated on between 2020 and 2023 were free of coronavirus disease 2019 on the day of gallbladder surgery.

Study variables and data collection

The study variables were classified as follows: baseline demographic information, preoperative characteristics, intraoperative, and postoperative 30-day events, and long-term outcomes (>30 days). These variables are shown in column 1 of Tables 1–4. Among these are the Charlson Comorbidity Index,²⁸ Tokyo grade of severity for acute cholecystitis, and cholangitis,^29,30 American Society of Anesthesiologists classes,³¹ ranking of postoperative complications by Clavien–Dindo,³² technical variants and subvariants of STC, and types of completion of STC.^4,33,34 Individual patient-specific data points were collected by examining electronic data, reports, and document management systems in 2023 and January 2024. The final follow-up was conducted via an electronic review of patient charts on January 31, 2024.

Table 1.

Baseline Demographic Information and Preoperative Characteristics of the 37-Patient Cohort Following Abandoned Cholecystectomy, 2013–2023

Characteristic and category	Value	Proportion, %	95% Confidence interval
Baseline demographic
Age
Median (range; IQR)	63.0 (30–83; 18.0)	—	—
Mean (SD)	62.5 (12.7)	—	—
Sex
Female	20	54.1	38.4–69.0
Male	17	45.9	31.0–61.6
Preoperative
Body mass index
Median (range; IQR)	31.8 (18.1–54.0; 10.9)	—	—
Mean (SD)	33.2 (7.8)	—	—
Charlson Comorbidity Index
Median (range; IQR)	3 (0–11; 3)	—	—
Mean (SD)	3.2 (2.3)	—	—
0	3	8.1	2.8–21.3
1–2	11	29.7	17.5–45.8
3–4	14	37.8	24.1–53.9
≥5	9	24.3	13.2–40.1
Surgical history, patients	6	16.2	7.7–31.1
Midline laparotomy	2	5.4	1.0–17.7
Laparoscopic bariatric	3	8.1	2.8–21.3
Retroperitoneal necrosectomy	1	2.7	0.1–13.8
Preoperative entity
Acute cholecystitis	20	54.1	38.4–69.0
Biliary pain (colic)	7	18.9	9.5–34.2
Acute cholangitis	4	10.8	4.3–24.7
Acute pancreatitis	2	5.4	1.0–17.7
Obstructive jaundice	1	2.7	0.1–13.8
Chronic symptoms	3	8.1	2.8–21.3
Acute cholecystitis, n = 20: hospitalization episodes
One episode	10	50.0	29.9–70.1
Two episodes	8	40.0	21.9–61.3
≥3 episodes	2	10.0	1.8–30.1
Acute cholecystitis/cholangitis, by Tokyo classification, n = 24
Grade 1 (mild)	5	20.8	9.2–40.5
Grade 2 (moderate)	19	79.2	59.5–90.8
Grade 3 (severe)	0	0	0–13.8
Interval between the first episode of acute biliary event and abandoned cholecystectomy, weeks
Median (range; IQR)	34 (1–224; 111.25)	—	—
Mean (SD)	72.85 (70.9)	—	—
Imaging prior to surgery
Computed tomography scan	20	54.1	38.4–69.0
MRCP	5	13.5	5.9–28.0
Endoscopic ultrasound scan	7	18.9	9.5–34.2
ERCP, therapeutic	7	18.9	9.5–34.2
Ultrasound scan, only	11	29.7	17.5–45.8
No data	1	2.7	0.1 to 13.8
Choledocholithiasis, ERCP proven	5	13.5	5.9 to 28.0
Percutaneous tube cholecystostomy	2	5.4	1.0 to 17.7
Admission route and operation
Elective, planned	36	97.3	86.2–99.9
Urgent, index admission	1	2.7	0.1–13.8
ASA class
Class 1	1	2.7	0.1–13.8
Class 2	18	48.6	33.4–64.1
Class 3	17	45.9	31.0–61.6
Class 4	1	2.7	0.1–13.8

ASA, American Society of Anesthesiologists; ERCP, endoscopic retrograde cholangiopancreatography; IQR, interquartile range; MRCP, magnetic resonance cholangiopancreatography; NA, not applicable; SD, standard deviation.

Table 2.

