Difficult gall bladder? ‘Divide and rule’!

Risk of bile duct injury (BDI) is at least 2–3 times more during laparoscopic than during open cholecystectomy.[1] The most common cause of BDI during laparoscopic cholecystectomy is visual perception error, i.e., common bile duct (CBD) mistaken for the cystic duct. Creation and demonstration of the critical view of safety (CVS), i.e., two and only two structures, namely cystic artery and cystic duct, are seen to be attaching the gall bladder (GB) to the hepatoduodenal ligament[2] is one of the techniques to avoid this error. It may, however, be difficult, not possible or even hazardous to demonstrate the CVS when the junction of the GB neck and the cystic duct or the cystic duct and the CBD is not clear because of difficult pathology, i.e., chronically inflamed thickened contracted GB with inflammatory fibrosis in the Calot’s triangle because of recurrent attacks of acute cholecystitis or long-standing chronic cholecystitis [Figure 1] resulting in a frozen, obliterated or even absent Calot’s triangle – the hidden cystic duct syndrome.[3] Persisting with dissection in the presumed area of the Calot’s triangle in such a situation may result in a BDI and/or a vascular injury to the right hepatic artery crossing in front of the CBD.Figure 1: No Calot’s triangleIn open cholecystectomy, funds-first (antegrade) approach is an option in such cases but use of the fundus-first approach in laparoscopic cholecystectomy may result in a major biliovascular injury to the right portal pedicle if a wrong plane (i.e., inside the liver parenchyma) is entered because of inflamed shortened contracted obliterated cystic plate.[4] Subtotal (earlier called partial) cholecystectomy (STC) is an option in such cases. STC is mentioned in the SAGES Safe Cholecystectomy Program,[5] Tokyo Guidelines for surgical management of acute cholecystitis[6] and IRCAD recommendation on safe laparoscopic cholecystectomy.[7] We had reported use of partial (now called subtotal) cholecystectomy in a difficult GB way back in 1993.[8] STC can be performed by doing a neck-first dissection, i.e., a plane is created between the liver and the GB neck at a safe distance from the hepatoduodenal ligament, and then, a stapler is fired across the GB neck. Disadvantages of this technique of STC are that the residual GB neck stump may contain stones and that the residual GB mucosa cannot be destroyed and may, therefore, form stones or develop cancer later. I describe another technique of STC, which I would like to name the ‘divide and rule’ technique. In the ‘divide and rule’ technique of STC, as a very first step, the GB is opened somewhere in the GB mid-body [Figures 2 and 3] area, i.e., at a safe distance from the hepatoduodenal ligament, thus dividing the GB into two parts – fundus-body on the right and body-neck on the left [Figures 4 and 5]. One advantage of opening the GB is that the opened single wall of the GB can be easily held in a grasper, especially a toothed grasper, even though the intact thick-walled GB could not be grasped earlier. All the stones are removed from both parts of the GB. The GB can then be visualised with a scope such as choledochoscope or ureteroscope or 5 mm telescope to ensure complete removal of all the stones. The transition of the GB neck lumen (wide) into the cystic duct lumen (narrow) is more obvious when seen from inside [Figure 6] than from outside the GB. Once the anatomy is clear, the entire fundus-body part and as much as possible of the body-neck part of the GB is removed. The mucosa in the residual GB neck is destroyed with electrocautery, preferably bipolar (or monopolar, at a low wattage), in order to avoid thermal injury to the adjacent CBD.Figure 2: Gall bladder being opened in the mid-bodyFigure 3: Gall bladder opened in the mid-bodyFigure 4: Gall bladder almost divided into two parts – fundus-body on the right and body-neck on the leftFigure 5: Posterior (superior) wall of the gall bladder mid-body being dividedFigure 6: The wide lumen of the gall bladder neck seen to be narrowing into the narrow lumen of the cystic duct from insideIf no bile is seen to be flowing back from the CBD through the cystic duct into the residual GB neck, it indicates that the cystic duct is blocked because of inflammatory fibrosis. In such cases, it is not mandatory to close the residual GB neck stump, and it can be left open as such or a suture taken to close the cystic duct opening (fenestrating type of STC).