Laparoscopic Completion Cholecystectomy Research Articles

Open versus laparoscopic completion cholecystectomy in patients with previous open partial cholecystectomy; a retrospective comparative study

Background: Some patients report recurrence or persistence of their manifestations after cholecystectomy, and retained gallstones may be a relevant etiology for their complaint. Completion cholecystectomy is advised for these cases to alleviate their manifestations. No previous studies have compared the outcomes of open versus laparoscopic outcomes in these patients, especially in patients who had initial open partial procedures. That is why we performed this study to report the perioperative outcomes of the two approaches in such patients. Methodology: This is a retrospective analysis of 80 patients who had a completion cholecystectomy in our center (40 open and 40 laparoscopic cases) after initial open partial cholecystectomy. Results: The duration elapsed since the primary procedure had an average of 18 months in the open group and 21 months in the laparoscopic group. Abdominal pain and dyspepsia were the most common presentations. Some patients had stump cholecystitis or jaundice. The intraoperative assessment revealed either the residual gallbladder or a long cystic duct stump. Laparoscopy yielded shorter operative time, earlier oral intake, and shorter hospitalization periods compared to the open approach (P<0.05). The latter was associated with a 20% wound infection rate that was never encountered after laparoscopy (P =0.003). Conclusion: Previous open partial cholecystectomy does not hinder subsequent laparoscopic completion cholecystectomy. Additionally, laparoscopy is associated with better perioperative outcomes than the open approach.

The Success Rate Is Lower but Completion Rate of Laparoscopic Cholecystectomy Is higher in Endoscopic Transpapillary Gallbladder Drainage than Percutaneous Gallbladder Drainage for Acute Cholecystitis.

We investigated the success and complication rates of endoscopic transpapillary gallbladder drainage (ETGBD) and percutaneous transhepatic gallbladder drainage (PTGBD) and the outcomes of subsequent cholecystectomy for acute cholecystitis. Patients (N=178) who underwent cholecystectomy after ETGBD or PTGBD were retrospectively assessed. ETGBD was successful in 47 (85.5%) of 55 procedures, whereas PTGBD was successful in 123 (100%) of 123 sessions ( P <0.001). Complications related to ETGBD and PTGBD occurred in 6 (12.8%) of 47 and 16 (13.0%) of 123 patients, respectively ( P =0.97). After propensity matching, 43 patients from each group were selected. Median time from drainage to cholecystectomy was 48 (14 to 560) days with ETGBD and 35 (1 to 90) days with PTGBD ( P =0.004). Laparoscopy was selected more often in the ETGBD group (97.7%) than in the PTGBD group (79.1%) ( P =0.007), and conversion from laparoscopy to open cholecystectomy was more common with PTGBD (41.2%) than with ETGBD (7.1%) ( P <0.001). Mean operation time was significantly shorter with ETGBD (135.8±66.7min) than with PTGBD (195.8±62.2min) ( P <0.001). The incidence of Clavien-Dindo grade ≥III postoperative complications was 9.3% with ETGBD and 11.6% with PTGBD ( P =0.99). The success rate is lower but completion of laparoscopic cholecystectomy is more in endoscopic gallbladder drainage than percutaneous gallbladder drainage for acute cholecystitis.

OGBN P03 Surgeons’ perceptions of elective laparoscopic cholecystectomy in the post-COVID era

