Subtotal cholecystectomy as a bailout strategy in difficult cholecystectomy: Outcomes and patient selection criteria.

Surgical management of ectopic pregnancy in the morbidly obese patient safety and feasibility of laparoscopy

Operating on difficult cholecystectomy with the intent to proceed with total cholecystectomy can be associated with longer postoperative time, excessive bleeding, and increased risk of intraoperative bile duct injury and other complications. Subtotal cholecystectomy is a part of bail-out procedures recommended in cases of difficult cholecystectomy. It is a convenient alternative to total cholecystectomy as it is a comparatively more manageable and safer treatment procedure. The aim of this study was to assess the difference in outcomes between laparoscopic total cholecystectomy (LTC) and laparoscopic subtotal cholecystectomy (LSC). This retrospective, cross-sectional study was conducted at King Fahd Hospital of the University (KFHU), Saudi Arabia, between 2010 to 2020. The study included patients over 18 years of age who underwent laparoscopic (subtotal and total) cholecystectomy at KFHU. Out of 636 cases in the study period, only 21 patients underwent laparoscopic subtotal reconstituting cholecystectomy. The laparoscopic total cholecystectomy group was more diagnosed with biliary colic (56.1%), whereas those who underwent laparoscopic subtotal cholecystectomy were mainly diagnosed with acute cholecystitis (66.7%). We found a significant association between WBC, reticulocyte count level, and the conversion to LSC. Regarding postoperative outcomes, only 7.8% had a drain in the laparoscopic total cholecystectomy group compared to the majority (71.4%) in the laparoscopic subtotal cholecystectomy group (p<0.0001). A significantly longer length of stay was reported in the subtotal cholecystectomy group (9.14±7.63 versus 4.6±3.84) and a greater rate of reoperation (9.5% versus 0.7%). Laparoscopic subtotal cholecystectomy should be performed in difficult cases when total cholecystectomy is not possible, considering the possible complications of subtotal cholecystectomy. More prospective studies should take into consideration other patient-related factors that might influence postoperative outcomes and overall success rates.

In patients undergoing laparoscopic cholecystectomy (LC) for complicated biliary disease, complication rates increase up to 30%. The aim of this study is to assess the effect of differences in surgical strategy comparing outcome data of two large volume hospitals. A prospective database was created for all the patients who underwent a LC in two large volume hospitals between January 2017 and December 2018. In cases of difficult cholecystectomy in clinic A, regular LC or conversion were surgical strategies. In clinic B, laparoscopic subtotal cholecystectomy was performed as an alternative in difficult cases. The difficulty of the cholecystectomy (score 1-4) and surgical strategy (regular LC, subtotal cholecystectomy, conversion) were scored. Postoperative complications, reinterventions, and ICU admission were assessed. For predicting adverse postoperative complication outcomes, uni- and multivariable analyses were used. A total of 2104 patients underwent a LC in the study period of which 974 were from clinic A and 1130 were from clinic B. In total, 368 procedures (17%) were scored as a difficult cholecystectomy. In clinic A, more conversions were performed (4.4%) compared to clinic B (1.0%; p < 0.001). In clinic B, more subtotal laparoscopic cholecystectomies were performed (1.8%) compared to clinic A (0%; p = < 0.001). Overall complication rate was 8.2% for clinic A and 10.2% for clinic B (p = 0.121). Postoperative complication rates per group for regular LC, conversion, and subtotal cholecystectomy in difficult cholecystectomies were 45 (15%), 12 (24%), and 7 (35%; p = 0.035), respectively. The strongest predictor for Clavien-Dindo grade 3-5 complication was subtotal cholecystectomy. Surgical strategy in case of a difficult cholecystectomy seems to have an important impact on postoperative complication outcome. The effect of a subtotal cholecystectomy on complications is of great concern.

