Subtotal Cholecystectomy
What the Examiner Expects
Partial removal of the gallbladder, intentionally leaving the infundibulum or posterior wall attached to the liver bed when severe inflammation prevents safe identification of the critical view of safety. This is the most important bail-out procedure during a difficult cholecystectomy. The reconstituting technique leaves the posterior wall attached to the liver, removes stones, cauterizes residual mucosa, and closes the remnant. The fenestrating technique leaves the remnant open with a drain. The examiner expects you to understand that accepting a subtotal cholecystectomy is far safer than risking a major bile duct injury by blindly dissecting in an inflamed Calot's triangle.
Key Examiner Focus Points
- Bail-out procedure when CVS cannot be achieved safely
- Two types: reconstituting (leaves posterior wall on liver, closes remnant) and fenestrating (leaves remnant open with drain)
- Prevents bile duct injury in severely inflamed/fibrotic gallbladders
- Accept a higher rate of recurrent biliary symptoms vs risk of major bile duct injury
- Remove as many stones as possible and cauterize residual mucosa
Common Curveballs
After subtotal cholecystectomy, the patient has persistent bilious drainage from the drain
Bile leak from an open cystic duct stump or from the gallbladder remnant. Most will seal with time and drainage. If persistent, ERCP with sphincterotomy and/or temporary biliary stent reduces the pressure gradient across the sphincter and promotes healing of the leak.
Retained gallstone in the remnant causing recurrent cholecystitis 1 year later
This is a known risk of subtotal cholecystectomy. Evaluate with MRCP. If symptomatic, options include ERCP for stone extraction if accessible, or completion cholecystectomy (difficult due to adhesions — should be performed by an experienced surgeon).
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