Background: Laparoscopic cholecystectomy is the gold standard for gallbladder disease. However, dense adhesions, severe inflammation, empyema, gangrene, impacted stones, choledocholithiasis and anatomical anomalies may render conventional laparoscopic cholecystectomy unsafe.
Methodology: This is a retrospective observational study that included 130 patients who underwent laparoscopic cholecystectomy or laparoscopic subtotal cholecystectomy between July 2012 and January 2025 at a tertiary referral centre. Preoperative evaluation included clinical assessment, laboratory investigations, and ultrasonography in 100 (76.92%) or ultrasonography with magnetic resonance cholangiopancreatography in 30 (23.08%). Outcomes included operative details, postoperative recovery, complications and hospital stays. Statistical analysis utilised the Chi-square test, Fisher’s exact test, Student’s t-test and one-way ANOVA, with p < 0.05 considered significant.
Results: Laparoscopic cholecystectomy was completed in 85 (65.38%), laparoscopic subtotal cholecystectomy was required in 43 (33.08%), and open conversion occurred in 2 (1.54%). Controlled bile leak developed in 53 (40.77%), resolving spontaneously in 35 (66.04%) within 15 to 21 days. Mean operative time was (2.14 ± 0.75) hours, and mean hospital stay was (1.86 ± 1.0) days. Overall morbidity was 8 (6.15%), with complications including common bile duct stricture in 2 (1.54%), common bile duct injury in 1 (0.77%), hepatic artery injury in 1 (0.77%) and mortality in 1 (0.77%) from cardiac arrest unrelated to surgery.
Conclusion: Laparoscopic cholecystectomy, including laparoscopic subtotal cholecystectomy with mucosectomy and endoscopic retrograde cholangiopancreatography with common bile duct stenting when indicated, is a safe and effective approach in both acute and chronic cholecystitis, even in complex gallbladder cases, which are technically difficult cases.

Laparoscopic subtotal cholecystectomy, Mucosectomy, Endoscopic retrograde cholangiopancreatography, Bile duct, Complex gallbladder disease, Three-port technique, Calculus cholecystitis.

Laparoscopic cholecystectomy has become the gold standard for gallbladder removal, surpassing open cholecystectomy in recent years due to its minimally invasive nature and favourable outcomes. The aim of this study is to evaluate a safe bailout technique using a dual laparoscopic-endoscopic approach for managing complex gallbladder disease in the same operative session with using 3 port technique in a single centre cohort. Historically, conversion to open surgery was the standard when intraoperative challenges such as failure to achieve the critical view of safety due to dense adhesions, empyema, gangrene, anatomical anomalies, choledocholithiasis, common bile duct dilatation (with or without stones) or fistulous connections were encountered. More recently, laparoscopic subtotal cholecystectomy with mucosectomy has emerged as a safer alternative [1-5]. This approach, sometimes leaving the cystic duct or stump open, is often followed by endoscopic retrograde cholangiopancreatography with common bile duct stenting in the same session to facilitate bile drainage and prevent complications [6-8] by aiming to decompress the high-pressure system having a valvular mechanism at the distal end. Complete mucosectomy reduces the risk of residual mucosa undergoing metaplasia or malignant transformation. The controlled bile leakage from the cystic stump is common postoperatively, which usually resolves within 15 to 21 days in the presence of a common bile duct stent. The purpose and objective of this study is to prove whether combining all these procedures in one session can reduce complications, avoid open surgery and provide better recovery in complex cholecystic diseases by comparing postoperative outcome, complication rates, operative findings and management strategies.

After doing necessary haematological and radiological investigations and assessing fitness for surgery, obtaining written and video-informed consent from the patient and an attendant, the procedure begins with the patient placed in the supine position for intubation. Routine insertion of a nasogastric tube for gastric decompression or aspiration is typically not performed, as it is generally unnecessary. We prefer 3 port technique, supine position with head up & left tilting. The first port (10 mm camera port) is inserted at the supraumbilical position. Carbon dioxide insufflation is initiated, maintaining an intra-abdominal pressure of 10 to 12 mmHg and a flow rate of 4 to 6 litres/minute. Under direct visualisation through the 1^st port, the 2^nd port (10 mm working port) is placed in the epigastric region, and the 3^rd port (5 mm working port) is positioned at the right midclavicular line, maintaining an approximate 60-degree angle between all 3 ports (Figure 1).