Intraoperative Features of the 37-Patient Cohort in Whom Cholecystectomy Was Abandoned, 2013–2023

Characteristic and category	Events	Proportion, %	95% Confidence interval
Approach, n = 37
Laparoscopic surgery planned	37	100	90.6–100
Laparoscopic surgery performed or started	35	94.6	82.3–99.0
Laparoscopic surgery	34	91.9	78.7–97.2
Conversion to open	1	2.7	0.1–13.8
Abandonment before incision	2	5.4	1.0–17.7
Liver appearance, n = 35
Puckering above the presumed site of the gallbladder	11	31.4	18.6–48.0
Diffuse liver disease (steatosis, fibrosis, or cirrhosis)	9	25.7	14.2–42.1
Hepatomegaly	5	14.3	6.3–29.4
Portal hypertension and varices	2	5.7	1.0–18.6
Malignancy suspected	2	5.7	1.0–18.6
No data (implies normal morphology)	6	17.1	8.1–2.7
Gallbladder, by primary inspection, n = 35
Unseen	18	51.4	35.6–67.0
Partially seen	10	27.0	15.4–43.0
Minimally	6	17.1	8.1–32.7
Moderately	4	11.4	4.5–26.0
Fully visible	6	17.1	8.1–32.7
No data	1	2.9	0.1–14.5
Attempt to expose the gallbladder, n = 35
Yes	19	54.3	38.2–69.5
No	16	45.7	30.5–61.8
Extent of exposure of the gallbladder, n = 19
No effect	11	57.9	36.3–76.9
Gallbladder fundus exposed	1	5.3	0.3–4.6
Part of the gallbladder body exposed	1	5.3	0.3–24.6
Fundus and a part of the body exposed	2	10.5	1.9–31.4
Gallbladder fully exposed	4	21.1	8.5–43.3
Gallbladder, by secondary inspection, n = 35
Partially intrahepatic	7	20.0	10.0–35.9
Shrunken (contracted)	11	31.4	18.6–48.0
Other descriptions	17	48.6	33.0–64.4
Reason for abandonment, n = 37
Chronic pericholecystic mass	20	54.1	38.4–69.0
Chronic pericholecystic mass with fistula probable	2	5.4	1.0–17.7
Gallbladder cancer suspected	6	16.2	7.7–31.1
Liver malignancy suspected	2	5.4	1.0–17.7
Ascending colon cancer suspected	1	2.7	0.1–13.8
Pregnancy, the second trimester, incidental finding	1	2.7	0.1–13.8
No experience in laparoscopic surgery	1	2.7	0.1–13.8
Severe desaturation	1	2.7	0.1–13.8
Cardiac asystole	1	2.7	0.1–13.8
Inflammatory mass palpated before incision	1	2.7	0.1–13.8
Breach in sterile tray, noticed before incision	1	2.7	0.1–13.8
Second opinion from a consultant, n = 37	20	54.1	38.4–69.0
Drain placement, n = 35	4	11.4	4.3–24.7

Table 3.

Postoperative 30-Day Outcomes Following Abandoned Cholecystectomy in 37 Patients

Characteristic and category	Value	Proportion, %	95% Confidence interval
Length of stay, bed days
Median (range; IQR)	2 (1–20; 2)	—	—
Mean (SD)	2.8 (3.2)	—	—
Duration of drainage
One day, patient	1	2.7	0.1–13.8
Three days, patients	2	5.4	1.0–17.7
Prolonged, 2nd surgery	1	2.7	0.1–13.8
Discharge	36	97.3	86.2–99.9
Readmission	7	18.9	9.5–34.2
Emergency	4	10.8	4.3–24.7
Planned	3	8.1	2.8–21.3
Secondary surgeries, cholecystectomies	5	13.5	5.9–28.0
Emergency	2	5.4	1.0–17.7
Within index admission	1	2.7	0.1–13.8
During readmission	1	2.7	0.1–13.8
Elective	3	8.1	2.8–21.3
Ranking of postoperative complications, by Clavien–Dindo
Grade 0	22	59.5	43.5–73.7
Grade 1	6	16.2	7.7–31.1
Grade 2	2	5.4	1.0–17.7
Grade 3	0	0	0.0–9.4
Grade 4	6	16.2	7.7–31.1
Grade 4A^a	5	13.5	5.9 –28.0
Grade 4B^b	1	2.7	0.1–13.8
Grade 5 (death)	1	2.7	0.1–13.8
Individual complications, severe	9	21.6	11.4–37.2
Asystole, admission to CCU	1	2.7	0.1–13.8
Respiratory insufficiency, admission to CCU	3	8.1	2.8–21.3
Peritonitis, biliary	2	5.4	1.0–17.7
Localized, necrotizing cholecystitis	1	2.7	0.1–13.8
Generalizing, duodenal perforation	1	2.7	0.1–13.8
Injury to	2	5.4	1.0–17.7
Common hepatic duct, admission to CCU	1	2.7	0.1–13.8
Duodenum, admission to CCU	1	2.7	0.1–13.8
ERCP-induced pancreatitis	1	2.7	0.1–13.8
Gallbladder cancer, proven	3	8.1	2.8–21.3

All 5 patients with Clavien–Dindo grade 4A complications experienced intraoperative adverse events: respiratory failure requiring admission to the intensive care unit (3 patients), asystole requiring external cardiac massage in 1 male patient, and injury to the common hepatic duct (1 patient).

