The use of laparoscopic subtotal cholecystectomy for complicated cholelithiasis

Abstract

Dear Editor:We read with interest the article entitled The Use of Lap-aroscopic Subtotal Cholecystectomy for ComplicatedCholelithiasis published in Surgical Endoscopy [1]. Wecongratulate the authors for their results, and we agree withtheir conclusion that laparoscopic subtotal cholecystec-tomy (LSC) is a valuable procedure during laparoscopiccholecystectomy (LC) when Calot’s triangle cannot bedissected and that it will prevent unnecessary laparotomy.We have adopted this approach for many years in our busyLC practice.We raise two issues we consider complementary to thevaluable contents of the article. With LSC, there is alwaysa risk of missing a stone in the cystic duct or residual partof Hartman’s pouch because it is inaccessible or difficult todissect. This may lead to occasional recurrence of rightupper quadrant pain, which needs to be managedaccordingly.Although LSC without cystic duct ligation has beendescribed as a practical alternative even with predictablebile leak [2], we have attempted closure of the ‘‘stump’’whether this stump is the junction of the cystic duct toHartman’s pouch or part of Hartman’s pouch. Ideally, thisclosure can be achieved safely with Vicryl endoloops.However, dissection of the posterior wall occasionally iscompromised and unsafe, in which case we have closed thestump by a running suture that takes the anterior andposterior part of the stump which is adherent to the liverbed. These maneuvers have helped us keep biliary leakrates very low in our series.References