Abstract Background The COVID-19 pandemic has significantly impacted healthcare systems worldwide, leading to modifications in surgical practices. Laparoscopic cholecystectomy (LC), a common elective procedure, has faced challenges in the post-COVID era, with increased waiting times and episodes of acute gallstone disease in patients awaiting their procedure. This poses the question as to whether modifications to routine practice should be made. This study aims to explore surgeons' perceptions on performing laparoscopic cholecystectomy in the current post-pandemic landscape. Methods An anonymous survey was conducted among general surgeons with expertise in LC across multiple healthcare institutions nationally. The survey included questions relating to surgeons’ speciality, and their experience with elective LCs, intraoperative cholangiograms (IOC) and laparoscopic common bile duct exploration (LCBDE) in post-COVID era. Further opinions were sought on complicated intraoperative findings, rate of aborting procedure, rate of conversion to open and number of elective LCs completed by trainees. The data obtained was analysed using descriptive statistics and Fisher’s exact test for statistical significance calculations. Results 40 surgeons with varying levels of experience with LC completed the survey: 8 (20%) &amp;lt;50, 16 (40%) 100-500 LCs,10 (25%) 500-&amp;gt;1000. Overall, 21 (53%) perceived LC to be more challenging. Analysis between the different groups found no significant difference (p = 0.68) between those who performed &amp;lt;50 LCs (6/8) and 500- &amp;gt;1000 LCs (6/10). 8 (20%) respondents found no increase in complicated intraoperative findings. Of those not working in specialist centres, 11/36 perceived an increase in referral to a hepatobiliary unit. 14 (35%) perceived an increase in unplanned admission. 21 (53%) perceived a reduction in completion of LC by trainees. Conclusions This study demonstrates that a significant proportion of respondents believe that LC has become more technically challenging. In patients with increased time till surgery or episodes of acute gallstone disease, MRCP should be considered at pre-assessment. Furthermore, during challenging LCs, options to ‘bail-out’ or convert to open should be considered. This study also raises awareness on the reduction in training opportunities and the need to ensure trainees progress appropriately. Limitations include small sample size and subjective nature of responses. Further research on patient outcomes is required to provide strong recommendations to optimise surgical practice of LC in the post-pandemic era.

The use of indocyanine green and near-infrared imaging in laparoscopic completion cholecystectomy for the management of stump cholecystitis: A case series.

Stump cholecystitis is managed by performing a completion cholecystectomy, which can be done either laparoscopically or by an open method. The use of indocyanine green (ICG) is known to improve the identification of the biliary tree anatomy, facilitating Calot's triangle dissection and shortening surgery, thereby reducing the risk of bile duct injuries and making laparoscopic cholecystectomy safer. A retrospective analysis was performed of prospectively collected data from 15 patients at our institution from March 2016 to March 2021. Magnetic resonance cholangiopancreatography was performed in all 15 cases, showing remnant gall bladder in all cases with calculi within. Four cases had a dilated common bile duct (CBD) with CBD calculi. Endoscopic retrograde cholangiopancreatography (ERCP) and stone removal followed by CBD stenting were performed in the four patients with CBD calculi. These four cases were scheduled for surgery 4 weeks post-ERCP. All 15 patients underwent laparoscopic completion cholecystectomy. The mean operating time was 80 min. The post-operative period of all cases was uneventful, and the patients were discharged on post-operative day 2 or day 3. All patients remained asymptomatic during 1-5 years of follow-up. Laparoscopic completion cholecystectomy was performed safely in cases of stump cholecystitis and resulted in symptom relief during short-term follow-up. The use of ICG and near-infrared imaging in such cases helps identify the biliary anatomy, may contribute to the safety of laparoscopic completion cholecystectomy and might reduce the duration of surgery.

Laparoscopic completion cholecystectomy for patients with residual gallstone disease: a single-center experience

Background The incidence of residual gallbladder after cholecystectomy procedures may reach 2.5%. That remnant part of the gallbladder may harbor or develop stones, leading to recurrent symptoms. Surgical excision is recommended in such patients. Herein, we describe our experience regarding laparoscopic management of patients with residual gallbladder or cystic duct stump stones. Patients and methods We retrospectively reviewed the data of 24 patients with previous diagnosis, who were managed by laparoscopy in our tertiary-care setting. Relevant preoperative, intraoperative, and postoperative data were collected. Results The time interval since the previous cholecystectomy ranged between 3 and 120 months. Most patients had previously undergone an open cholecystectomy (75%), while the remaining cases were performed through laparoscopy. The laparoscopic assessment revealed residual gallbladder and cystic duct stump stones in 87.5% and 12.5% of cases, respectively. Conversion to the open approach was needed only in two cases (8.3%). Operative time ranged between 60 and 130 min (mean = 108.83), while intraoperative blood loss had a mean value of 111.88 mL (range, 50–150). The duration of hospitalization ranged between 1 and 4 days (median = 1). Postoperative morbidity occurred in eight patients (33.33%). Wound infection, gallbladder bed collection, and pulmonary embolism occurred in 16.7, 16.7, and 4.2% of patients, respectively. No specific risk factors for postoperative morbidity were identified. Conclusion Laparoscopic completion cholecystectomy is considered a safe and effective procedure in experienced hands for managing patients with symptomatic gallbladder residuals .

