Abstract
Backgrounds/Aims
Subtotal cholecystectomy is a salvage procedure when critical safety margins cannot be achieved in difficult cases. This study evaluated the impact of surgical approach and technique on short- and long-term outcomes.
Methods
A retrospective review of 101 patients who underwent subtotal cholecystectomy between January 2010 and November 2024 was conducted. Patients were grouped by approach: laparoscopic (n = 42), open (n = 31), and conversion (n = 28). Techniques were classified as fenestrating or reconstituting. Complications were assessed using the Clavien-Dindo classification. Logistic regression identified risk factors, and Cox regression evaluated long-term outcomes. Intention-to-treat analysis was performed.
Results
The mean follow-up was 6.7 years. Morbidity was lower in the laparoscopic group (9.5%) than in the open group (45.2%) (p < 0.001). However, after adjustment for age, American Society of Anesthesiologists score, and emergency status, surgical approach was not an independent risk factor (adjusted odds ratio 1.54, p = 0.214). No significant differences were observed between fenestrating and reconstituting techniques. Five-year complication-free survival was 92.9% in the laparoscopic group and 74.2% in the open group (p = 0.018). No stone recurrence was observed.
Conclusions
Subtotal cholecystectomy is a safe option in complex cases. Outcome differences are likely related to patient selection rather than technique. Technique selection should be based on intraoperative findings.
Keywords: Laparoscopic, Biliary tract surgical procedures, Postoperative complications, Treatment outcome
INTRODUCTION
Laparoscopic cholecystectomy is the standard treatment for gallbladder disease; however, severe inflammation and distorted anatomy can complicate the procedure, making it a difficult cholecystectomy [1]. The Tokyo Guidelines 2018 (TG18) categorize acute cholecystitis into three severity levels, assisting surgeons in selecting appropriate surgical methods based on patients’ medical conditions [2]. The risk of bile duct injury increases in grade II and III cases due to poor visualization of anatomical structures [3,4].
Converting to open surgery is a safety measure during high-risk procedures. Subtotal cholecystectomy (SC) has emerged as an effective emergency solution for these cases since its recent introduction [5]. The TG18 framework provides a standardized approach to assess the severity of acute cholecystitis, guiding both the timing of surgery and the surgical techniques employed [2]. The medical community recognizes SC as a safe emergency option for patients requiring grade II or III treatment, particularly when surgeons cannot achieve the critical view of safety (CVS) during the procedure [6].
While the literature indicates that SC may have advantages over total cholecystectomy (TC) in managing complications, there is still a lack of comprehensive analyses comparing the clinical outcomes of laparoscopic versus open SC, particularly concerning surgeon experience and patient selection criteria [7]. This study investigates patient outcomes following laparoscopic SC and the circumstances under which the procedure transitions to open surgery, contributing new data to existing research [8].
MATERIALS AND METHODS
Study design and patient selection
This retrospective cohort study involved 101 patients who underwent SC at the General Surgery Department of Adıyaman Training and Research Hospital from January 2010 to November 2024. The institutional ethics committee approved the study protocol (IRB no. 2024/10-4), and due to its retrospective nature, written informed consent was waived; all data were analyzed in anonymized form.
Patients were divided into three groups based on the surgical approach: laparoscopic (L, n = 42), open (O, n = 31), and laparoscopic converted to open (LO, n = 28). The conversion group was analyzed separately, as these patients represented a distinct clinical subset with increased technical difficulty. Additionally, an intention-to-treat (ITT) analysis was conducted, combining the L and LO groups (n = 70), to evaluate outcomes based on the initial surgical approach.
Surgical technique
Two SC techniques were used in accordance with the TG18 and the principles of the CVS. The choice between reconstituting and fenestrating SC was determined intraoperatively, based on the degree of inflammation, local tissue quality, extent of adhesions, and anatomical clarity of the hepatocystic triangle. Reconstituting SC was preferred when safe approximation and closure of the residual gallbladder wall were feasible. Fenestrating SC was selected in the presence of severe inflammation, friable tissue, or when primary closure could not be performed safely.