Figure 1: Port Position

Following full carbon dioxide gas insufflation, the patient is tilted to the left with the head elevated (reverse Trendelenburg position). All abdominal quadrants are inspected to rule out associated pathologies or trocar entry injuries. Using the left-hand instrument via the 3^rd port, the fundus of the gallbladder is identified and retracted, while dissection is carried out using the right-hand instrument via the 2^nd port. Initial assessment includes evaluation of the hepatobiliary anatomy, presence of adhesions, gallbladder wall thickness and oedema (Figure 3a). Adhesiolysis is performed using electrocautery or a harmonic scalpel to expose Calot’s triangle and to achieve the critical view of safety (Figure 3b). In cases of anatomical variation, dense adhesions, empyema, gangrene or fistulous connections, safe dissection may be hindered. In such scenarios, the 3^rd port is directly and carefully introduced into the gallbladder via the fundus under vision, and its contents, including bile, sludge or pus, are aspirated (Figure 3c). This decompression facilitates easier manipulation and retraction of the gallbladder. Another attempt is then made to dissect Calot’s triangle (Figure 3b) safely. If dissection remains unsafe and failure to achieve the critical view of safety again, the decision is made to proceed with a laparoscopic subtotal cholecystectomy. The anterior wall of the gallbladder is excised using electrocautery or a harmonic scalpel, working as low as possible toward the cystic duct, without crossing Rouviere’s sulcus or damaging surrounding structures (Figure 3d). Haemostasis is ensured. Gallstones and the excised anterior wall are retrieved using an endo bag and temporarily placed in the right hepatic gutter (Figure 3e). A mucosectomy is then performed (Figures 3f, 3g, 3h) carefully by excising the mucosa of the posterior wall of the gallbladder. It is to be done by using a spatula with electrocautery, starting from an inferior to superior direction, by coagulating all mucosal surfaces that remain adherent to the liver bed. The cystic duct/stump is intentionally left open (Figures 2a, 2c, 3g, 3h, 3i) [1,2,3,4]. A negative suction drain is placed adjacent to the cystic opening and exteriorised through the third port (Figure 3j).

Figure 2: Types of Laparoscopic Subtotal Cholecystectomy

2a: Preservation of the posterior wall of the gallbladder with open remnant/ cystic stump

2b: Preservation of the posterior wall of the gallbladder with a closed remnant/ cystic stump

2c: Open remnant/ cystic stump without preservation of the posterior wall of the gallbladder

Figure 3: Steps of Laparoscopic Subtotal Cholecystectomy

3a: Gall bladder and hepatobiliary assessment showing a gangrenous gallbladder with frozen Calot’s triangle, which requires assessment of the critical view of safety

3b: Adhesinolysis and Calot’s triangle showing altered anatomy, which makes assessment & dissection difficult due to frozen Calot’s triangle, having to assess the critical view of safety

3c: Aspiration from the gall bladder under vision with the suction cannula or with a laparoscopic wide-bore needle

3d: Excision of the anterior wall of the gall bladder, keeping the posterior wall of the gall bladder

3e: Stone retrieval done from the cystic stump

3f: Initial step of mucosectomy

3g: Completed mucosectomy

3h: Cystic stump pointed with suction cannula and the posterior wall of the gall bladder in the gall bladder fossa

3i: Final appearance of laparoscopic subtotal cholecystectomy with keeping the posterior wall of the gallbladder after mucosectomy