The second 'gallbladder operation'.

Subtotal cholecystectomy has been reported in 8% and 3.3% of patients undergoing open and laparoscopic cholecystectomy, respectively. According to a recent nationwide survey, the utilisation of subtotal cholecystectomy in the treatment of acute cholecystitis is on the rise. In 1.8% of subtotal cholecystectomies, a reoperation is required. Reoperations for residual gallbladder (GB), gallstones, and related complications accounted for half of the reoperations described in the literature after subtotal cholecystectomy. The purpose of this study was to evaluate the clinical profile, risk of complications, and feasibility of laparoscopic approaches and surgical procedures in patients with recurrent symptoms from a residual GB that necessitated a completion cholecystectomy. Patients who underwent surgery for residual GB with stones and/or complications between January 2007 and January 2020 were included in the study group. A prospectively maintained database was used to review patient information retrospectively. The demographic profile, operation details of the index surgery, current presentation, investigations performed, surgery details, morbidity and mortality were all included in the clinical information. There were 13 patients who underwent completion cholecystectomy. The median age was 55 years (22-63 years). Prior operative notes mentioned subtotal cholecystectomy in only seven patients. The average time between the index surgery and the onset of symptoms was 30 months (2-175 months). A final diagnosis of residual GB with or without calculi was made by ultrasound (USG) in 11 patients and by magnetic resonance cholangiopancreatography (MRCP) in two others. Choledocholithiasis (n = 4, 30.7%), acute cholecystitis (n = 2, one with empyema and GB perforation) and Mirizzi syndrome (n = 1) were seen as complications of residual gallstones in seven patients. All 13 patients underwent successful laparoscopic procedures. A fifth port was used in all. A critical view of safety was achieved in 12 patients. Two patients required laparoscopic common bile duct (CBD) exploration for CBD stones. Intraoperative cholangiograms were done in eight patients (61.5%). There were no conversions, injuries to the bile duct or deaths. Morbidity was seen in one. The patient required therapeutic endoscopic retrograde cholangiography for cholangitis and CBD clearance on the fifth post-operative day. The median hospital stay was 4 days (3-7 days). At a median follow-up of 99 months, symptom resolution was seen in all 13 patients. Gallstones in the residual GB are associated with more complications than conventional gallstones. The diagnosis requires a high level of suspicion. MRCP is more accurate in establishing the diagnosis and identifying the associated complications, even if the diagnosis is made on USG in most patients. A pre-operative roadmap is provided by the MRCP. For patients with residual GB, laparoscopic completion cholecystectomy is a feasible and safe option.

Management of Acute Disease in the Remnant Gallbladder: The Effectiveness of Repeat Laparoscopy

Introduction: Subtotal cholecystectomy has become a widely accepted alternative for patients presented with acute cholecystitis resulting in significant inflammation and anatomic distortion. Recurrent cholecystitis of the remnant gallbladder is an accepted complication of this procedure. International studies have shown completion cholecystectomy to be the definitive management of recurrent cholecystitis. Few investigators in the United States have focused on management of this scenario, and to this point open surgical approach has been recommended. Methods: Cholecystectomies undertaken by one hepatobiliary surgeon over a two-year period from 2017-2019 were reviewed. Cases of patients with previous cholecystectomy who then presented with acute cholecystitis and underwent laparoscopic completion cholecystectomy were compiled and reviewed to determine interval from initial cholecystectomy, operative time, use of intraoperative cholangiography, use of intraoperative indocyanine green (ICG), placement of drain, and total length of hospital stay (LOS). Results: Seven patients met inclusion criteria. The mean interval from initial cholecystectomy was 22 months (range 3-89 months with one patient presenting an unknown length of time from initial operation). Mean operative time was 119 minutes (range 79 minutes to 141 minutes). Five patients had an intraoperative cholangiogram and one case was completed with intraoperative ICG. A drain was left at the completion of three out of seven cases. Average LOS was less than one day (range 0-2) with three patients discharged in good condition post-operative day 0. Conclusions: Laparoscopy is a safe and effective approach to completion cholecystectomy for patients with recurrent cholecystitis that avoids an open surgical procedure.