The fenestrating technique was performed on 73 patients (72.3%). In this approach, the gallbladder was opened, gallstones were evacuated, the mucosa was cauterized, and the posterior wall was left adherent to the liver bed. The majority of the gallbladder wall was excised, residual mucosal surfaces were ablated using monopolar electrocautery, and adequate biliary drainage was ensured. The reconstituting technique was applied to 28 patients (27.7%), where the gallbladder neck was partially excised and then primarily closed. In reconstituting cases, monopolar electrocautery was applied to all visible areas of the residual gallbladder mucosa before closure to minimize residual mucosal activity and reduce the risk of remnant gallbladder disease. In laparoscopic procedures, a standard four-trocar technique was used, maintaining pneumoperitoneum at 12–14 mmHg. When CVS could not be safely achieved, the decision was made to perform SC. A retrograde dissection technique was employed to mobilize the gallbladder from the liver bed. When severe inflammation or anatomical distortion precluded safe isolation of Hartmann’s pouch, the gallbladder was decompressed via needle aspiration prior to excision. Excision was then performed using an Echelon FlexTM EndopathⓇ stapler (Johnson & Johnson MedTech) (Fig. 1). Laparoscopic intracorporeal suturing was subsequently applied to reduce the volume of the residual cavity, minimizing the residual mucosal surface area.
Fig. 1.
Ethicon Echelon FlexTM EndopathⓇ (Johnson & Johnson MedTech) powered endoscopic linear stapler used for the transection of the gallbladder infundibulum during laparoscopic subtotal cholecystectomy.
In open procedures, a right subcostal or paramedian incision was preferred. For cases with dense adhesions, a fundus-first dissection was performed (Fig. 2). In both open and converted cases, following resection of the majority of the gallbladder wall and complete clearance of intraluminal stones, monopolar electrocautery was applied to all visible areas of the residual gallbladder mucosa to achieve thorough mucosal ablation. The edges of the remnant gallbladder were then inverted and closed using interrupted absorbable sutures (2-0 polyglactin) (Fig. 3), thereby obliterating the residual cavity and minimizing its volume. A subhepatic drain was placed in all patients.
Fig. 2.
Intraoperative photographs demonstrating open subtotal cholecystectomy in complicated cholecystitis. (A) Severely inflamed and edematous gallbladder with gangrenous changes adherent to the liver bed; antegrade dissection is being performed from the fundus toward Hartmann’s pouch. (B) Fundus-first dissection technique in a case with dense adhesions and frozen Calot’s triangle; the gallbladder corpus is being separated from surrounding structures before addressing the infundibulum.
Fig. 3.
Sequential steps for reconstituting subtotal cholecystectomy following partial excision. (A) Complete ablation of the remaining gallbladder mucosa using monopolar electrocautery to prevent mucocele formation; note the coagulated mucosal surface with no viable secretory tissue remaining. (B) Extraction of residual stones from Hartmann’s pouch using stone forceps to achieve complete clearance of the gallbladder remnant. (C) Final closure of the gallbladder wall using 2-0 polyglactin interrupted sutures, resulting in complete obliteration of the remnant cavity to minimize residual volume. Steps (A)–(C) were performed in open and converted cases; in laparoscopic cases, excision was performed using a linear stapler (Echelon Flex™; Johnson & Johnson MedTech) followed by intracorporeal suturing for residual cavity reduction.
Criteria for conversion included dense adhesions that prevented safe dissection, uncontrolled bleeding, unclear anatomy, and technical difficulties.
Data collection and follow-up
Operative variables recorded included the surgical indication, technique used, timing of surgery (elective or emergency), duration of the procedure, estimated blood loss, and any intraoperative complications. Postoperative complications were classified using the Clavien-Dindo system, with grade II or higher complications categorized as overall morbidity.
An active surveillance protocol was established, with patients followed at 1, 3, 6, 12, and 24 months post-surgery, and then annually thereafter. Each follow-up visit included a clinical examination and an ultrasonographic evaluation. Gallstone recurrence was assessed via ultrasound. Follow-up was completed for 89 patients (88.1%), while 12 patients were lost to follow-up. The mean duration of follow-up was 6.7 ± 3.2 years (range: 1.2–14.8 years).
Statistical analysis
Statistical analyses were conducted using SPSS version 26.0 (IBM Corp.). Continuous variables were compared with independent-samples t-tests or one-way analysis of variance, while categorical variables were analyzed using the chi-square test or Fisher’s exact test, as appropriate. Risk factors for postoperative morbidity were assessed through logistic regression analysis, with variables showing p < 0.10 in univariate analysis included in the multivariate model. Long-term complications were evaluated using the Cox proportional hazards regression model. The Kaplan–Meier method was utilized to calculate complication-free survival, which was compared using the log-rank test.
A post hoc power analysis was performed using G*Power version 3.1. Statistical significance was set at p < 0.05. Although propensity score matching was considered to adjust for baseline intergroup differences, it was ultimately not performed due to a limited sample size; instead, adjusted analyses were applied.