Rapidly progressing multiorgan failure was associated with a leak from the duodenum.

CCU, critical care unit; ERCP, endoscopic retrograde cholangiopancreatography; IQR, interquartile range; SD, standard deviation.

Table 4.

Long-Term, >30-Day Outcomes Following Abandoned Cholecystectomy^a

Characteristic and category	Value	Proportion, %	95% Confidence interval
Patients: imaging or/and endoscopy performed	28	77.8	62.0–88.3
Computed tomography scan, procedures	27	75.0	58.9–86.25
MRCP, procedures	8	22.2	11.7–38.1
Liver magnetic resonance imaging, procedures	2	5.6	1.0–18.1
ERCP, procedures	2	5.6	1.0–18.1
OGD, procedures	3	8.3	2.9–21.8
Colonoscopy, procedures	5	13.9	6.1–28.7
Emergency admissions, biliopancreatic events, patients	6	16.7	7.9–31.9
Biliary events	5	13.9	6.1–28.7
Pancreatitis	1	2.8	0.1–14.2
Patients relisted for elective cholecystectomy^a	13	41.9	26.4–59.2
The secondary gallbladder operation, urgent or elective^b	13	41.9	26.4–59.2
Urgent (STC, laparoscopic converted to open)	1	3.2	0.2–16.2
Elective	12	38.7	23.7–56.2
Total cholecystectomy	9	29.0	16.1–46.6
Laparoscopic	9	29.0	16.1–46.6
Open	0	0	0–11.0
Subtotal cholecystectomy	2	6.5	1.1–20.7
Laparoscopic	2	6.5	1.1–20.7
Open, primary	0	0	0–11.0
Cholecystolithotomy, tube cholecystostomy, open	1	3.2	0.2–16.2
Mortality	9	25.0	13.75–41.1
Associated with liver, biliary, and pancreatic diseases	5	13.9	6.1–28.7
Gallstone necrotizing pancreatitis	1	2.8	0.1–14.2
Liver cirrhosis	1	2.8	0.1–14.2
Gallbladder cancer	2	5.6	1.0–18.1
Pancreatic cancer	1	2.8	0.1–14.2
Associated with other diseases	4	11.1	4.4–25.3
Melanoma	1	2.8	0.1–4.2
Rectal cancer	1	2.8	0.1–14.2
Cancer, primary not-proven, HCC suspected	1	2.8	0.1–14.2
Community acquired pneumonia	1	2.8	0.1–14.2
Malignancy, proven	5	13.9	6.1–28.7
Other cases	4	11.1	4.4–25.3

One case was excluded from the 37-patient cohort (a patient who died within 30 days after abandoned cholecystectomy).

Percentage proportions and confidence intervals were computed from the 31-patient subcohort (the other 5 patients underwent gallbladder surgery within 30 days).

ERCP, endoscopic retrograde cholangiopancreatography; HCC, hepatocellular carcinoma; MRCP, magnetic resonance cholangiopancreatography; OGD, oesophagogastroduodenoscopy; STC, subtotal cholecystectomy.

Statistical analysis

Data were analyzed using GraphPad Prism version 10.2.3 (347) for macOS (GraphPad Software LLC, Boston, MA, USA). Categorical data were summarized as counts and percentage proportions with 95% confidence intervals (CIs) calculated using the Wilson–Brown method (https://www.graphpad.com/features). Continuous one-dimensional data were reported using central tendency metrics—the mean with standard deviation (SD) and standard error, and the median with interquartile range.

Results

Rates of AbC

Between 2013 and 2023, 4402 patients underwent total cholecystectomy. Cholecystectomy was abandoned in 37 patients (0.8%, 95% CI, 0.6–1.1). The mean proportion for AbC in the elective surgery setting was 1% (95% CI, 0.7–1.4). The median for AbC was three cases per year (interquartile range [IQR], 2.0).