Laparoscopic Completion Cholecystectomy: An Audit from the Americas Hepato-Pancreato-Biliary Association (AHPBA) Caribbean Chapter.

ObjectiveRemoval of a gallbladder remnant occasionally becomes necessary when retained stones become symptomatic. Although the laparoscopic approach has been described, it is not yet considered the standard of care. We sought to determine the outcomes after completion cholecystectomies in the resource-poor setting within the Caribbean. MethodsWe carried out an audit of the databases from all hepatobiliary surgeons in the Anglophone Caribbean. We identified all patients who had completion cholecystectomy over the five-year period from July 1, 2012 to June 30, 2018. Retrospective chart review was performed to extract the following data: patient demographics, diagnoses, presenting complaints, operative details, morbidity, mortality, and clinical outcomes. Descriptive statistics were generated using Statistical Packaging for Social Sciences (SPSS), version 12.0 (SPSS Inc., Chicago IL)ResultsThere were 12 patients who were subjected to laparoscopic completion cholecystectomy for acute cholecystitis (7), severe biliary pancreatitis (3), and chronic cholecystitis (2) secondary to stones in a gallbladder remnant. There were 10 women and two men at a mean age of 47.4 years (range 32-60; standard deviation (SD) +/-7.81; median 48; mode 52) and a mean body mass index (BMI) of 30.8 Kg/M2 (SD +/-3.81; range 26-38; median 29.5). The mean interval between the index operation and the completion operation was 14.8 months (SD +/- 12.3; range 1-48; median 13; mode 18). Five (42%) patients had their original cholecystectomy using the open approach. Five (42%) index operations were done on an emergent basis and the gallbladder remnant was deliberately left behind in three (25%) index operations. The completion cholecystectomies were all completed laparoscopically in 130.5 minutes (SD +/- 30.5; range 90-180, median 125; mode 125) without any conversions or mortality. There were two minor bile leaks that resolved without intervention through an indwelling drain. DiscussionCompletions cholecystectomy can be completed via the laparoscopic approach with good outcomes and acceptable morbidity and mortality rates. The patients derive the same advantages as elective cholecystectomies. Therefore, the laparoscopic approach, when performed by hepatobiliary surgeons with advanced laparoscopic expertise in specialized centers, should be the new standard of care.

Laparoscopic Completion Cholecystectomy for Residual Gallbladder and Cystic Duct Stump Stones: Our Experience and Review of Literature

Post cholecystectomy syndrome (PCS) is a term used for the persistence of antecedent symptoms following cholecystectomy. The etiology is mainly non-biliary but remnant gallbladder or cystic duct stump calculi may be the cause in some patients. Ultrasonography is the initial imaging modality but MRCP provides a more accurate diagnosis and serves as a roadmap during surgery. Such patients need a completion cholecystectomy for relieving their symptoms. The study included 41 patients who underwent laparoscopic completion cholecystectomy (LCC) at two health institutions of our state by the same team of operating surgeons over a period of 7 years from January 2013 to December 2019. All the patients included had previously undergone open cholecystectomy at different health centers and reported to us with PCS. The data regarding presentation, imaging, intraoperative findings, complications, and follow-up after LCC were noted and analyzed. Laparoscopic completion cholecystectomy was successfully done in 38 patients (92.6%) and 3 (7.3%) cases had to be converted to open procedure. No major bile duct injury was encountered in any case and there were no mortalities. The majority of the patients (36 patients 87.8%) had complete resolution of symptoms after completion cholecystectomy. Laparoscopic completion cholecystectomy in the hands of an expert laparoscopic surgeon is a safe alternative with good outcomes and acceptable complication rates.