PurposeCholecystectomy is one of the most frequently performed surgeries. Although laparoscopy is considered the gold standard approach, it cannot prevent biliary injuries. Subtotal cholecystectomy has been performed mainly to prevent biliary injuries during difficult cholecystectomies. This study aimed to analyse our subtotal cholecystectomy results for difficult cholecystectomy cases and to evaluate the fenestrating and reconstituting techniques.MethodsRetrospective data were collected and analysed statistically for cases that underwent subtotal cholecystectomy in a single referral centre between 2015 and 2020. Comparisons were made of the patients’ age, gender, preoperative American Society of Anaesthesiologists (ASA) score, comorbidities, surgical timing, surgical procedure choice, postoperative complications, and mortality.ResultsThe number of patients who underwent subtotal cholecystectomy was 46; 30.4% underwent emergent surgery and 69.6% underwent elective surgery. Twelve patients had subtotal fenestrating cholecystectomy and 34 had subtotal reconstituting cholecystectomy. Wound issues were noted in 17.4% of the patients, while 10.9% had temporary biliary fistulas that resolved spontaneously. Reoperation was performed in one patient due to high-output biliary drainage. Patients with postoperative complications had significantly higher co-morbid conditions (p=0.000), but surgery timing (p=0.192) and type of subtotal cholecystectomy (p=0.409) had no statistically significant effect on complications. Mortality showed a statistically significant correlation with patient comorbidities, surgery timing, and the type of procedure (p<0.05). Postoperative complications showed a statistically significant correlation with mortality (p<0.05).ConclusionSubtotal cholecystectomy prevents major biliary complications after cholecystectomy. Yet, the frequency of postoperative complications after subtotal cholecystectomy is incontrovertible. Intraoperative characteristics and the surgeon’s expertise decide the optimal choice of the subtotal cholecystectomy technique.

This study aimed to evaluate the perioperative outcomes of patients with benign and malignant liver lesions scheduled for laparoscopic and open surgery using a propensity score-matched approach to analyze additional cofactors influencing outcomes. In this study, we retrospectively reviewed 270 patients who underwent laparoscopic or open liver resection at our institute between October 2016 and November 2021. Patients were divided into open and laparoscopic liver resection groups and compared according to the intention to treat principle. In the purification process for the nonrandom nature of the study, a matching analysis was performed at a 1:1 case-control ratio. The PS model included selected data on body mass index, additional data on the American Society of Anesthesiology score, cirrhosis, lesion <2cm from the hilum, lesion <2cm from the hepatic vein or inferior vena cava, and type of neoadjuvant chemotherapy. The operation time and 30- and 90-day mortality rates were similar between the groups. The average length of hospital stay was 11 days in the open surgery group and 9 days in the laparoscopic surgery group after matching ( P =0.011). The 30-day morbidity rate was statistically different between the groups before and after matching, favoring the laparoscopic group ( P =0.001 and 0.006, respectively). After the propensity score-matched approch, the open group's Pringle time was shorter than that of the laparoscopic group. The total operative time was longer in the laparoscopic than in the open surgery group. This did not change after matching (300 vs. 240min). Laparoscopic surgery is a feasible and safe treatment option for patients with liver tumors, with promising results in terms of morbidity and hospital stay.