RESULTS
Patient characteristics and operative data
A total of 101 patients participated in the study: 42 underwent laparoscopic surgery, 31 had open surgery, and 28 required conversion from laparoscopy to an open approach. Significant demographic differences were noted among the groups. The laparoscopic group was considerably younger, with a mean age of 45.3 years, compared to 68.2 years in the open surgery group. Approximately one-third of patients in the laparoscopic group had an American Society of Anesthesiologists (ASA) physical status of III–IV, while this proportion rose to nearly 90% in the open surgery group. Comorbid conditions, particularly diabetes mellitus and cardiovascular disease, were also significantly more prevalent among patients undergoing open surgery (Table 1).
Table 1.
Patient demographics, preoperative characteristics, and operative data
| Characteristics | Laparoscopic (n = 42) | Open (n = 31) | Laparoscopic converted to open (n = 28) | Total (n = 101) | p-value | Test |
|---|---|---|---|---|---|---|
| Demographics | ||||||
| Age (yr) | 45.3 ± 11.8 | 68.2 ± 14.9 | 59.1 ± 13.2 | 56.8 ± 15.9 | < 0.001 | ANOVA |
| Sex | 0.342 | χ2 | ||||
| Male | 22 (52.4) | 14 (45.2) | 15 (53.6) | 51 (50.5) | ||
| Female | 20 (47.6) | 17 (54.8) | 13 (46.4) | 50 (49.5) | ||
| BMI (kg/m2) | 27.1 ± 4.0 | 29.9 ± 5.2 | 28.8 ± 4.9 | 28.5 ± 4.8 | 0.124 | ANOVA |
| ASA physical status | < 0.001 | χ2 | ||||
| ASA I | 10 (23.8) | 0 (0) | 0 (0) | 10 (9.9) | ||
| ASA II | 17 (40.5) | 4 (12.9) | 4 (14.3) | 25 (24.8) | ||
| ASA III | 13 (31.0) | 18 (58.1) | 15 (53.6) | 46 (45.5) | ||
| ASA IV | 2 (4.7) | 9 (29.0) | 9 (32.1) | 20 (19.8) | ||
| Comorbiditiesa) | < 0.001 | χ2 | ||||
| Diabetes mellitus | 13 (31.0) | 14 (45.2) | 13 (46.4) | 40 (39.6) | ||
| Hypertension | 11 (26.2) | 15 (48.4) | 12 (42.9) | 38 (37.6) | ||
| Coronary artery disease | 3 (7.1) | 8 (25.8) | 7 (25.0) | 18 (17.8) | ||
| COPD | 6 (14.3) | 6 (19.4) | 6 (21.4) | 18 (17.8) | ||
| Prior abdominal surgery | 7 (16.7) | 11 (35.5) | 8 (28.6) | 26 (25.7) | 0.038 | χ2 |
| Preoperative ERCP | 5 (11.9) | 7 (22.6) | 6 (21.4) | 18 (17.8) | 0.115 | χ2 |
| Surgical indications | < 0.001 | χ2 | ||||
| Acute cholecystitis | 22 (52.4) | 12 (38.7) | 15 (53.6) | 49 (48.5) | ||
| Gallbladder perforation | 3 (7.1) | 11 (35.5) | 6 (21.4) | 20 (19.8) | ||
| Gangrenous cholecystitis | 2 (4.8) | 5 (16.1) | 3 (10.7) | 10 (9.9) | ||
| Cholelithiasis | 15 (35.7) | 3 (9.7) | 4 (14.3) | 22 (21.8) | ||
| Subtotal cholecystectomy techniqueb) | 0.024 | χ2 | ||||
| Fenestrating | 28 (66.7) | 24 (77.4) | 21 (75.0) | 73 (72.3) | ||
| Reconstituting | 14 (33.3) | 7 (22.6) | 7 (25.0) | 28 (27.7) | ||
| Timing of surgery | < 0.001 | χ2 | ||||
| Elective | 34 (81.0) | 13 (41.9) | 19 (67.9) | 66 (65.3) | ||
| Emergency | 8 (19.0) | 18 (58.1) | 9 (32.1) | 35 (34.7) | ||
| Operative data | ||||||
| Operative time (min) | 52.4 ± 17.8 | 86.2 ± 26.4 | 98.7 ± 29.3 | 75.2 ± 28.9 | < 0.001 | ANOVA |
| Estimated blood loss (mL) | 82.6 ± 43.8 | 215.4 ± 97.2 | 185.6 ± 87.3 | 155.2 ± 92.8 | < 0.001 | ANOVA |
| Intraoperative complications | 0.002 | Fisher | ||||
| Hemorrhage | 2 (4.8) | 5 (16.1) | 4 (14.3) | 11 (10.9) | ||
| Bile duct injury | 1 (2.4) | 3 (9.7) | 2 (7.1) | 6 (5.9) | ||
| Visceral injury | 0 (0) | 2 (6.5) | 1 (3.6) | 3 (3.0) | ||
| Reasons for conversionc) | - | - | n = 28 | - | NA | - |
| Dense adhesions/difficult dissection | - | - | 12 (42.9) | - | ||
| Uncontrolled bleeding | - | - | 7 (25.0) | - | ||
| Unclear anatomy | - | - | 6 (21.4) | - | ||
| Technical difficulty | - | - | 3 (10.7) | - |
Values are presented as mean ± standard deviation or number (%).