Should laparoscopy be the initial approach for completion cholecystectomy in recurrent cholecystitis after subtotal cholecystectomy?

Presenter: Ileana Horattas MD | Cleveland Clinic, Akron General Background: Subtotal cholecystectomy has become a widely accepted alternative for patients presented with acute cholecystitis resulting in significant inflammation and anatomic distortion. Recurrent cholecystitis of the remnant gallbladder is an accepted complication of this procedure. International studies have shown completion cholecystectomy to be the definitive management of recurrent cholecystitis. Few investigators in the United States have focused on management of this scenario, and to this point open surgical approach has been recommended. Methods: Cholecystectomies undertaken by one hepatobiliary surgeon over a two-year period from 2017-2019 were reviewed. Cases of patients with previous cholecystectomy who then presented with acute cholecystitis and underwent laparoscopic completion cholecystectomy were compiled and reviewed to determine interval from initial cholecystectomy, operative time, use of intraoperative cholangiography, use of intraoperative indocyanine green (ICG), placement of drain, and total length of hospital stay (LOS). Results: Seven patients met inclusion criteria. The mean interval from initial cholecystectomy was 22 months (range 3-89 months with one patient presenting an unknown length of time from initial operation). Mean operative time was 119 minutes (range 79 minutes to 141 minutes). Five patients had an intraoperative cholangiogram and one case was completed with intraoperative ICG. A drain was left at the completion of three out of seven cases. Average LOS was less than one day (range 0-2) with three patients discharged in good condition post-operative day 0. No patients required an open operation. Conclusion: Laparoscopy is a safe and effective approach to completion cholecystectomy for patients with recurrent cholecystitis that avoids an open surgical procedure.

Laparoscopic management of symptomatic gallbladder stump calculi

Aim: The aim of the present study was to evaluate the safety of laparoscopic completion cholecystectomy in patients with symptomatic gallbladder stump calculi. Materials and Methods: Ours was a prospective study conducted in three peripheral hospitals over a period of 6 years. All the patients undergoing elective laparoscopic cholecystectomy during this period were enrolled in the study. The outcomes of laparoscopic completion cholecystectomy in patients with gallbladder stump calculi were compared to those undergoing primary laparoscopic cholecystectomy with regards to perioperative morbidity and mortality. Results: A total of 3127 laparoscopic cholecystectomies were performed. Out of them, laparoscopic completion cholecystectomy was done in 36 (1.15%) patients. There were 21 males and 15 females in these 36 patients. The operative time and hospital stay were significantly increased in the completion group. None of our patients in the completion group required conversion. Perioperative complications were seen more often in the patients posted for completion cholecystectomy (6 [6.67%] vs. 207 [6.69%]; P = 0.0026). Bleeding was the most frequent intraoperative complication seen in the patients undergoing completion cholecystectomy. Conclusion: Laparoscopic completion cholecystectomy, though technically demanding, can be safely done even in a peripheral health setup with acceptable morbidity rate.

Laparoscopic completion cholecystectomy for late postcholecystectomy Mirizzi syndrome Csendes type 1 due to a sessile gallbladder remnant calculus

Laparoscopic completion cholecystectomy for late postcholecystectomy Mirizzi syndrome Csendes type 1 due to a sessile gallbladder remnant calculus

Laparoscopic completion cholecystectomy is generally feasable, safe and allays the symptoms in post cholecystectomy patients with gallbladder and cystic duct remnants

Laparoscopic completion cholecystectomy is generally feasable, safe and allays the symptoms in post cholecystectomy patients with gallbladder and cystic duct remnants

Laparoscopic completion cholecystectomy: an audit from the caribbean chapter of the ahpba

Laparoscopic completion cholecystectomy: an audit from the caribbean chapter of the ahpba