Background: Cholecystectomy is a commonly performed laparoscopic surgery but because of variability in anatomy, surrounding inflammation and fibrosis because of recurrent attacks of cholecystitis, can be a potentially difficult surgery. Laparoscopic total cholecystectomy in difficult gall bladder cases sometimes can cause severe complications. Laparoscopic subtotal cholecystectomy can be a bridge and a safe and feasible option between open subtotal cholecystectomy and laparoscopic cholecystectomy. Aim: To study indications, morbidity and clinical outcomes in patients undergoing subtotal cholecystectomy with laparoscopy or with open surgery. Settings and Design: It was a prospective observational study. Patients presenting with signs and symptoms of cholecystitis in either OPD or IPD and in emergency were included in this study. Materials and Methods: Total 38 patients who presented to our institute with clinical and ultrasonographic evidence of acute cholecystitis were included in the study. All patients underwent detailed and thorough clinical examination, laboratory investigations, ultrasonographic, and contrast enhanced computed tomography scan in selected patients. Based on intraoperative findings, decision of subtotal cholecystectomy either by laparoscopy or via open method was made. Various outcomes like intraoperative complications, postoperative complications and need of postoperative interventions, hospital stay, and returning to daily activity were observed and charted. Statistical Analysis: The data obtained were tabulated in Microsoft Excel and analyzed using SPSS version 17.0. Continuous variables were expressed as mean ± standard deviation value. Probability value (P value) was used to determine the level of significance. P value &lt;.05 was considered as significant; P value &lt;0.001 was considered as highly significant. Results: The common indications for subtotal cholecystectomy were severe cholecystitis with dense fibrous adhesions (97.4%), empyema (34.2%) or gangrenous gallbladder (31.6%), and Mirizzi syndrome (2.6%). Conversion rate was 21.1%. Morbidity rates were relatively low with subtotal cholecystectomy (bile leak 21.1%, sub hepatic collections 10.5%, retained stones 5.3%, paralytic ileus 18.4%, wound infection 7.9%, and common bile duct stricture 2.6%). Postoperative interventions were necessary in 18.4% of the cases (retained stones 5.3%, bile leak 7.9%, common bile duct stricture 2.6%, and subhepatic collection 2.6%). Mean duration of hospital stay was 7.5 days and returning to routine daily activity was 11.05 days. Conclusion: Subtotal cholecystectomy is a safe and feasible method for difficult gallbladder cases with a positive outcome. Laparoscopic subtotal cholecystectomy decreases the conversion rate in difficult gallbladder cases but it is not a substitute to open conversion if deemed necessary.

Parastomal hernia (PSH) is very common. Recent reports suggest increased frequency after laparoscopic stoma formation compared with open surgery. A retrospective chart review was designed to appraise the outcomes regarding PSH in open and in laparoscopic procedures. All patients operated by rectal resection and planned end-colostomy in the period from 2004 to 2018 were reviewed. A total of 70 open and 101 laparoscopic operations were identified. A modified retromuscular mesh application through the trephine was used for the prevention of PSH in 42% of patients in the laparoscopic group. The median follow-up was 58 (1 to 167) months in the open group and 43 (0 to 153) months in the laparoscopic group. Patient characteristics were evenly distributed between the groups, except for more male patients and higher American Society of Anesthesiologists Score as well as higher rates of patients with neoadjuvant treatment and mesh prophylaxis, in the laparoscopic group. Clinical PSH occurrences were 2 (3%) in the open group and 18 (18%) in the laparoscopic group (P=0.00). Propensity-weighted analysis estimates increased odds ratio (OR) for PSH in the laparoscopic group [OR=11.8; 95% confidence interval (CI): 1.4-96.6]. PSH repair rates were 0 in the open group and 6/18 (33%) in the laparoscopic group. Mesh prophylaxis in the laparoscopic group did not influence PSH outcome (OR=1.4; 95% CI: 0.5-4.0). Computed tomography scans were assessable in 48 and 66 patients, with median follow-up timepoints of 42 and 30 months in the open and laparoscopic groups, respectively, and 8 (18%) and 21 patients (32%) were diagnosed with PSH. Computed tomography assessment implied an increased risk for PSH in laparoscopy (OR=3.5; 95% CI: 1.1-11.9). Aggregate of chart and computed tomography occurrence of PSH showed an equivalent hazard (OR=3.2; 95% CI: 1.1-9.5). Laparoscopic operations with stoma formation seem to have an increased rate of PSH in comparison with open operations and the results support previous claims. Retromuscular keyhole mesh placement may not be the ideal method of PSH prevention in laparoscopic stoma formation.