BMI, body mass index; ASA, American Society of Anesthesiologists score; COPD, chronic obstructive pulmonary disease; ERCP, endoscopic retrograde cholangiopancreatography; -, not available; NA, not applicable.
a)Patients may have multiple comorbidities.
b)Fenestrating: posterior gallbladder wall left attached to liver bed; reconstituting: primary closure of gallbladder neck after partial excision.
c)Only for laparoscopic-to-open conversions. Statistical significance: p < 0.05.
Acute cholecystitis was the most common indication for surgery in all groups. However, gallbladder perforation and gangrenous cholecystitis occurred at notably higher rates in the open surgery group. Emergency procedures comprised 19.0% of cases in the laparoscopic group, compared to 58.1% in the open group. The fenestrating technique was used in approximately three-quarters of all patients, while the reconstituting technique was used slightly more often in laparoscopic cases (Table 1).
The mean operative time was 52.4 minutes for the laparoscopic group, 86.2 minutes for the open surgery group, and nearly 98.7 minutes for the conversion group. Estimated blood loss followed a similar trend, exceeding twice the amount in the open surgery group compared to the laparoscopic group. Dense adhesions were the most common reason for conversion to open surgery (Table 1).
Postoperative outcomes
The mean length of hospital stay was 1.2 days for the laparoscopic group and 3.6 days for the open surgery group. Overall morbidity was significantly lower after laparoscopic surgery (9.5%) compared to open surgery (45.2%). Major complications, such as bile leakage, intra-abdominal abscess, and reoperation, were more common in the open surgery group. Mortality was limited to one patient across the entire cohort (Table 2).
Table 2.
Clinical outcomes: postoperative complications, long-term follow-up, and survival analysis
| Outcomes | Clavien-Dindo classification grade | Laparoscopic (n = 42) | Open (n = 31) | Laparoscopic converted to open (n = 28) | Total (n = 101) | p-value | Test |
|---|---|---|---|---|---|---|---|
| Postoperative outcomes | |||||||
| Length of hospital stay (day) | - | 1.2 ± 0.4 | 3.6 ± 2.2 | 2.7 ± 1.6 | 2.6 ± 1.9 | < 0.001 | ANOVA |
| Bile leakage | II–IIIa | 0 (0) | 2 (6.5) | 1 (3.6) | 3 (3.0) | 0.043 | Fisher |
| Postoperative hemorrhage | II–IIIb | 1 (2.4) | 3 (9.7) | 1 (3.6) | 5 (5.0) | 0.035 | Fisher |
| Intra-abdominal abscess | IIIa | 1 (2.4) | 3 (9.7) | 1 (3.6) | 5 (5.0) | 0.035 | Fisher |
| Surgical site infection | I–II | 0 (0) | 3 (9.7) | 1 (3.6) | 4 (4.0) | 0.028 | Fisher |
| Bilioma | IIIa | 0 (0) | 2 (6.5) | 1 (3.6) | 3 (3.0) | 0.043 | Fisher |
| Pancreatitis/cholestasis | II | 2 (4.8) | 4 (12.9) | 2 (7.1) | 8 (7.9) | 0.021 | Fisher |
| Reoperation | IIIb | 0 (0) | 3 (9.7) | 1 (3.6) | 4 (4.0) | 0.028 | Fisher |
| Mortality | V | 0 (0) | 1 (3.2) | 0 (0) | 1 (1.0) | 0.115 | Fisher |
| Postoperative ERCP requirement | IIIa | 2 (4.8) | 6 (19.4) | 2 (7.1) | 10 (9.9) | 0.012 | Fisher |
| Overall morbidity (≥ grade II)a) | - | 4 (9.5) | 14 (45.2) | 6 (21.4) | 24 (23.8) | < 0.001 | χ2 |
| Follow-up data | |||||||
| Duration of follow-up (yr) | - | 6.4 ± 3.2 | 7.3 ± 3.5 | 6.9 ± 3.3 | 6.7 ± 3.2 | 0.428 | ANOVA |
| Follow-up completion rateb) | - | 38 (90.5) | 27 (87.1) | 24 (85.7) | 89 (88.1) | 0.782 | χ2 |