Management of residual gall bladder: A 15-year experience from a north Indian tertiary care centre

Backgrounds/AimsA residual gallbladder (RGB) following a partial/subtotal cholecystectomy may cause symptoms that require its removal. We present our large study regarding the problem of a RGB over a 15 year period.MethodsThis study involved a retrospective analysis of patients managed for symptomatic RGB from January 2000 to December 2015.ResultsA RGB was observed in 93 patients, who had a median age of 45 (25–70) years, and were comprised of 69 (74.2%) females. The most common presentation was recurrence pain (n=64, 68.8%). Associated choledocholithiasis was present in 23 patients (24.7%). An ultrasonography (USG) failed to diagnose RGB calculi in 10 (11%) patients; whereas, magnetic resonance cholangio-pancreatography (MRCP) accurately diagnosed RGB calculi in all the cases except for 2 (4%) and, additionally, detected common bile duct (CBD) stones in 12 patients. Completion cholecystectomy was performed in all patients (open 45 [48.4%]; laparoscopic 48 [51.6%] and 19 [20.4%] patients required a conversion to open). The RGB pathology included stones in 90 (96.8%), Mirizzi's syndrome in 10 (10.8%) and an internal fistula in 9 (9.7%) patients. Additional procedures included CBD exploration (n=6); Choledocho-duodenostomy (n=4) and Roux-en-Y hepatico-jejunostomy (n=3). The mortality and morbidity were nil and 11% (all wound infection), respectively. Two patients developed incisional hernia during follow up. The mean follow up duration was 23.1 months (3–108) in 65 patients and the outcome was excellent and good in 97% of the patients.ConclusionsPost-cholecystectomy recurrent biliary colic should raise suspicion of RGB. MRCP is a useful investigation for the diagnosis and assessment of any associated problems and provides a roadmap for surgery. Laparoscopic completion cholecystectomy is feasible, but is technically difficult and has a high conversion rate.

Safe Completion of Laparoscopic Cholecystectomy and Its Conversion Rate in a Tertiary Care Hospital

AbstractObjectives: Laparoscopic cholecystectomy is a very good and safe procedure for the removal of gall bladder. The objective of our study was to see the conversion rate of laparoscopic cholecystectomy in our unit.Methods: This is a retrospective descriptive study. We conducted this study on 167 patients who under-went gall bladder removal in our unit at a Public sector hospital of Lahore.Results: Our study showed that 163 (97.6%) out of 167 patients had safe complete laparoscopic cholecystectomy while 4 (2.4%) had to be converted to open cholecystectomy. About 40% of the procedures completed by laparoscope were difficult. Approximately 98% were completed by consultants and 42% weresafely performed by the senior registrars.Conclusion: Gall bladder surgery can be safely completed with laparoscope with good team effort and self-awareness of team.

Universal safe procedure of laparoscopic cholecystectomy standardized by exposing the inner layer of the subserosal layer (with video).

An incorrect approach to the critical view of safety can cause bile duct and/or vascular injury. However, only superficial anatomical features have been proposed as surgical landmarks to initiate laparoscopic cholecystectomy (LC) safely in previous reports. Accordingly, we have proposed a novel surgical anatomical definition of the gallbladder wall, in which the subserosal (SS) layer is divided into the inner layer of the SS (SS-Inner) layer consisting of vasculature and fibrous tissue, and the outer layer of the SS (SS-Outer) layer consisting of abundant fat tissue. By dissecting the gallbladder along the SS-Inner layer after exposure at a safe region, bile duct and/or vascular injury can be avoided, even in cholecystitis cases. Furthermore, recognition of this surgical anatomy reveals several aspects. In cholecystitis cases associated with severe fibrotic change, completion of LC by dissecting along the SS-Inner layer is impossible, resulting in abandonment of regular LC. An abscess in the liver bed associated with acute cholecystitis usually forms in the SS-Outer layer, thus, the gallbladder can be dissected easily. In the dome-down technique, the right hepatic duct is endangered by whole-layer dissection, in which the SS-Outer layer is also removed. The proposed procedure should become the universal standard for LC.