Introduction: Laparoscopic cholecystectomy is commonly performed procedure in daily surgical practice worldwide in symptomatic gallbladder stone patients. During laparoscopic cholecystectomy, operating surgeons may encounter great difficulty during Calot’s triangle dissection and not able to achieved critical view of safety to proceed safe dissection with preventing common bile duct injury. In that case, we need to identified preoperative risk factors in the form of patient’s factor including comorbidity, no. of pain episode experience before current hospital admission, total number of hospital admission required for same complaints and radiological investigation including ultrasound abdomen-pelvis, CECT-A-P-T, MRCP which collectively indicate difficult cholecystectomy in preoperative periods. Intraoperative surgical findings may necessitate conversion into retrograde gallbladder dissection before doing unsafe calot’s triangle dissection to avoid major catastrophe and performing subtotal cholecystectomy in the form of either fenestrating or reconstituting subtotal cholecystectomy depending upon the condition of cystic duct opening and observing postoperative short term and long-term morbidity.[1] Methods: We retrospectively reviewed 25 patients who underwent subtotal cholecystectomy in a single unit at our institute during specific time period. Gathered all relevant preoperative, intra operative and post-operative information that predict difficult cholecystectomy during Preoperative as well as intra operative time and observed post operative short term and long term sequences(morbidity and mortality) in patients who underwent subtotal cholecystectomy Results: We analysed 25 patients who underwent subtotal cholecystectomy using either fenestrating (n-9) or reconstituting (n-16) approaches with regards to post operative bile leak. Patient who underwent Fenestrating subtotal cholecystectomy was associated with higher rate of post operative bile leak as compared to reconstituting subtotal cholecystectomy.Post operative bile leak effectively managed either by conservative management with delayed drain removal or need of postoperative ERCP, USG guided pigtail insertion as well as re-laparoscopic peritoneal lavage with drain placement in a patient who developed signs of bile peritonitis. Conclusions: Fenestrating subtotal cholecystectomy is associated with higher rate of postoperative bile leak as compared to reconstituting subtotal cholecystectomy but bile leak effectively managed non-operative or operative method. So, both approaches are safe in view of difficult cholecystectomy. We encourage the subtotal cholecystectomy approach in difficult cholecystectomy considering trends in improved short- and long-term outcomes.

This study compared laparoscopic with open sigmoid colectomy for patients with a diagnosis of diverticulitis. Increased use of less invasive techniques makes it vitally important to evaluate outcomes of these techniques as compared with standard open procedures. Patients undergoing sigmoid colectomy for diverticulitis without hemorrhage (code 56211) between January 1997 and December 2001 were reviewed. Two groups were identified: those undergoing open sigmoid colectomy and those undergoing laparoscopic sigmoid colectomy; American Society of Anesthesiologists (ASA) scores, operative time, intensive care unit (ICU) and hospital length of stay, morbidity/mortality, and hospital charges were compared. During the study period 271 sigmoid colectomies were performed for diverticulitis without hemorrhage: 56 laparoscopically and 215 with the standard open technique. Four patients required conversion from laparoscopic to open colectomy. Mean ASA scores were: open group 2.4; laparoscopic group, 1.9 ( P &lt; 0.001). Mean operative times were: laparoscopic group, 170 ± 45 minutes; open group, 140 ± 49 minutes ( P &lt; 0.001). In the open group 39 patients required transfer to the ICU; one patient in the laparoscopic group required transfer to the ICU. Average hospital lengths of stay for the open and laparoscopic groups were 9.06 and 4.12 days, respectively ( P &lt; 0.001). Complications were recorded in 57 (27%) of 215 patients who underwent an open procedure versus 5 (9%) of 56 patients who underwent laparoscopic sigmoid colectomy ( P &lt; 0.01). There were three deaths in the open group and none in laparoscopic group. Average total hospital charges were $25,700 for open sigmoid colectomy and $17,414 for laparoscopic colectomy. Laparoscopic sigmoid colectomy compares favorably with open sigmoid colectomy for patients with a diagnosis of diverticulitis.