| Lost to follow-up | - | 4 (9.5) | 4 (12.9) | 4 (14.3) | 12 (11.9) | - | - |
| Histopathological findings | |||||||
| Chronic cholecystitis | - | 24 (57.1) | 13 (41.9) | 14 (50.0) | 51 (50.5) | < 0.001 | χ2 |
| Xanthogranulomatous cholecystitis | - | 9 (21.4) | 4 (12.9) | 4 (14.3) | 17 (16.8) | 0.548 | χ2 |
| Long-term complications | |||||||
| Biliary stricture | - | 0 (0) | 2 (6.5) | 1 (3.6) | 3 (3.0) | 0.043 | Fisher |
| Incisional hernia | - | 0 (0) | 2 (6.5) | 1 (3.6) | 3 (3.0) | 0.043 | Fisher |
| Stone recurrencec) | - | 0 (0) | 0 (0) | 0 (0) | 0 (0) | NA | - |
| Chronic abdominal pain | - | 3 (7.1) | 5 (16.1) | 3 (10.7) | 11 (10.9) | 0.024 | χ2 |
| Dyspeptic symptoms | - | 2 (4.8) | 3 (9.7) | 2 (7.1) | 7 (6.9) | 0.682 | χ2 |
| Complication-free survival (%)d) | Log-rank p | ||||||
| 1-year CVS rate | - | 97.6 (41/42) | 87.1 (27/31) | 92.9 (26/28) | 93.1 (94/101) | 0.038 | Log-rank |
| 3-year CVS rate | - | 95.2 (40/42) | 80.6 (25/31) | 89.3 (25/28) | 89.1 (90/101) | 0.024 | Log-rank |
| 5-year CVS rate | - | 92.9 (39/42) | 74.2 (23/31) | 85.7 (24/28) | 85.1 (86/101) | 0.018 | Log-rank |
| 10-year CVS rate | - | 90.5 (38/42) | 67.7 (21/31) | 82.1 (23/28) | 81.2 (82/101) | 0.012 | Log-rank |
| Number at riske) | |||||||
| At 1 yr | - | 42 | 31 | 28 | 101 | - | - |
| At 3 yr | - | 40 | 28 | 26 | 94 | - | - |
| At 5 yr | - | 36 | 25 | 23 | 84 | - | - |
| At 10 yr | - | 24 | 18 | 16 | 58 | - | - |
Values are presented as mean ± standard deviation, number (%), or number only.
ERCP, endoscopic retrograde cholangiopancreatography; CVS, critical view of safety; -, not available; NA, not applicable.
a)Unique patients with ≥ 1 complication (individuals may have multiple complications).
b)Active surveillance: clinical exam + ultrasonography at 6, 12, 24 months, then annually.
c)Stone recurrence assessed by ultrasonography; computed tomography, only when clinically indicated.
d)Kaplan-Meier estimates; parentheses: patients free from complications/total enrolled.
e)Patients under active follow-up at each time point after censoring for loss to follow-up, death, or insufficient duration; differs from CFS numerator (all complication-free patients regardless of current follow-up status).
Long-term follow-up
During a mean follow-up period of 6.7 years, 88.1% of patients completed the surveillance protocol. Notably, no cases of gallstone recurrence were detected. Biliary stricture and incisional hernia occurred exclusively in the open surgery group, while the laparoscopic group experienced no such complications. The five-year complication-free survival rate was significantly higher in the laparoscopic group (92.9%) compared to the open surgery group (74.2%) (Table 2).
Risk factor analysis
In the univariate analysis, open surgery was initially linked to a higher risk of postoperative complications. However, this association lost significance after adjusting for age and ASA score (adjusted odds ratio [OR], 1.54; p = 0.214). Independent risk factors for postoperative morbidity included ASA III–IV status, emergency surgery, and the presence of a gangrenous or perforated gallbladder. Notably, malignant pathology was identified as the strongest predictor of long-term complications. Additionally, there were no significant differences in outcomes between the fenestrating and reconstituting techniques (Table 3).
Table 3.
