Essential strategies for the management of challenging laparoscopic cholecystectomy procedures

Abstract

Laparoscopic cholecystectomy (LC) represents the most frequently conducted surgical intervention for managing symptomatic cholelithiasis. However, in the contemporary context of laparoscopic and robotic cholecystectomy procedures, open cholecystectomy remains a relevant surgical approach that minimizes the risk of severe complications. LC is considered to be a straightforward procedure in approximately 60% of cases and presents no significant challenges for most surgeons. However, in 20%-30% of cases, the procedure involves a moderate level of difficulty, and in 10%-15% of cases, the complexity is substantial, thus potentially requiring conversion to an open cholecystectomy approach and the involvement of a highly experienced surgeon who is proficient in both laparoscopic and open techniques. Existing scoring systems have the potential to predict procedural difficulty. Obesity, cirrhosis, elevated American Society of Anesthesiologists scores, prior abdominal surgeries, and the presence of acute cholecystitis or common bile duct stones have been identified as factors contributing to the complexity of cholecystectomy procedures. Radiological findings such as gallbladder wall thickening, pericholecystic fluid accumulation, and impacted gallstones are also correlated with increased surgical difficulty. Elevated body mass index and increased C-reactive protein levels were identified as significant independent predictors of surgical difficulty during LC in patients with acute cholecystitis. For cases in which the operation is anticipated to be challenging, the utilization of intraoperative imaging techniques (including intraoperative cholangiography, intraoperative ultrasound, and near-infrared cholangiography) is advised. When the safe attainment of the critical view of the hepatocystic triangle is not feasible, alternative surgical strategies [such as subtotal cholecystectomy (STC) or an anterograde approach] should be considered. Conversion to open surgery is recommended in instances of significant hemorrhage, cholecystoenteric fistula, Mirizzi syndrome, or suspected malignancy. Furthermore, consultation with or assistance from an additional surgeon is advised under complex operative conditions. The body-first approach and STC represent significant surgical approaches in cases of severe inflammation and fibrosis (including cholecystitis, choledocholithiasis, and biliary pancreatitis) and anatomical variations. Laparoscopic STC encompasses both fenestrating and reconstituting techniques. Moreover, robotic subtotal fenestrating cholecystectomy is the prevailing technique due to the three-dimensional view. Thus, failure to appropriately manage challenging cases may result in severe complications, given the demanding nature of biliary surgery.

Keywords: Gallbladder diseases; Cholelithiasis; Laparoscopic cholecystectomy; Biliary surgery; Complications; Common bile duct injury; Difficult cholecystectomy; Bailout techniques

Core Tip: Patient safety requires increased caution and precision in decision-making when challenges are experienced during laparoscopic cholecystectomy. It is essential to incorporate valuable available diagnostic tools and alternative bailout operative interventions into the management plan for complex cases, along with recognizing when to stop or convert the approach to open cholecystectomy. Failure to accomplish this task may result in catastrophic complications during the procedure. Training and expertise are necessary preconditions for favorable outcomes.