[9] If bile is seen, the residual GB neck is closed with a continuous interlocking absorbable suture (reconstituting type of STC)[9] [Figure 7]. Care should be taken to avoid the suture bites taking a part of the CBD wall; for the same reason, a 5-mm stump of the GB neck should be left behind for the suturing. STC using the ‘divide and rule’ technique is better than that using stapler (vide supra) where the residual GB cannot be emptied of stones and the mucosa cannot be destroyed.Figure 7: The residual gall bladder neck being closed with a suture (reconstituting type of subtotal cholecystectomy)Conversion from laparoscopic to open operation is also an option in such cases, but it has to be kept in mind that even at the open operation, delineation of the anatomy in the Calot’s triangle may be equally difficult and a BDI can still occur if proper precautions are not taken. Moreover, surgeons these days do not have adequate and appropriate experience of performing an open cholecystectomy, more so in a difficult situation. STC using the ‘divide and rule’ technique can be performed laparoscopically by an averaged-skilled surgeon. Bile leak is very likely to occur after STC. In a systematic review and meta-analysis of STC for difficult GB, bile leak occurred in 18% of patients who underwent STC.[10] Bile leak is more likely to occur in patients with the fenestrating type versus the reconstituting type of STC (18% vs. 7%).[11] Matsui[12] reported STC in 50 patients; a piece of free omentum was plugged into the residual GB stump in 18 cases – only one had post-operative bile leak versus bile leak in 14 of 32 cases where omentum was not used. We have reported the use of a vascularised omental flap based on an epiploic artery to protect the pancreatic anastomosis in pancreatoduodenectomy.[13] The author has used a similar omental flap to cover the residual GB neck stump after STC also. A drain must always be placed in the subhepatic fossa, and one should have a low threshold for endoscopic intervention in the form of papillotomy and stenting in case bile leak occurs in the post-operative period. A theoretical disadvantage of STC is reformation of stones in the residual GB stump. This will obviously not happen, if the GB stump is not closed (fenestrating type of STC). It is unlikely to happen in the reconstituting type also if the residual GB mucosa was destroyed. Even if some mucosa is left behind in the sutured GB stump, the chances that stones will form in the residual GB are small because the cystic duct is usually blocked and no bile flows from the CBD into the residual GB lumen. A systematic meta-analysis including 15 publications and 625 patients of laparoscopic partial cholecystectomy (now called STC) for difficult GB revealed recurrence of symptoms of stones in only 2.2% of cases.[14] van Dijk et al.[11] reported laparoscopic STC in 191 patients performed in 4 teaching hospitals in the Netherlands. At the median follow-up of 6 years, recurrent biliary symptoms occurred in 9% of patients with the fenestrating type and 18% with the reconstituting type of STC. Completion cholecystectomy was required in 12/191 patients over a median follow-up of 6 years.[11] If required, reoperative completion cholecystectomy can also be performed laparoscopically. We reported reoperation for a residual GB after STC in 93 patients – completion cholecystectomy could be performed laparoscopically in 48 (52%) cases.[15] Another risk of leaving a part of the GB wall behind is the occurrence of cancer, especially in patients in areas with high incidence of GB cancer (GBC), but this risk can be reduced by destroying the residual mucosa with electrocautery. For medicolegal reasons, if STC is performed, this should be well documented in the operation notes, and the patient should be informed that an ultrasound performed in the follow-up may reveal a residual GB stump, and there is a definite, albeit small, risk of reformation of gall stones and GBC during the long-term follow-up. SURGICAL HISTORY ‘Divide and rule’ (or divide and conquer, from Latin dīvide et imperā) is ‘gaining and maintaining power by breaking up larger concentrations of power into pieces that individually have less power than the one implementing the strategy’-‘divide and rule’ strategy was used by the British to rule India from 1600 (when the East India Company came to India to only do business – open the GB) to 1947 (when India gained independence from the British rule). The surgeon performing cholecystectomy can use the ‘divide and rule’ strategy to break a large concentration of power (i.e., a difficult GB) into pieces (i.e., GB fundus-body and body-neck) and gain power (i.e., perform safe cholecystectomy). At the time of independence in 1947, the undivided India (GB) was partitioned into two countries – larger India and smaller Pakistan; the GB specimen after a ‘divide and rule’ STC is in two pieces – larger fundus-body and smaller body-neck [Figure 8]. Later in 1971, the erstwhile Pakistan (East and West) split into Pakistan (former West Pakistan) and Bangladesh (former East Pakistan) – sometimes, the GB specimen after a ‘divide and rule’ STC is in three parts – one larger fundus-body and two (or more) smaller parts of body-neck [Figure 9].Figure 8: Gall bladder specimen after a ‘divide and rule’ subtotal cholecystectomy is in two pieces – larger fundus-body and smaller body-neckFigure 9: Sometimes, the gall bladder specimen after a ‘divide and rule’ subtotal cholecystectomy is in three parts – one larger fundus-body and two smaller parts of body-neckFinancial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.