Baseline demographics and preoperative characterization

As presented in Table 1, the median patient age was 63 years (IQR, 18 years). The female-to-male ratio was 1.2:1. Acute cholecystitis (n = 20) and cholangitis (n = 4) were documented in 64.9% of patients. The severity of acute inflammation was classified as grade 2 according to the Tokyo classification in 19 patients (79.2 %). The mean interval between the first episode of acute cholecystitis and AbC was 73 weeks (SD, 71 weeks), and the median was 34 weeks (IQR, 111 weeks). Among 20 patients with acute cholecystitis, 10 were hospitalized more than once.

One in 4 patients (24.3%) in the cohort had a history of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) (7 patients, 18.9%) or tube cholecystotomy (2 patients, 5.4%). One patient (2.7%) underwent surgery, which was classified as urgent during the index admission for acute cholecystitis. The remaining 36 patients underwent elective cholecystectomy.

Intraoperative informatics

Two AbCs (5.4%) were pronounced before the skin incisions. As shown in Table 2, cholecystectomy was abandoned during the initial laparoscopy in 34 patients (91.9%). In one case (2.7%), it was abandoned following conversion to an open surgical procedure.

Of the 35 surgeries performed, liver puckering above the presumed gallbladder³⁵ site was documented in 11 patients (31.4 %). Two (5.7%) patients had signs of portal hypertension. Liver malignancy was suspected in 2 patients (5.7%). In 18 (51.4%) patients, the gallbladder was not visible during primary laparoscopic inspection.

An attempt to expose the gallbladder via pericholecystic adhesiotomy was made in 19 patients (54.3%). The visceral wall of the gallbladder was fully exposed in 4 patients (21.1%) and partially exposed in 4 patients. A partially intrahepatic or shrunken (contracted) gallbladder was observed in 18 patients (51.4%). Table 2 incorporates the reasons for AbC in descending order. A chronic pericholecystic inflammatory mass was the most common cause of AbC (22 patients, 59.5%).

A second opinion from a consulting hepatobiliary surgeon was obtained for 20 patients (54.1%). The subhepatic space was drained in 4 of 35 patients (11.4%). No intraoperative complications were observed.

Thirty-day postoperative outcomes

As shown in Table 3, the features included a prolonged length of stay (median, 2; IQR, 2; range, 1–20), iatrogenic injuries (2 patients, 5.4%), and a readmission rate of 18.9% (7 patients). Four were emergencies (10.8%), and the other 3 (8.1%) were planned readmissions. The second surgical procedure was performed in 5 (13.5%) patients—2 (5.4%) were emergencies, and 3 were planned. Five (13.5%) patients were admitted to the critical care unit after AbC (4 patients) or secondary emergency surgical procedure (1 patient).

Of 37 patients, 15 (40.5%) experienced complications. Six patients (16.2%) experienced a grade 4 complication (5 had subgrade 4A and 1 had 4B). One death (2.7%) was associated with postERCP pancreatitis after biliary stenting for a malignant common hepatic duct (CHD) stricture. Gallbladder cancer was confirmed in 3 patients (8.1%).

One patient underwent emergency surgery on postoperative day 10 after readmission with sudden onset biliary peritonitis—laparoscopic conversion to open total cholecystectomy with extrahepatic bile duct resection and hepaticojejunostomy was performed. Histopathological assessment of the resected gallbladder and bile duct confirmed the presence of necrotizing cholecystitis and chronic cholangitis. A second emergency laparotomy was performed in 1 patient due to rapidly progressing multiorgan failure and peritonitis associated with external and internal leaks from the duodenum on postoperative day 1.

Long-term postoperative outcomes

As one female patient diagnosed with gallbladder cancer died within 30 days after AbC, the remaining 36 patients with a mean age of 62 years (SD, 12.6) and a median age of 62.5 years (IQR, 17.5) comprised the surgical subcohort of interest (Table 4). Radiological and endoscopic investigations were performed in 28 patients (77.8%). Emergency admissions with acute biliary or pancreatic events were documented in 6 patients (16.7%). Thirteen patients were relisted for elective secondary cholecystectomy. Of these, 1 patient underwent urgent laparoscopic conversion to open STC. Of the 12 elective secondary surgeries performed, 9 patients underwent total cholecystectomy, 2 underwent STC, and 1 underwent cholecystolithotomy and tube cholecystostomy.

There was one case of unplanned readmission with cholangitis after elective open STC and suture repair of the CHD with the placement of a T-tube. Nine (25%) patients died. Of these, five died from proven gallbladder (2 patients), pancreas, rectum adenocarcinoma, and melanoma.