Risk factor analysis: univariate and multivariate regression models
| Risk factor | Postoperative morbidity (logistic regression) | Long-term complications (Cox regression) | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Crude OR | 95% CI | p | Adjusted ORa) | Crude HR | 95% CI | p | Adjusted HRb) | ||
| ASA III–IV (vs. I–II) | 3.42 | 1.86–6.28 | < 0.001 | 2.87 (1.42–5.81c) | 2.84 | 1.46–5.52 | 0.002 | 2.31 (1.08–4.94)c) | |
| Age > 65 yr (vs. ≤ 65) | 2.85 | 1.54–5.27 | 0.001 | 1.92 (0.94–3.91) | 2.36 | 1.24–4.49 | 0.009 | 1.74 (0.82–3.69) | |
| Emergency surgery (vs. elective) | 2.63 | 1.42–4.88 | 0.002 | 2.18 (1.08–4.41)c) | 1.94 | 1.04–3.62 | 0.037 | 1.56 (0.78–3.12) | |
| Presence of comorbidities | 2.14 | 1.18–3.89 | 0.012 | 1.68 (0.86–3.29) | - | - | - | - | |
| Open surgery (vs. laparoscopic) | 1.95 | 1.06–3.59 | 0.032 | 1.54 (0.78–3.05) | 2.15 | 1.12–4.13 | 0.021 | 1.72 (0.84–3.52) | |
| Conversion to open (vs. laparoscopic) | 2.61 | 1.15–5.93 | 0.022 | 2.24 (0.92–5.47) | - | - | - | - | |
| BMI ≥ 30 kg/m2 (vs. < 30) | 1.78 | 0.92–3.44 | 0.086 | 1.45 (0.71–2.96) | - | - | - | - | |
| Gangrenous/perforated gallbladder | 3.18 | 1.62–6.25 | < 0.001 | 2.41 (1.12–5.18)c) | 2.67 | 1.38–5.16 | 0.003 | 2.12 (1.02–4.41)c) | |
| Fenestrating technique (vs. reconstituting) | 1.42 | 0.74–2.73 | 0.292 | 1.28 (0.64–2.56) | 1.38 | 0.68–2.80 | 0.372 | 1.24 (0.59–2.60) | |
| Postoperative complications | - | - | - | - | 2.08 | 1.12–3.86 | 0.020 | 1.89 (1.01–3.54)c) | |
| Malignant pathology | - | - | - | - | 3.42 | 1.75–6.68 | < 0.001 | 3.18 (1.58–6.40)c) | |
OR, odds ratio; CI, confidence interval; HR, hazard ratio; ASA, American Society of Anesthesiologists; BMI, body mass index; -, not available.
a)Multivariate logistic regression adjusted for age, sex, ASA score, emergency status, and comorbidities; outcome: any postoperative complication (Clavien-Dindo grade ≥ II).
b)Multivariate Cox model adjusted for age, sex, ASA score, emergency status, surgical approach, and postoperative complications; outcome: time to any long-term complication.
c)p < 0.05. Median follow-up: 6.7 years (range: 1.2–14.8 years). Variables with minimal change between crude and adjusted estimates (e.g., BMI, fenestrating technique) indicate weak confounding by adjustment covariates.
Intention-to-treat analysis
When conversion cases were included in the laparoscopic group based on the ITT principle, the results remained consistent. Overall morbidity was 14.3% versus 45.2%, and five-year complication-free survival was 90.0% versus 74.2% for the laparoscopic and open surgery groups, respectively. Post hoc power analysis indicated adequate statistical power for the primary endpoints, although the study was underpowered to detect rare complications (Table 4).
Table 4.
Supplementary analysis: intention-to-treat and statistical power
| Outcome | Initial laparoscopic (n = 70) | Initial open (n = 31) | p-value | Test | Effect size | Achieved power | Sample size requireda) |
|---|---|---|---|---|---|---|---|
| Postoperative outcomes | |||||||
| Overall morbidityb) | 10 (14.3) | 14 (45.2) | < 0.001 | χ2 | h = 0.85 | 94.2% | 22 per group |
| Bile leakage | 1 (1.4) | 2 (6.5) | 0.212 | Fisher | h = 0.52 | 42.8% | 116 per group |
| Postoperative hemorrhage | 2 (2.9) | 3 (9.7) | 0.162 | Fisher | - | - | - |
| Reoperation | 1 (1.4) | 3 (9.7) | 0.078 | Fisher | - | - | - |
| Length of hospital stay (day)c) | 1.8 ± 1.2 | 3.6 ± 2.2 | < 0.001 | t-test | d = 1.52 | > 99% | 9 per group |
| Long-term outcomes | |||||||
| Any long-term complicationd) | 2 (2.9) | 4 (12.9) | 0.064 | Fisher | - | - | - |
| Biliary stricture | 1 (1.4) | 2 (6.5) | 0.212 | Fisher | h = 0.52 | 42.8% | 116 per group |
| Incisional hernia | 1 (1.4) | 2 (6.5) | 0.212 | Fisher | - | - | - |
| 5-year complication-free survival (%) | 90.0 (63/70) | 74.2 (23/31) | 0.041 | Log-rank | h = 0.56 | 68.4% | 68 per group |
Values are presented as mean ± standard deviation (SD) or number (%).