3j: Negative suction drain placement in the gallbladder fossa

The camera is then shifted to the 2^nd port, and the specimen is retrieved via the 1^st port using the endo bag to avoid spillage. Finally, the camera is returned to the 1^st port and the abdominal cavity is inspected for bile spillage, residual gallbladder tissue and stones, followed by a thorough saline lavage. The transversus abdominis plane block is administered to manage postoperative pain and reduce the need for systemic analgesia. All ports are closed in two layers. The drain is securely fixed, and sterile, waterproof dressings are applied. Immediately after the laparoscopic procedure, endoscopic retrograde cholangiopancreatography is performed by the gastroenterologist in the same session to remove common bile duct stones and insert a common bile duct stent. In selected cases, like acute cholecystitis, suspecting frozen Calot’s triangle or common bile duct dilatation with or without stone, preoperative endoscopic retrograde cholangiopancreatography with common bile duct clearance and stenting is done prior to laparoscopic subtotal cholecystectomy during the same operative session. Patients are usually discharged on postoperative day 2 or 3, with a drain in place and oral medications. They often experience immediate symptom relief following surgery. The 1^st follow-up visit is scheduled between postoperative days 8 and 10 for suture removal. Drain removal is planned during the 2^nd follow-up, once bile leakage has ceased. If there is no leakage, the drain removal was still not performed before the 1st follow-up. The common bile duct stent is generally removed between postoperative days 21 and 30, during the 3rd follow-up visit.

A retrospective analysis was conducted on 130 patients who underwent surgery between July 2012 and January 2025.

Table 1: Demographics

Table 2: Preoperative data

Table 3: Intraoperative data

Table 4: General data

Table 5: Postoperative data

Interpretation: In this series of 130 patients, the study population predominantly comprised middle-aged females with a mean age of (47.17±17) years and a mean body mass index of (29.31±6.76), indicating a strong association of gallstone disease with obesity and female gender (p < 0.001). Nearly 57 (43.85%) had comorbidities, most commonly diabetes mellitus in 15 (26.31%) and hypertension in 24 (42.11%), which reflects the metabolic profile often associated with biliary pathology. Chronic cholecystitis was more common than acute cholecystitis, 83 (63.85%) v/s 47 (36.15%) (p < 0.001), while 64 (49.23%) had choledocholithiasis on magnetic resonance cholangiopancreatography, which necessitated endoscopic retrograde cholangiopancreatography in the majority. Intraoperatively, most procedures were completed laparoscopically in (2.14±0.75) hours with <10 ml of blood loss. Laparoscopic subtotal cholecystectomy was required in 43 (33.08%), primarily due to the inability to achieve the critical view of safety (p < 0.001), while the conversion to open surgery was rare in 2 (1.54%). Postoperatively, controlled bile leak was observed in 53 (40.77%) but resolved spontaneously within 15 to 21 days in the majority of 47 (88.68%). The mean hospital stay was short (1.86±1.00) days (p < 0.001), and postoperative pain was negligible, with nearly all 127 (97.69%) reporting no or minimal discomfort. Overall, laparoscopic cholecystectomy including selective laparoscopic subtotal cholecystectomy with mucosectomy using 3 ports combination with endoscopic retrograde cholangiopancreatography and common bile duct stenting in a same operative session (bailout procedure) in 115 (88.46%) demonstrated a very favourable safety profile with no procedure related mortality. Complications occurred in only 8 (6.15%), mainly biliary or vascular and were successfully managed without any long-term sequelae. No procedure-related mortality was noted, and good postoperative recovery was achieved in 122 (93.85%) (p < 0.001). The data (Clavien-Dindo classification) support that laparoscopic cholecystectomy, even in high-risk biliary cases, is safe with excellent recovery, minimal complications and statistically significant positive outcomes. These findings confirm that laparoscopic cholecystectomy is a safe and effective approach even in complex biliary cases, with outcomes well aligned with international standards.

Table 6: Clavien–Dindo classification summary table for postoperative complications

Laparoscopic cholecystectomy has replaced open surgery as the gold standard for gallbladder disease because of shorter hospital stays, reduced pain and faster recovery. However, complex cases with dense adhesions, severe inflammation, empyema, gangrene or anomalous biliary anatomy may prevent attainment of the critical view of safety and increase the risk of bile duct or vascular injury. Historically, conversion to open surgery was the standard bailout technique, but laparoscopic subtotal cholecystectomy with mucosectomy, combined with endoscopic retrograde cholangiopancreatography and common bile duct stenting in the same operative session, has emerged as a safer alternative, supported by international guidelines such as the Tokyo Guidelines 2018 [1-9]. In this series of 130 patients, 43 (33.08%) underwent laparoscopic subtotal cholecystectomy, primarily due to failure to obtain the critical view of safety or severe inflammation at Calot’s triangle. This rate is consistent with reported figures of 20 to 35% in high-risk cholecystectomy cohorts. Importantly, open conversion was required in only 2 (1.54%), which is markedly lower than historical rates of 5 to 10% in difficult cholecystitis. These findings support laparoscopic subtotal cholecystectomy as an effective bailout procedure that avoids unnecessary open procedures while maintaining safety. A controlled postoperative bile leak was observed in 53 (40.77%), attributable to leaving the cystic stump open with planned endoscopic retrograde cholangiopancreatography and common bile duct stenting. In most cases, 47 (88.68%), the leak resolved spontaneously within 15 to 21 days, in line with previous reports [10,11], highlighting that controlled drainage should be considered an expected outcome rather than a complication.

