Preoperative Prediction of Laparoscopic Subtotal Cholecystectomy for Severe Cholecystitis

Abstract

Introduction: Laparoscopic cholecystectomy for cholecystitis with severe inflammation and/or fibrosis in Calot's triangle is associated with bile duct injury and a high conversion rate. However, some studies have reported the usefulness of laparoscopic subtotal cholecystectomy (LSC) in such condition, although laparoscopic experience and skills are demanded. In this study, we displayed our LSC, and developed a predictive score for LSC to avoid risky dissection on Calot's and conversion to open. Methods: Our LSC consists of transection at the gallbladder neck followed by closure of the remnant gallbladder stump, without dissection of Calot's. Between January 2004 and December 2013, 110 patients underwent LSC due to severe inflammation or fibrosis in Calot's triangle, and 1466 underwent conventional laparoscopic cholecystectomy (LC). Their clinical records were analyzed for their effect on the ratio of LSC to LC (LSC rates) by multivariate analysis, and a constant and coefficients for these independent variables were calculated and formed the predictive score. Results: All of 110 LSC were completed without conversion to open procedure. Postoperative complications were recorded in 11 of 110 patients (10.0%), of which all were treated conservatively. Bile duct injury and mortality were not observed in LSC series. Among the clinical characteristics of all patients, significant association with LSC rates were found in 5 variables, that is, preoperative CRP elevation (Symbol5), wall thickened Gallbladder, atrophic Gallbladder, pericholecystic abscess, and structure of extra hepatic bile duct. Mean of the predictive score in LSC was 8.2, and ideal cut-off point for score was 8; specificity and sensitivity toward LSC was 76.0% and 77.0%, respectively.SymbolConclusion: LSC for severe cholecystitis is safe and feasible. An experienced surgeon should operate on the patients who have the predictive score over 8, making a decision to LSC appropriately.