Overall mortality

The median follow-up duration was 1584 days (IQR, 1744), viz. 4.4 years (IQR, 4.9), with a minimum of 17 days and a maximum of 4036 days (11.3 years). The overall all-cause mortality rate in the cohort of 37 patients with AbC was 27% (10 deaths).

The mortality rate was higher in female patients (30.0%, six deaths vs. 23.5%, four deaths). By age, eight deaths were observed in the >70 years age group. One patient in her 30s died due to necrotizing pancreatitis associated with gallstone disease. One patient in his 60s died from liver cirrhosis.

Three patients (8.1%) died from gallbladder cancer. Proven or highly probable (one case) malignancy was the cause of death in seven patients.

Elective gallbladder surgery following AbC

The intraoperative features and postoperative outcomes of 15 elective secondary gallbladder surgeries following 37 AbC procedures are presented in Table 5. Eleven (29.7%) total cholecystectomies (nine laparoscopic and two open), three (8.1%) STCs (two laparoscopic and one open), and one (2.7%) open cholecystolithotomy with tube cholecystostomy formation were performed. An intraoperative cholangiogram was performed on a patient with an iatrogenic CHD injury. The subhepatic space was drained in 7 patients.

Table 5.

Intraoperative Features and Clinical Outcomes of 15 Elective Secondary Gallbladder Surgeries Following 37 Abandoned Cholecystectomies, 2013–2023

Characteristic and category	Value	Proportion, %	95% Confidence interval
Elective secondary gallbladder surgeries	15	40.5	26.3–56.5
Secondary gallbladder operations
Total cholecystectomy	11	29.7	17.5–45.8
Laparoscopic	9	24.3	13.4–40.1
Open	2	5.4	1.0–17.7
Primary	1	2.7	0.1–13.8
Converted from laparoscopic	1	2.7	0.1–13.8
Subtotal cholecystectomy	3	8.1	2.8–21.3
Laparoscopic	2	5.4	1.0–17.7
Open, primary	1	2.7	0.1–13.8
Cholecystolithotomy, cholecystostomy, open	1	2.7	0.1–13.8
Other surgical details
Intraoperative cholangiogram	1	2.7	0.1–13.8
Common bile duct exploration	1	2.7	0.1–13.8
T-tube utilization	1	2.7	0.1–13.8
Drainage, one drain	7	18.9	9.5–34.2
Intraoperative complication
Injury to common hepatic duct, 25% perimeter	1	2.7	0.1–13.8
30-Day postoperative complications, severity grading by Clavien–Dindo
Grade 1	4	10.8	4.3–24.7
Grade 2	1	2.7	0.1–13.8
Grade 3A	0	0	0–9.4
Grade 3B^a	1	2.7	0.1–13.8
Grade 4A	1	2.7	0.1–13.8
Grade 4B	1	2.7	0.1–13.8
Grade 5 (death)	0	0	0–9.4
30-day morbidity, moderate or severe^b	3	8.1	2.8–21.3
Bile leak	0	0	0–9.4
Readmission
≤ 30-day	0	0	0–9.4
31–90-day (T-tube related cholangitis)	1	2.7	0.1–13.8
Postoperative length of stay, bed days
Median (range, IQR)
Mean (SD)
Histopathology
Chronic cholecystitis	13	35.1	21.8–51.2
Xanthogranulomatous cholecystitis	1	2.7	0.1–13.8
No tissue resected	1	2.7	0.1–13.8

Grade 3B, injury to the common hepatic duct.

Moderate or severe morbidity, Clavien–Dindo grade 3 or 4.

CI, confidence interval; IQR, interquartile range; SD, standard deviation; STC, subtotal cholecystectomy.

Three (20%) of 15 patients had postoperative 30-day complications categorized as Clavien−Dindo grade 3 or 4. No external or internal bile leakage was observed. The postoperative length of hospital stay varied from 1 to 8 days. Eleven patients were discharged within the first four postoperative days. Chronic inflammatory changes in the resected gallbladder were reported for 14 patients. Xanthogranulomatous cholecystitis was diagnosed in 1 patient.

Discussion

The primary focus of this study was highlighting the utilization rates of AbC, characterizing a patient cohort, describing perioperative procedure-related events, and long-term clinical outcome data. Notably, the following 10 AbC-related themes merit attention: the state of knowledge on AbC, generalizability of the study findings, biliary surgery policy perspective, adherence to national or international guidelines and key performance indicators, classification of the causes of AbC, preventability of AbC, staging of AbC by how far the dissection is processed anatomically, preoperative assessment of the patients, secondary elective gallbladder surgery, and definition of AbC.

