SP6.1.8Fundus-first laparoscopic cholecystectomy for complex gallbladders: A systematic review

Abstract

Abstract Aims Retrograde ‘fundus-first’ cholecystectomy is when the dissection 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, it remains an underutilized approach. We aimed to systematically review the fundus-first laparoscopic cholecystectomy and study its safety and feasibility. Methods 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 2010 to 2020. Search keywords included ‘retrograde cholecystectomy’, ‘fundus-first cholecystectomy’ and ‘fundus-down cholecystectomy’. Quality assessments were applied using the Medical Education Research Quality Instrument (MERSQI) score. The protocol was registered with PROSPERO register. Results A total of 3503 studies formed the base for evidence evaluations. 12 studies with 1978 fundus-first cholecystectomies were assessed. Three citations were scored high and 5 moderate quality. Endpoints included blood loss, rate of conversion to open, bile duct injury, gallbladders perforations, postoperative pain and hospital stay. Nine studies provided both strong and moderate scientific evidence for a positive outcome of the fundus-first approach. Conclusion The fundus-first cholecystectomy was associated with a reduced need for intraoperative cholangiography, shorter operating time, lower incidence of intra-operative complications, bile duct injury and reduced incidence of conversion to open cholecystectomy.