Laparoscopic subtotal cholecystectomy as a bailout procedure for difficult cholecystectomy: a narrative review

Background and Objective: The 2018 Tokyo Guidelines proposed a bailout procedure (BOP) to avoid bile duct injury (BDI) in highly difficult cases during laparoscopic cholecystectomy (LC). Subtotal cholecystectomy (SC) is a BOP, and cases requiring laparoscopic subtotal cholecystectomy (LapSC) have been increasing. Accordingly, recent studies have highlighted the usefulness of LapSCs. In this study, we reviewed the outcomes of LapSCs, focusing on several clinical questions. Methods: Systematic literature search and narrative review were performed. A comprehensive search of published literature until November 2024 in the PubMed, Cochrane Library and Scopus databases was conducted, using the keywords including “bailout procedure” or “subtotal cholecystectomy”. A set of study questions focused on the advantages of LapSC, risk factors of conversion to SC, postoperative complications, and techniques of LapSCs. Key Content and Findings: After a comprehensive literature search, 44 studies were included in the qualitative narrative review. The incidence of BDI and bile leakage after LapSC was reported as 0–2.4% and 0–47.2%, respectively. Short-term complications after LapSC include subhepatic hematoma or abscess, which rarely occur after total cholecystectomy. Residual gallbladder stones are a major long-term complication of LapSC treatment. Almost all symptomatic stones in the gallbladder remnants after SC required open surgery. A treatment history of choledocholithiasis or preoperative endoscopic retrograde cholangiopancreatography (ERCP) was considered a risk factor for conversion to BOP. Disruption of the common bile duct from a cystic duct defect during magnetic resonance cholangiopancreatography (MRCP) also increased the risk of SC. Conclusions: To avoid BDI during LC, LapSC is a useful option. The techniques or rate of operative complications for LC vary among institutions. Therefore, further studies and technical standardization are required.