First, more information is needed regarding AbC, although it has been used in surgical practice for many years.^22–24 The unavailability of the surgical code^19,20 or miscoding of AbC aggravates the search and identification of cases. In this study, AbC was an unexpected surgical event in all 37 patients, as the primary indication for gallbladder surgery was complicated (in 4 of 5 patients) or symptomatic (in 1 of 5 patients) cholecystolithiasis.

Second, a second opinion was obtained for shared decision-making in more than half of the cases (54%). This suggests that AbC is a recognized surgical procedure in centers, where a gallbladder damage control concept is acknowledged.^5,14,27,34 A recently published study on 180 adult patients who underwent STC between 2013 and 2017 highlighted that 24 (13.3%) of these patients underwent AbC in other hospitals of the geographical region and were referred to a specialized regional center for hepatobiliary surgery.^14,15 Therefore, the findings of this study can be viewed as partially generalizable to gallstone disease management guidelines and, consequently, cholecystectomy practices in the regions and across England are similar.^21,36–38

Third, over the one-decade span from 2013 to 2023, there is no observable shift in the annual rates (1%). This suggests providing exceptional biliary surgery policy perspectives in organized ways, of which the first approach is to emphasize the contribution of AbC when gallbladder surgery risks are too high to the burden of biliary disease (extension in Supplementary Data).

Fourth, the long interval between the first episode of an acute biliary event and AbC—73 weeks on average—was an extraordinary feature of this cohort of patients. This finding corresponds with the previously expressed cardinal rule that the likelihood of adapting principles of damage control or limitation of gallbladder surgery directly corresponds to the duration of complicated gallstone disease.^14,27

Most surgical associations, societies, institutions, and clinical scientists advocate urgent cholecystectomy for acute calculous cholecystitis.^{36,37,39–41} In the United Kingdom, the National Institute for Health and Care Excellence guidelines for managing individuals with gallstones serve as a primary resource for clinicians. The latest update of this document was published in June 2024.⁴¹ For patients with acute cholecystitis, early LC is recommended within 1 week of diagnosis.⁴¹ This recommendation aligns with the national Association of Upper Gastrointestinal Surgery of Great Britain and Ireland guidelines, which state that patients with acute cholecystitis should ideally undergo LC during the same admission or within 7 days.³⁶ Furthermore, the 2016 and 2020 guidelines from the World Society of Emergency Surgery also recommend early LC for patients with acute calculous cholecystitis—within 7 days of hospital admission and 10 days from the onset of acute symptoms.³⁹ Similar statements are found in the Tokyo Guidelines 2018.⁴² Interestingly, the European Association for the Study of the Liver recommendation, which is based on high-quality data, is even more categorical—early LC should preferably be performed within 72 hours of admission.⁴³ In the United States, performing LC within 3 days of diagnosis in most patient populations is the first-line therapy for uncomplicated and complicated acute cholecystitis.⁴⁴

However, it is important to note that laparoscopic STC and conversion from laparoscopic to open cholecystectomy, which often results in the same STC, are alternative treatment options in extraordinary cases of complicated cholecystitis.^14,15,27,45 Percutaneous tube cholecystostomy is reserved for patients admitted due to septic shock or those with a very high perioperative risk.^40,44,46

The results of our study call for a multifaceted approach, with local, regional, and national policies that would address the less-than-satisfactory provision of urgent care for patients admitted to hospital wards with acute biliary problems^11,38,47,48 and enhance the advocacy of using the acute cholecystectomy rate as a key surgical process and performance indicator to measure the quality of care for patients admitted with acute gallbladder or bile duct disease.⁴⁸ Besides, the AbC rate can be viewed as another performance indicator of the opposite significance.

Fifth, this analysis separated the causes of AbC into five groups according to the leading intraoperative finding or event in the operating theater. They are as follows: (1) chronic pericholecystic inflammatory mass (almost 60% of cases); (2) suspected malignancy of the gallbladder, liver, and other surrounding organs (almost 25%); (3) life-threatening cardiovascular or respiratory events: asystole, severe desaturation (5%); (4) unforeseen preincision occurrences related to human factors (5%); (5) unexpected apparent pregnancy (3%); and (6) incompetence in laparoscopic surgery (3%). The individual subcomponents of each cause group warrant a broader investigation in various contexts in larger cohorts of patients, for example, the causes of a severe cardiovascular event.⁴⁹