Postoperative recovery was favourable in 122 (93.85%), with a low complication rate in 8 (6.15%). The incidence of bile duct injury in 1 (0.77%) and vascular injury in 1 (0.77%) was comparable to international standards, and no procedure-related mortality occurred. Mean operative time (2.14±0.75) hours and short hospital stay (1.86±1.00) days were consistent with minimally invasive surgery benchmarks, further supporting the feasibility of this approach. My findings align with prior studies, including those by Elshaer et al. and Henneman et al., which reported 5 to 8% complication rates and confirmed the safety of laparoscopic subtotal cholecystectomy in difficult gallbladders. The mucosectomy technique offers an added advantage by removing residual mucosa, thereby reducing risks of long-term complications such as mucocele formation or malignant transformation, which are concerns associated with fenestrating techniques. Overall, this combined laparoscopic–endoscopic bailout strategy demonstrates safety, reproducibility and superior outcomes compared to open conversion in complex biliary surgery. While short-term outcomes were excellent, prospective studies with larger cohorts and extended follow-up are needed to validate long-term safety, especially regarding stone recurrence, strictures and mucosal regrowth.

Strengths and limitations: The major strength of this study is the relatively large single-centre cohort (n=130) with standardised surgical technique, performed by an experienced surgeon, which minimises variability in outcomes. The inclusion of both preoperative and postoperative endoscopic retrograde cholangiopancreatography as adjuncts provides a comprehensive view of the combined laparoscopic endoscopic bailout strategy. Detailed documentation of bile leak resolution, drain management and complications further strengthens the reliability of the findings. However, this study has certain limitations. First, it is a retrospective single-centre analysis, which carries inherent selection bias and limits the generalizability of results. Second, the follow-up period was relatively short, preventing assessment of long-term sequelae such as recurrent choledocholithiasis, residual gallbladder disease or malignant transformation in retained mucosa. Third, no direct control group (e.g., conventional conversion to open cholecystectomy) was available for comparison, which restricts the ability to make definitive conclusions about superiority. Finally, comorbidities and variations in disease severity were not stratified in multivariate analysis, which may have influenced outcomes. Despite these limitations, our study provides meaningful evidence that laparoscopic subtotal cholecystectomy with mucosectomy using 3 ports combination with endoscopic retrograde cholangiopancreatography and common bile duct stenting in a same operative session is a safe, effective and reproducible bailout strategy in difficult cholecystectomy cases.

Laparoscopic subtotal cholecystectomy with mucosectomy using 3 ports combination with endoscopic retrograde cholangiopancreatography and common bile duct stenting in the same operative session, represents a safe and effective bailout strategy for difficult cholecystectomy cases, with low conversion rates and acceptable complication profiles. The short-term outcomes, such as bile leak resolution and recovery, and the long-term outcomes, such as mucocele formation and conversion to malignancy, were favourable in complex cholecystectomy cases.

Not reported

None

Jitenkumar H Panchal
Department of General, Laparoscopic & Bariatric Surgery
Blue Bell Clinic, Surat, Gujarat, India
Email: jitenkumarpanchal@gmail.com

The author contributed to the Conceptualisation, Investigation and Data Curation by acquiring and critically reviewing the selected articles and was involved in the Writing – Original Draft preparation and Writing – Review & Editing to refine the manuscript.

Informed consent was received from the patient.

The author declares no conflicts of interest.

None

https://doi.org/10.63096/medtigo30922313

Panchal JH. A Study of Combined Laparoscopic-Endoscopic Approach for Complex Cholecystic Disease in A Same Operative Session With 3 Ports Technique: A Safe Bailout Strategy. medtigo J Emerg Med. 2025;2(3):e30922313. doi:10.63096/medtigo30922313 Crossref