Initial laparoscopic group: completed laparoscopic procedures (n = 42) + converted to open (n = 28), analyzed by intention-to-treat principle.
-, not available.
a)Sample size/group for 80% power. Study adequately powered for overall morbidity and hospital stay, underpowered for rare complications (bile leakage, biliary stricture).
b)Unique patients with ≥ 1 complication.
c)Mean ± SD; weighted average: (42 × 1.2 + 28 × 2.7)/70 = 1.8 days.
d)Biliary stricture and incisional hernia only (chronic pain/dyspepsia excluded as residual symptoms). Post-hoc power: G*Power v3.1, α = 0.05 (two-tailed). Effect sizes: h = Cohen’s h (proportions), d = Cohen’s d (continuous).
DISCUSSION
Difficult cholecystectomy is one of the most challenging scenarios surgeons encounter in the operating room. Severe inflammation, extensive adhesions, or unclear anatomy can make insisting on TC risky, as it may lead to bile duct injuries. In such cases, SC becomes a viable option.
In our study, we evaluated patients who underwent SC over a fourteen-year period. Our objective was not merely to determine which surgical method is superior; rather, we aimed to assess the performance of this salvage strategy among patients with varying risk profiles. Our findings suggest that the differences in outcomes between the laparoscopic and open surgery groups are more closely related to patient selection than to the surgical technique itself. Adjusted analyses indicated that the surgical approach was no longer an independent risk factor, reinforcing this conclusion. As anticipated, there was no significant difference in outcomes between fenestrating and reconstituting techniques.
Additionally, our study revealed notable demographic differences between the laparoscopic and open surgery groups. Patients undergoing open surgery were, on average, 23 years older, and the ASA III–IV rate was 87% in this group. Rates of emergency surgery, gangrenous cholecystitis, and comorbidities were also significantly higher among patients undergoing open surgery. This is in line with findings from a meta-analysis by Kamarajah et al. [9], which reviewed 326,517 patients and showed that advanced age increased the risk of complications by 2.4 times and the likelihood of conversion to open surgery by 2.2 times. The same study highlighted a tenfold increase in mortality for patients over 80 years of age [9].
In our series, univariate analysis indicated that open surgery nearly doubled the risk of complications (crude OR, 1.95). However, after adjusting for age, ASA score, and emergency surgery status, this association lost its significance (adjusted OR, 1.54; p = 0.214). This suggests that the observed difference may be attributed to patient selection rather than the surgical technique itself. A similar trend is observed in the study by Lunevicius and Haagsma [10] involving 180 patients, where the rate of laparoscopic SC varied significantly among surgeons, ranging from 0% to 97%. This variation indicates that patient selection largely depends on the surgeon’s preference.
Therefore, instead of asserting that “the laparoscopic approach is superior,” it would be more accurate to discuss our experiences with patients of varying risk profiles. As emphasized by Chávez-Villa et al. [6], SC should be viewed as a rescue strategy for challenging cases, and the choice of technique should be determined by the patient’s clinical condition.
The TG18 define SC as a rescue procedure when critical visualization (CVS) is not achievable in grade II and III acute cholecystitis [2]. In our study, CVS could not be attained in 21.4% of the 28 patients who required conversion due to uncertain anatomy, aligning with this guideline’s recommendation. Abdallah et al. [1] also highlighted in their recent review that SC is the most effective strategy for preventing bile duct injuries.
In our series, the bile leakage rate of 3% is notably low compared to existing literature. Loh et al. [11] reported bile leakage rates of 9.3% using the fenestrating technique and 8.3% with the reconstituting technique. Similarly, Gross et al. [12] observed bile leakage rates of approximately 10% in their series of 218 patients. Our lower rate may be attributed to our meticulous mucosal ablation and primary closure techniques.
The low rate of gallbladder-related complications in our series may be attributable to the systematic mucosal ablation performed in all reconstituting cases prior to closure. This technique effectively reduces the residual mucosal surface area and obliterates the remnant cavity through inversion suturing, thereby minimizing the risk of bile stasis, mucocele formation, and stone recurrence. Furthermore, the intraoperative, individualized selection of either the fenestrating or reconstituting technique–guided by tissue quality and the degree of local inflammation–likely contributed to the favorable outcomes observed across both approaches.
In our series, the postoperative requirement for endoscopic retrograde cholangiopancreatography was 9.9%, which is lower than the 16.7% reported by Loh et al. [11] for the reconstituting group. Notably, no stone recurrence was observed in any patient during an average follow-up of 6.7 years. Additionally, Gross et al. [12] reported a completion cholecystectomy requirement of only 0.9% at 63 months of follow-up. These findings support the long-term reliability of SC as a viable option.