Sixth, this classification shows that five of six AbC causes are preventable. Adhering to the aforementioned clinical guidelines is crucial for preventing a chronic pericholecystic inflammatory mass. The low threshold for suspecting liver or colonic cancer is concerning. Querying only gallbladder cancer was reasonable in 50% of cases, as it was confirmed in 3 of 6 patients within 30 days after AbC. These three cancer cases comprised 8% of our patients, suggesting that the preoperative diagnostic assessment may have been suboptimal. However, incidental gallbladder cancer is a well-reported finding in many series and is related to the difficulty of differentiating inflammatory from malignant change on imaging. Furthermore, the rates of incidental gallbladder cancer directly correspond with the grade of difficulty of cholecystectomy. For example, it was reported to be 0.05% for LC, 0.6% for LC converted to open cholecystectomy, and 1.13% for open cholecystectomy.⁵⁰ In our STC 180-case series, incidental gallbladder cancer was reported in 1.7% of patients (1 of 60 patients).¹⁴

Pregnancy testing may be offered (it should not be mandatory) to women of childbearing age for whom the result would alter the scope of informed consent, preoperative shared decision-making, and even surgical actions (supraumbilical incision instead of infraumbilical incision) if laparoscopic or robot-assisted LC is undertaken.⁵¹ The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guidelines on laparoscopy during pregnancy indicate that LC is the preferred treatment for pregnant patients with symptomatic gallbladder disease, regardless of the trimester.⁵² However, it is important to note that the perioperative risks, including those related to pregnancy (miscarriage, fetal loss, eclampsia, antepartum hemorrhage, preterm delivery, and cesarean section), and the benefits of LC should be thoroughly discussed with each pregnant patient. The applicability of the SAGES guidelines should be considered with utmost caution when discussing laparoscopic and open cholecystectomies with patients in the third trimester of pregnancy. A California state-wide study of 17,893 women who underwent cholecystectomy from 3 months before delivery to 3 months after delivery demonstrated that patients operated on during the third trimester of pregnancy have a twofold greater risk of preterm delivery. This is associated with multiple adverse infant outcomes, as the final weeks of pregnancy, particularly between 37 and 40 weeks, are critical for the development of the neonatal brain, lungs, and liver.⁵³ Additionally, a cholecystectomy performed during the third trimester of pregnancy is associated with a longer hospital stay and a twofold higher 30-day nonobstetric readmission rate compared with a cholecystectomy performed within 3 months postpartum. The conclusion that patients presenting with symptoms and complications of benign biliary disease in the third trimester of pregnancy should have their cholecystectomy delayed until the postpartum period, whenever possible, is strongly supported by the findings of this study.⁵³ For pregnant patients for whom cholecystectomy is urgently indicated, surgery should be performed at biliary centers that have obstetric and neonatal services available on-site.⁵⁴ A multidisciplinary approach with a standardized perioperative care protocol for pregnant patients, including perioperative steroid use, indications for and dosage of tocolytics, and fetal heart rate monitoring, is essential to achieve the best clinical outcomes.⁵⁵

The fourth and sixth causes are solely related to human factors and professional relationships; therefore, they are preventable, too.

Seventh, the findings of the primary inspection of the subhepatic space were classified into four categories: unseen gallbladder, minimally seen, moderately seen, and fully visible. Visualization of the gallbladder was not possible in more than 50% of the cases. In 2 of the 3 patients, it was unseen or minimally seen. Therefore, it is impractical to offer anatomical terminology or acronyms for the gallbladder portions—the fundus, body, and neck—to describe the site on the partially visible portion of the gallbladder. Furthermore, it can be grossly imprecise in some cases, particularly when operated on partially intrahepatic and contracted gallbladders (>50% of the cases). In our case series, the ratio between the attempt to expose the gallbladder and no attempt to expose it was approximately 1:1. More importantly, the dissection trial failed or was minimally effective in 13 (68%) of 19 patients. In all the cases, no attempts were made to dissect the cystic artery or duct. Staging AbC based on how far the dissection is processed anatomically²¹ has no theoretical or practical rationale.

Eighth, the findings from an analysis of long-term outcomes associated with AbC demonstrate a concerning preoperative evaluation and decision-making methodology. Hence, 4 of 5 patients underwent additional investigations after AbC, 3 of 5 patients were readmitted with acute biliary or pancreatic occurrence, 2 of 5 patients were listed for elective secondary gallbladder surgery, urgent gallbladder surgery was required in 1 of 13 patients, and bailout surgical procedures were performed in 25% of patients in an elective surgery setting. One patient sustained a CHD injury. The overall death rate of 25% reflected the morbidity status of these patients.

