Laparoscopic Subtotal Cholecystectomy for Gangrenous Cholecystitis in a Liver Cirrhosis Patient: A Case Report

Abstract

Introduction: Subtotal cholecystectomy should be considered when structures of calot can not be identified or critical view of safety can not be achieved. Here, we present a case of laparoscopic subtotal fenestrating cholecystectomy for gangrenous cholecystitis in a liver cirrhosis patients. Case report: A 64 year-old male came to emergency room after suffering from RUQ pain for 4 days. Underlying medical conditions included hypertension, diabetes, and alcoholic liver cirrhosis with BMI of 22.5. Initial laboratory results were as following: WBC count of 12670/ul, platelet count of 90000/ul, C-reactive protein of 20.35 mg/dL, AST/ALT of 58/52 IU/L, Total bilirubin/Direct bilirubin of 3.88/2.37 mg/dL. Computed tomography showed gangrenous cholecystitis with cystic duct stones and liver cirrhosis with splenomegaly. The patient underwent laparoscopic cholecystectomy using conventional four port approach. Upon entering the peritoneum, severe adhesion around the gallbladder and macronodular cirrhosis were noted. Due to severe adhesion and collateral vessels, calot dissection was not possible. After identifying the cystic duct and retrieving the stones, cystic duct stump was sutured internally with 4-0 vicryl and laparoscopic subtotal cholecystectomy was completed after inserting a drain. Total operation time was 210 minutes with blood loss of 100cc. Patient was discharged on postoperative day #10 after conservative care for ascites. Conclusion: Subtotal cholecystectomy is an important tool for hepatobiliary surgeons facing complex intra operative situations with high risk of postoperative complications. Figures: A, B) preoperative CT, C) postoperative 1 month CT, D) Dissection of gallbladder, E) Identification of cystic duct, F) Cystic duct stump internally sutured