Laparoscopic Roux-en-Y gastric bypass surgery (RYGB) was introduced at the authors' institution 5 years ago. The authors analyzed the short- and long-term results of this procedure compared with those for the same procedure using the laparotomy approach over the same period. Retrospective analysis of a prospectively collected bariatric database used the outcome end points used by the American Society of Bariatric Surgery (ASBS) and the American College of Surgeons (ACS) in their center of excellence programs. From January 2001 to July 2005, 568 laparoscopic and 399 open gastric bypasses were performed at Vanderbilt University. The patients were from the same bariatric surgery program and therefore received the same pre- and postoperative care. The hospital length of stay in the laparoscopic group was significantly shorter (2.5 +/- 2.4 days) than in the open group (3.7 +/- 3.7 days; p = 0.001). The procedure time was significantly shorter in the laparoscopic group (164 +/- 50 min) than in the open group (195 +/- 50 min; p = 0.0001). The follow-up assessment response at 2 years was 76.6%. At 2 years, the excess weight loss (EWL) was significantly greater in the laparoscopic group (71.3% +/- 18.4%) than in the open group (67.3% +/- 15.3%; p = 0.03). The wound infection rate was significantly higher in open group (9.2%) than in the laparoscopic group (1.7%; p = 0.001). There was no significant difference in 30-day mortality: open (0.50%) versus laparoscopic (0.17%; p = 0.371). There was no significant difference in the 30-day reoperation rate between the open (2.4%) and laparoscopic (2.6%; p = 0.705) groups. The 30-day readmission rate was similar in the open (5.0%) and laparoscopic (5.2%; p = 0.852) groups, as was the rate of leakage from the gastrojejunostomy in the open (0.50%) and laparoscopic (0.35%; p = 0.127) groups. The conversion rate from laparoscopic procedure to laparotomy was 1.7%. In the authors' institution, a laparoscopic bariatric surgery program with a very low rate of morbidity and mortality has been introduced. Operative time, hospital stay, and wound complications are reduced with the laparoscopic approach. The laparoscopic and open procedures are equally safe, with equivalent 30-day mortality, readmission, reoperation, and gastrojejunostomy leakage rates.

IntroductionThe use of laparoscopic surgery has increased in the treatment of colorectal cancer (CRC). However, achieving oncological outcomes similar to those of open surgery remains challenging, particularly for CRC. In this comparative, retrospective study, we aim to investigate and compare the postoperative complications of open and laparoscopic CRC surgery in Jordan.MethodsUsing a retrospective study design, patients’ records were obtained from the electronic hospital database of King Hussein Medical Center, Amman, Jordan, during the period between 2016 and 2024. Demographic data were collected for age and gender. Clinical data were collected for tumor site, tumor grade, body mass index, American Society of Anesthesiologists (ASA) score, lymph node ratio (LNR), postoperative complications such as ileus, anastomosis, stoma, renal complications, pain, wound infection, and death, and length of hospital stay.ResultsWe included 857 CRC patients, with 437 (51.0%) undergoing laparoscopic resection and 420 (49%) undergoing open resection. The mean age was 58 years, with no age difference between the study groups. Most patients (507, 59%) were in good health based on the ASA score. The majority (671, 78%) had moderately differentiated tumors, with 320 (76%) in the open surgery group and 351 (80%) in the laparoscopy group. The mean LNR was 0.19, trending higher in the group that underwent open surgery (0.33 vs. 0.09, p = 0.065). The open surgery group had a significantly longer hospital stay (5.28 days) relative to the laparoscopic group (3.77 days, p < 0.001). Postoperative complications included wound infection (33, 3.9%), ileus (19, 2.2%), stoma (15, 1.8%), anastomosis (10, 1.2%), renal complications (9, 1.1%), and pain (6, 0.7%). The mortality rate was higher in the open surgery group (p = 0.035). Most patients (711, 83%) did not experience postoperative complications.ConclusionThis is the first Jordanian study to compare long-term outcomes of CRC patients undergoing open versus laparoscopic surgical resection. Our findings suggested that the laparoscopic group had a shorter hospital stay, with no differences in postoperative complications rate between the study groups. Mortality rates were low overall but significantly higher in the open surgery group. These results suggest that laparoscopic resection may be superior for CRC surgery, though further multicenter studies are warranted to confirm our findings.