Ninth, 15 patients underwent repeat operations in an elective surgery setting. Their technical execution varied between laparoscopic and open surgery, total cholecystectomy, and bailout surgical procedures, such as STC and tube cholecystostomy. The estimated total-to-subtotal cholecystectomy ratio is similar to the ratio reported in the first study on secondary gallbladder surgeries following AbC, which was 7:3.²² However, the rate of laparoscopic procedures (73%) was higher in our series of secondary surgeries. Overall, the clinical outcomes of this subgroup of patients were satisfactory, with moderate to severe morbidity rates of 20%, no bile leaks, no 30-day readmissions, and no mortality. Unfortunately, bile duct injury should be regarded as a reminder that this complication should not occur even though conventional or bailout operations are performed in the most challenging anatomical and pathological conditions.^56,57

Finally, the definition of AbC used in this study is broad, as the term “canceled cholecystectomy” was deemed unsuitable for defining the procedure started documentarily (World Health Organization Surgical Safety Checklist), anesthesiologically (general anesthetic), logistically (operating table), and procedurally (skin preparation). The earlier suggested definition—AbC is defined as an operation intended to be a total cholecystectomy, but in which no portion of the gallbladder is excised, with the cause for discontinuing the procedure being extensive inflammation—is a technically selective approach.²²

This study has some limitations. First, a complex method of patient identification was used. Some AbCs may have been insufficiently defined or underreported; therefore, they were not included in the hospital data sources or captured for this study. Second, the comparative sparsity of the primary data hindered the precision of the mean estimates and 95% CIs. Third, there is insufficient direct generalizability beyond a single-center cohort of patients. Theoretically, prospective case identification and the introduction of a preplanned form for data accumulation in 2012 would have eliminated some of the limitations of this study. Another way to generate new, high-quality knowledge on AbC is through a well-planned, designed, and protocolized multicenter, long-term observational study. The Global Evaluation of Cholecystectomy Knowledge and Outcome study is one example.⁵⁸

However, a strength of this study is that it highlighted the specific gallbladder bailout surgical procedure and its side effects. This comprehensive multiaspect analysis can serve as a resource for surgical care organizers. In addition, this study can be viewed as a call by professionals responsible for updating the statistical code classifications of surgical interventions and procedures. Locally, at the level of health care facilities or surgical departments, this study shows that surgical care providers must have a thought-out policy for managing gallstone disease and a pathway with a cholecystectomy timeframe for patients—an important clinical implication arising from this study.

Conclusions

The precision of preoperative assessment at any phase of care and the selection of patients for LC are areas for thoughtful consideration. A significant delay in gallbladder surgery for patients with complicated gallstone disease is the primary cause of AbC. Thus, it is crucial to follow national and international guidelines and recommendations, which emphasize the importance of early LC in acute cholecystitis and other complications of gallstone disease.

Individual or shared decisions to convert laparoscopic surgery to open surgery or bail out by abandoning cholecystectomy when other options for damage control and limitation surgery are not applicable should be made early to avoid the burden associated with laparoscopic surgical efforts to expose the gallbladder.

A statistical code for the AbC is required—a condition for introducing the annual AbC utilization rate as a new potential performance benchmark for evaluating the surgical care provision for patients with benign biliary disease.

Footnotes

Authors’ Contributions

R.L.: Conceptualization, methodology, project administration, data curation, formal analysis, and writing—original draft, review, and editing. S.W.F.: Writing—review and editing.

Data Availability Statement

The processed data are presented in the article. The raw data underlying this article cannot be shared publicly due to the inability to assure the confidentiality of patients.

Disclosure Statement

The authors have no conflicts of interest to declare.

Funding Information

No funding was received.

Supplementary Material

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Abandoned Cholecystectomy: A Single—Center Retrospective Cross-Sectional Cohort Study,2013–2024

Abstract

Introduction:

Materials and Methods:

Results:

Conclusions:

Introduction

Materials and Methods

Design, registration, and adherence

Patients, period, and definition

Identification of patients

Study variables and data collection

Statistical analysis

Results

Rates of AbC

Baseline demographics and preoperative characterization

Intraoperative informatics

Thirty-day postoperative outcomes

Long-term postoperative outcomes

Overall mortality

Elective gallbladder surgery following AbC

Discussion

Conclusions

Footnotes

Authors’ Contributions

Data Availability Statement

Disclosure Statement

Funding Information

Supplementary Material

References