The “inside approach of the gallbladder” is an alternative to the classic Calot’s triangle dissection for a safe operation in severe cholecystitis

Abstract

External dissection of Calot's triangle and the gallbladder associated with complete cholecystectomy is considered the gold standard technique to achieve a safe cholecystectomy. However, in severe acute or chronic cholecystitis, the laparoscopic application of this standard technique may be technically difficult, with an increased risk of bile duct injury, even in the hands of an experienced surgeon. In a consecutive series of 552 cholecystectomies, 39 patients (7.1%) with difficult local conditions within Calot's triangle, such as gangrenous cholecystitis (three patients), severe scleroatrophic cholecystitis with or without anomalous right hepatic duct (24 and 10 patients, respectively), or Mirizzi syndrome (seven patients), underwent a routine exclusive "endovesicular approach" as an alternative to dissection of Calot's triangle prior to further subtotal cholecystectomy. All patients were examined by control cholangiography 3 months postoperatively to confirm the safety of the technique. The operation was well tolerated by all patients with only 15.4% minor complications. Intraoperative cholangiography was feasible in 79.5%. There were no postoperative biliary or infectious complications. At 4.3 months follow-up, all patients were symptom-free, except for two patients (5.1%) with residual common bile duct stones which were successfully treated by endoscopic sphincterotomy. An endovesicular approach for gallbladder dissection followed by subtotal cholecystectomy is a safe alternative to the classic Calot's dissection in the case of severe cholecystitis or difficult local conditions. This technique is recommended as an attractive solution to prevent bile duct injury, particularly when severe inflammation is associated to extrahepatic anatomic variants of the biliary tree.