Difficult cholecystectomies are associated with a higher risk of severe bilio-vascular injuries. Obesity, cirrhosis, high American Society of Anesthesiologists score, previous abdominal operations, and presence of acute cholecystitis or common bile duct stones are associated with difficult cholecystectomies. On imaging, thickened gallbladder wall, pericholecystic fluid, and an impacted gallstone are associated with difficult cholecystectomies. In challenging operations, the use of imaging (intraoperative cholangiography, intraoperative ultrasound, near-infrared cholangiography) is recommended. If the critical view of the hepatocystic triangle cannot be safely achieved, bailout strategies, such as tube cholecystostomy, subtotal cholecystectomy, or an anterograde approach, should be considered. Conversion to open surgery should be considered for significant bleeding, cholecystoenteric fistula, Mirizzi syndrome, or malignancy. Seeking advice or assistance from another surgeon is recommended when conditions are challenging. Knowledge of perioperative and intraoperative adjuncts and alternative surgical options aid surgeons in performing difficult cholecystectomies safely.

Background Laparoscopic Cholecystectomy (LC) is the main treatment for symptomatic gallstone disease. Sub-total cholecystectomy (SC) has become increasingly utilised as a safe alternative to conversion to open when unable to visualise the critical view of safety. This avoids the morbidity of an open operation whilst minimising the risk of iatrogenic injury to the common bile duct. Male sex, increasing age, previous acute cholecystitis and ERCP have previously been identified as independent risk factors for SC. We aim to identify factors that increased the likelihood of SC within our cohort and the effect of SC on post-operative morbidity. Method All patients who had LC as either an elective or emergency procedure between 1st July 2020 and 30th June 2022 were identified and included in this study. Patient and operative details were retrieved from their electronic record and a Charlson co-morbidity index was calculated. Any post-operative complication was noted and graded according to the Clavien-Dindo classification. Statistical analysis was performed using SPSS with ANOVA analysis being performed for continuous data. Odds ratios were calculated with a 95% confidence interval. Statistical significance was taken as a p value &amp;lt; 0.05. Results 974 patients underwent LC with 4.8% having SC. Factors associated with increased risk of SC included: previous acute cholecystitis (OR 9.37 (4.69-18.70), increased age (mean = 58.7 vs 50.9), higher Charlson co-morbidity index (mean = 2.60 vs 1.43) male sex (OR 2.49 (1.38-4.48), emergency operation (OR 2.30 (1.23-4.30), Diabetes Mellitus (OR 2.58 (1.23-5.36); and previous ERCP (OR 2.62 (1.13-6.11). 30-day morbidity was higher for SC (25.5% vs 8.1%) with major complication (Clavien-Dindo &amp;gt; 2) being significantly more frequent (OR 6.64(2.53-17.4). Median post-operative length of stay was 2 days for SC and 0 days for LC. Conclusion Although regarded as a safe option in difficult cholecystectomy, our study shows that there is significant morbidity associated with subtotal cholecystectomy. However, the majority of patients only require a short hospital stay post-operatively. Multiple risk factors were identified for SC with previous acute cholecystitis being the most strongly associated with SC. Diabetes was identified as an independent risk factor alongside higher Charlson co-morbidity index as a generic marker of co-morbidity. Interestingly, CBD diameter &amp;gt; 8mm on pre-operative imaging was not shown to increase risk of SC.