Laparoscopic completion cholecystectomy for remnant gallbladder following previous incomplete cholecystectomy: a case series

Laparoscopic completion cholecystectomy for remnant gallbladder following previous incomplete cholecystectomy: a case series

OC-064 Damage control cholecystectomy: four years experience in a dgh

Introduction Around 60,000 laparoscopic cholecystectomies are performed each year in the UK. Increasingly patients are being operated on during periods of active gallbladder inflammation. Identification of the anatomy can prove challenging during a “hot” cholecystectomy. Sub-total cholecystectomy is an increasingly accepted method of minimising operative complications for patients with complicated cholecystitis. The aim of the study is to determine whether complications can be kept to a minimum without needing to perform an open procedure. Method Retrospective analysis of 32 patients’ cases who underwent sub-total cholecystectomy in a District General hospital between 01/2011 and 12/2014. Results During the study period 840 cholecystectomies were performed in 664 women (79.0%) and 176 men (21.0%). 32 subtotal cholecystectomies were performed (3.8%, 31 laparoscopic, 1 lap converted to open). 808 total cholecystectomies were performed (96.2%, 1 open, 3 lap converted to open). 132 cases (15.7%) were performed as ‘hot’ emergency or urgent procedures. 155 patients (18.1%) underwent on table cholangiograms. No bile duct injuries and 1 bile leak occurred in the total cholecystectomy population. In the subtotal cholecystectomy cohort there were 21 men and 11 women with a median age of 69 (range 44–83). 25 patients presented with cholecystitis, 2 with biliary colic, 4 with cholangitis and one with pancreatitis. 11 were performed as ‘hot’ emergency or urgent procedures (34%). Despite this, active inflammation was present in 24 cases. Empyema was present in five patients. Four gallbladders’ were perforated. 30 pts had sub-hepatic drain insertion. Of these, 7 were removed in clinic post discharge. Median time to drain removal was 2 days (range 1–15 days). Median length of stay was 2 day (range 1–19). No bile duct injuries occurred. 1 bile leak occurred and required ERCP and stent. 3 patients developed post operative abscesses. One patients required laparoscopy and washout, one required a radiologically inserted drain and was managed conservatively with IV antibiotics. 8 patients received a single follow up in clinic (range 6 days – 3 months). 2 patients were re-referred to clinic from primary care with on-going symptoms. Of these, one required laparoscopic completion cholecystectomy 13 months following the original procedure. Another suffered cholangitis attributed to pre-operative ERCP and sphincterotomy, managed conservatively. Conclusion In the context of indefinable anatomy, laparoscopic sub-total cholecystectomy with retrograde dissection is a safe procedure with minimal complications. It is sufficient management in the majority patients. It allows for safer re-intervention in the small proportion of patients suffering from ongoing biliary symptoms. Disclosure of interest None Declared.

Stump cholecystitis: laparoscopic completion cholecystectomy with basic laparoscopic equipment in a resource poor setting.

Introduction. Stump cholecystitis is a recognised condition in which a large gallbladder remnant becomes inflamed after subtotal cholecystectomy. When this occurs, a completion cholecystectomy is indicated. Traditionally, these patients were subjected to open surgery because the laparoscopic approach was anticipated to be technically difficult. We present a case of completion cholecystectomy using basic laparoscopic equipment in a resource poor setting to demonstrate that the laparoscopic approach is feasible. Case Description. A 57-year-old woman presented with right upper quadrant pain and vomiting. She had an elective open cholecystectomy seven years before but reported remarkably similar symptoms. Abdominal ultrasound suggested calculous acute cholecystitis. MRCP confirmed the presence of a large gallbladder remnant with stones. Gastroduodenoscopy excluded other differentials. She had an uneventful laparoscopic completion cholecystectomy performed. Discussion. Although traditional dogma suggested that a completion cholecystectomy should be performed through the open approach, several small studies have demonstrated that laparoscopic completion cholecystectomy is feasible and safe. This report adds to the existing data in support of the laparoscopic approach.