Fundus-first laparoscopic cholecystectomy for complex gallbladders: A systematic review

Abstract

Retrograde ‘fundus-first’ cholecystectomy (FF) signifies the dissection that starts from the fundus of the gallbladder to the infundibulum in case structures of Calot's triangle cannot be identified. Although feasible in laparoscopic cholecystectomy (LC), FF remains an underutilized approach in difficult cases. We aimed to systematically review the fundus-first laparoscopic cholecystectomy (FFLC) and to evidence-base its advantages and feasibility. A systematic review was performed in compliance with PRISMA guidelines. A literature search was performed using PubMed/MEDLINE, ScienceDirect and Cochrane-Library for articles published from 2001 to 2021. Search keywords included ‘retrograde cholecystectomy’, ‘fundus-first cholecystectomy’ and ‘fundus-down cholecystectomy’. Quality assessments were applied using the Medical Education Research Quality Instrument (MERSQI) scores. Also, evidence levels were employed using GRADE. The protocol was registered with PROSPERO register (CRD42021227518). Altogether 9393 citations were identified and reviewed for this study. A final 23 studies were included, with a total of 7973 cholecystectomies comprising 3020 with FF approach. The endpoints were operative time, duration of postoperative hospital-stay and intraoperative and postoperative complications, as well as rate of conversion to open surgery. MERSQI mean score was 10.2 (SD= 1.85). The FF dissection was evidenced to be a superior technique when compared to conventional anterograde dissection as regards duration of operation, pain, nausea, conversion to open surgery and duration of sick leave. Furthermore, FF was found to be appropriate for difficult LC The fundus-first laparoscopic cholecystectomy was associated with a shorter operating time, decrease in pain and nausea scores and reduced incidence of conversion to open cholecystectomy. Ultrasonic dissection was favoured in the retrograde dissection compared to that with electrocautery.