A textbook outcome (TO) is a composite quality measure that incorporates multiple perioperative events to reflect the most desirable outcome. The use of TO increases the event rate, captures more outcomes to reflect patient experience, and can be used as a benchmark for quality improvement. To introduce the concept of TO to elective laparoscopic cholecystectomy (LC), propose the TO criteria, and identify characteristics associated with TO failure. This retrospective cohort study was performed at 3 surgical units in a single health board in the United Kingdom. Participants included all patients undergoing elective LC between January 1, 2015, and January 1, 2020. Data were analyzed from January 1, 2015, to January 1, 2020. The TO criteria were defined based on review of existing TO metrics in the literature for other surgical procedures. A TO was defined as an unremarkable elective LC without conversion to open cholecystectomy, subtotal cholecystectomy, intraoperative complication, postoperative complications (Clavien-Dindo classification ≥2), postoperative imaging, postoperative intervention, prolonged length of stay (>2 days), readmission within 100 days, or mortality. The rate of TOs was reported. Reasons for TO failure were reported, and preoperative characteristics were compared between TO and TO failure groups using both univariate analysis and multivariable logistic regressions. A total of 2166 patients underwent elective LC (median age, 54 [range, 13-92] years; 1579 [72.9%] female). One thousand eight hundred fifty-one patients (85.5%) achieved a TO with an unremarkable perioperative course. Reasons for TO failure (315 patients [14.5%]) included conversion to open procedure (25 [7.9%]), subtotal cholecystectomy (59 [18.7%]), intraoperative complications (40 [12.7%]), postoperative complications (Clavien-Dindo classification ≥2; 92 [29.2%]), postoperative imaging (182 [57.8%]), postoperative intervention (57 [18.1%]), prolonged length of stay (>2 days; 142 [45.1%]), readmission (130 [41.3%]), and mortality (1 [0.3%]). Variables associated with TO failure included increasing American Society of Anesthesiologists score (odds ratio [OR], 2.55 [95 CI, 1.69-3.85]; P < .001), increasing number of prior biliary-related admissions (OR, 2.68 [95% CI, 1.36-5.27]; P = .004), acute cholecystitis (OR, 1.42 [95% CI, 1.08-1.85]; P = .01), preoperative endoscopic retrograde cholangiopancreatography (OR, 2.07 [95% CI, 1.46-2.92]; P < .001), and preoperative cholecystostomy (OR, 3.22 [95% CI, 1.54-6.76]; P = .002). These findings suggest that applying the concept of TO to elective LC provides a benchmark to identify suboptimal patterns of care and enables institutions to identify strategies for quality improvement.

Aim: Laparoscopic cholecystectomy is the optimal surgical treatment for benign gallbladder diseases. Under curtain conditions it is very hard to distinguish the Calot triangle and it becomes difficult to perform safe cholecystectomy. Subtotal cholecystectomy is a salvage option in such conditions. The aim of this study is to compare the results of open and laparoscopic subtotal cholecystectomy in difficult gallbladder management.Material and Methods: In this retrospective study results of all consecutive patients who were performed subtotal cholecystectomy between July 2014 and August 2017 were collected and laparoscopic and open methods were compared. Results:Forty-five of 396 laparoscopic cholecystectomy cases underwent subtotal cholecystectomy during the study period. Subtotal cholecystectomy was performed laparoscopically in 27 of 45 patients (Group I), and open method in 18 patients (Group II). Convertion rate was %34.1. No significant difference was observed in terms of both preoperative and postoperative laboratory results. There was no difference between two groups in terms of ERCP history. The rate of open operation was statistically higher in acute cases. The duration of surgery was significantly higher in laparoscopic group but length of hospital stay was significantly higher in open group. Total cost was higher in group 2 but this result did not reach statistical significance. Total bile leak rate was 2.2%.Conclusion: Laparoscopic subtotal cholecystectomy is a safe and appropriate method which can be compared with open subtotal cholecystectomy in difficult gallbladder management.