Partial cholecystectomy is a safe and efficient method

Introduction
Frequency of stone formation in gall bladder is about 5-22 percent (1). Approximately 33 % of these patients have acute cholecystitis attack throughout their life (2). Treatment of symptomatic bile stones is surgical and laparoscopic or open cholecystectomy is both proved safe procedure. However, in some cases, cholecystectomy may be highly challenging procedure for surgeon. When there is excess inflammation, fibrosis and portal hypertension around gall bladder or in presence of Mirizzi syndrome, bile ducts and hepatic artery may be possibly damaged during dissection of Calot triangle (3). In this case, it may be vital to complete cholecystectomy without causing damage in patient. In this study, we examined safety and efficiency of partial cholecystectomy operation which we perform when dissection of calot triangle is major source of potential morbidity (düzenle).

Material and Method
Patients who were undergone partial cholecystectomy in our clinic between 1996 and 2008 were retrospectively evaluated. Among these patients, individuals undergone partial cholecystectomy (PC) were enrolled into the study. Demographic date, type of anesthesia, diagnostic method, reason for partial cholecystectomy, operation date, morbidity and mortality rates of patients were evaluated.

Results
It was found that PC was performed in eighteen cases along twelve years. Demographic data, type of incision and type of anesthesia pertaining to those patients are given in Table 1. Acute cholecystitis was diagnosed in all patient via clinical examination, laboratory and ultrasonographic examination. Decision to perform this procedure is made during operation due to presence of excess inflammation and fibrosis around gall bladder.
In all cases, PC indication was reported as excess inflammation around Calot triangle. It was found that all patients were administered ceftriaxone for 10 days during both preoperative and postoperative period and no change was required due to culture and antibiogram results bile samples obtained during operation.
Surgical Technique: After intra-abdominal space was explored for other pathologies following laparotomy, gall bladder was opened from fundus, infected bile and stone content was removed; gall bladder was resected through Hartman pouch and remaining mucosa was cureted and cauterized. Cystic canal was found using stiletto and the canal was explored for stone; all-round closing stitches were placed around cystic canal using 3/0 absorbable suture. Remaining gall bladder was continuously closed using non-absorbable sutures. A drain was placed to gall bladder and thus, operation was completed.
During operation, gangrenous gall bladders were observed in 6 patients (33.3%); gall bladder was perforated from posterior aspect towards liver in three of six patients (16.6%). There was no intro-abdominal free abscess. It was found that postoperative subhepatic abscess occurred in one patient (5.5%) and it was treated by percutaneous drainage. Superficial wound site infection formed in four patients (22,2%). Cystic canal could be closed by all-round sutures in twelve patients (66,6%). Controlled bile fistula occurred in early post-operative period in two patients (11.1%) and said fistula spontaneously closed without requiring additional surgical procedure. Most common microorganism found in bile cultures was Escherichia coli, whereas Enterecoccus faecalis, Staphylococcus aureus and Pseudomonas aureus were also found.
Mean hospitalization period of patients was 8 days (range: 15-14 days) and mean follow-up period was 80 months (8-150 months). During follow up, hepatobiliary ultrasonography could be re-performed in 8 patients and no new stone formation was observed. In 7 patients, it was understood verbally that no postoperative gastrointestinal symptoms were present. No intraoperative or early postoperative mortality was ound. Three patients had died due to non-surgical reasons.

Discussion
Cholecystectomy performed due to cholecystitis with stone, acalculose cholecystic or biliary colic is among most common operations of general surgery clinics. Ninety percent of patients undergone surgical treatment are totally relieved within 1-4 days (4).
Attitudes of surgeons against surgical treatment of acute cholecystist have interindividual variations. Some perform operation 4-6 weeks following antibiotic treatment of acute cholecystitis episode, whereas others plan surgical treatment as soon as it is practical (5).
Cholecystectomy may be performed by laparoscopic or open methods. Recently, laparoscopic surgery is more frequently preferred due to less postoperative pain, shorter time to return work and better cosmetic appearance. However, frequency of bile duct damages were relatively increased in conjunction with increase in laparoscopic cholecystectomy (7). Principal reason of damages occurred in bile ducts or hepatic arteries during cholecystectomy is due to failure to determine regional anatomy accurately. Therefore, if there is doubt about regional anatomy during laparoscopic cholecystectomy, it will be best to progress with open cholecystectomy (8).
Besides all, it is not possible to perform safe traditional cholecystectomy using open or close method in acute cholecystitis cases if Calot triangle is involved. In those cases, percutaneous or open cholecystostomy, open or laparoscopic partial cholecystectomy can be alternatively performed.
For patients bearing risk for long surgical procedure, cholecystostomy performed within short time temporarily decompresses gall bladder and thus it relieves symptoms. Recently, open surgical cholecystostomy was replaced by percutaneous cholecystostomy (9). Despite temporary relief, surgical procedure can be required to be repeated in 25-30 % of those patients due to residue stones (10).
As traditional cholecystectomy, partial cholecystectomy has been performed for long years. It is particularly preferred in infected, gangrenous, perforated and fibrotic gall bladders as well as patients with portal hypertension who have high bleeding risk (11). In our cases, inflammation was severe enough to hinder safe dissection of Calot triangle.
On the contrary to cholecystostomy, all stones within gall bladder are removed in partial cholecystectomy. This minimizes stone-related recurrence of acute cholecystitis. Although frequency is low, formation of new stone has been reported in presence of blind pouch adjacent to remaining Hartman pouch (12). This condition can be prevented only by complete elimination of dead space via maximum closure to Hartman pouch. None of our patients experienced recurrent symptomatic stone formation.
One of most frustrated complications of partial cholecystectomy is infectious complications due to opening of infected gall bladder (12). Possible complications include sub-diagraphmatic abscess, mucus secretion act wall of remaining gall bladder and bile fistula from cystic canal stump. It was documented that infectious complications are not more common than complication of traditional cholecystectomy or operations where bilio-enteric anastomosis is performed (13). In our patients, no complications requiring additional surgical procedures occurred.
In literature, malignity in remaining gall bladder had been rarely reported as case presentation (14,15). No such cases were found among our patients.
Due to recent increase in laparoscopic experiences, PC was started to perform laparoscopically in a safe manner (16). We performed open PC in all our patients.
In conclusion, PC seems to combine availabvility of cholecystectomy in high-risk conditions and efficiency of traditional cholecystectomy under normal conditions. Keeping in mind that actual treatment of symptomatic gall bladder diseases in traditional cholecystectomy, if possible, PC can be safely and efficiently performed where dissection of Calot triangle is challenging.

References
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