Our mortality rate stands at a manageable 1%. TG18 highlighted that disease severity is directly related to 30-day mortality [2]. This rate is particularly reasonable given the high-risk nature of our patient group.
In our study, the fenestrating technique was preferred in 72.3% of cases, while the reconstituting technique accounted for 27.7%. This distribution is significant; the fenestrating technique was used in over 75% of cases in the open surgery and conversion groups, whereas the reconstituting technique was more commonly applied in the laparoscopic group (33.3%). This pattern reflects the increased risk associated with detaching the posterior wall from the liver bed in complex cases.
Alius et al. [13] have advocated for a similar approach, emphasizing that the choice of technique should be guided by intraoperative conditions, particularly in cases of severe inflammation where the structures in the Calot triangle are not clearly identifiable. In contrast, Függer [4] argued that the decision regarding the SC technique should depend on the surgeon’s experience and the patient’s risk profile.
A key finding of our study is that there was no significant difference in complications between the two techniques. Both short-term (adjusted OR, 1.28; p = 0.486) and long-term (adjusted hazard ratio, 1.24; p = 0.568) outcomes were comparable. Krishna et al. [14] also showed that with appropriate salvage strategies, morbidity could be maintained at 8% over their twenty-year experience. These findings support the notion that the choice of technique can be confidently made based on intraoperative conditions.
In conclusion, it is not feasible to predetermine whether the fenestrating or reconstituting technique should be preferred; the decision must be made during the operation, based on the anatomical situation.
In our study, morbidity was 9.5% in the laparoscopic group, compared to 45.2% in the open surgery group. Fu et al. [15] reported a general complication rate of 7.5% in a series of 478 laparoscopic cholecystectomies. The fact that our laparoscopic group had a rate close to this suggests that the subtotal technique may offer a safety profile comparable to that of standard cholecystectomy.
Bile leakage was not observed in the laparoscopic group, while it reached 6.5% in the open group. Fu et al. [15] reported a biliary fistula rate of 4% in their laparoscopic series. Our low rate may be attributed to careful technical application. The need for reoperation followed a similar pattern; it was zero in the laparoscopic group and 9.7% in the open group.
Even when including cases that underwent conversion in the ITT analysis of the laparoscopic group, the results remained consistent. Morbidity was calculated as 14.3% vs. 45.2%, and hospital stay as 1.8 vs. 3.6 days. The literature indicates that an early laparoscopic approach can be safely applied in low-stage cases according to the Tokyo Guidelines [16]. Five-year complication-free survival was found to be 90% vs. 74.2% in the ITT analysis, and this difference was significant (p = 0.041).
An important finding from long-term follow-up was that no patient required completion cholecystectomy due to stone recurrence. Mohtashami et al. [17] also reported that stones in the remnant gallbladder could be treated laparoscopically with a 78% success rate. However, it should be emphasized once again that these results cannot be evaluated independently of the patient selection differences discussed in the first paragraph.
Like any retrospective study, ours has certain limitations. Notably, there were significant demographic differences between the groups. Patients who underwent open surgery were older, had more comorbidities, and presented with more severe clinical conditions. Although we considered propensity score matching, the sample size was insufficient for this approach. Additionally, our statistical power was inadequate for detecting rare complications. On the positive side, our study has several strengths. The long follow-up period and active surveillance protocol enabled us to reliably assess long-term outcomes. By presenting both per-protocol and ITT analyses, we provided a more comprehensive interpretation of the results. We also attempted to control for confounding factors using multivariate regression models. Future prospective, multicenter studies, including randomized controlled trials, may better clarify the role of SC.
In conclusion, SC is a valuable rescue option for surgeons facing challenging cases where ensuring a critical safety profile is difficult. Our experience shows that this technique provides an acceptable safety profile, whether performed laparoscopically or through open surgery. The decision to use fenestrating or reconstituting techniques should be based on the anatomical conditions encountered during the procedure, rather than predetermined. In conclusion, SC is not an “inadequate” operation; it is a strategic approach that safeguards patients from serious biliary tract injuries. Broader acceptance of this method will enhance patient safety in complex cholecystectomies.
Footnotes
FUNDING
None.
CONFLICT OF INTEREST
No potential conflict of interest relevant to this article was reported.
AUTHOR CONTRIBUTIONS
Conceptualization: İHÖ, SH. Data curation: İHÖ. Formal analysis: İHÖ, SH. Investigation: İHÖ, SH. Methodology: İHÖ. Project administration: İHÖ. Resources: İHÖ. Software: İHÖ. Supervision: İHÖ. Validation: İHÖ, SH. Visualization: İHÖ, SH. Writing – original draft: İHÖ. Writing – review & editing: İHÖ, SH.
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