Spectrum of Difficult Cholecystectomies and Their Management

Abstract

Introduction:

Laparoscopic cholecystectomy (LC) is a commonly performed procedure by general surgeons. A difficult cholecystectomy (DC) is caused by a variety of factors, and every general surgeon faces these challenges.^1,2 The Calot’s triangle forms an important landmark to avoid injury during LC.^3,4 Various guidelines and landmarks may decrease the risk of this life-threatening complication.^5,6 In this video presentation, multiple cases of DCs and their management are presented. Following safe cholecystectomy steps, these cases can be successfully completed to prevent morbidity and mortality.

Materials and Methods:

This study comprises multiple patients with DC. For a grossly dilated short cystic duct, subtotal cholecystectomy with staplers was performed. For varices due to portal hypertension, the dissection stayed as far as possible from the Calot’s triangle, and a subtotal cholecystectomy was performed. For inadvertent bleeding, pressure, electrocautery, clips, or sutures may be applied. For a Moynihan humped artery, careful delineation of the short cystic artery was completed, followed by clipping and division. For a cholecystoenteric fistula, a stapler was placed away from the duodenum and closer to the gallbladder wall. Choosing the proper instruments plays a critical role in preventing bowel injury. Use of energy device in the vicinity of bowel should be used judiciously.

Results:

All the patients were discharged on postoperative day 1 or 2. On follow-up at 1 week and 1 month, there was no bleeding, bile duct injury, subhepatic abscesses or persistent symptoms.

Conclusions:

Subtotal cholecystectomy, the fundus-first approach, tube cholecystostomy, using adjuncts such as extra ports, staplers, and intraoperative cholangiography, and open cholecystectomy are safe and feasible options for patients with DC.

Patient Consent Statement:

Corresponding Author have received and archived patient consent for video recording/publication of the video without exhibiting patient demographic details in advance.

Source of work or study:

This is an original work carried out in a tertiary care public hospital, and there are no conflicts of interest or obligations resulting from it to any of the authors.

Author Disclosure Statement:

There are no commercial associations during the last 3 years that might create a conflict of interest in connection with the video.

Authors have already received and archived patient consent for video recording/publication of the surgical procedure video without exhibiting patient identity in advance.