Techniques for difficult laparoscopic cholecystectomy cases

Our basic techniques for the management of difficult cases in laparoscopic cholecystectomy (LC) are presented. If access to Calot's triangle cannot be performed safely, dissection should be started at the fundus or body of the gallbladder (GB), rather than the neck. In cases with a large cystic duct, a transfixing suture should be applied for ligation instead or clipping. EndoGIA is useful to ligate and transect the short and wide cystic duct, avoiding a subsequent stricture caused by usual ligation. Intraoperative cholangiography should be performed near the neck of the GB in cases in which orientation is lost during dissection. More dissection should be performed in the direction of the junction of the bile ducts after orientation is regained. In cases with stone-filled GB, accompanied by severe fibrosis, part of the GB is incised to remove the stones and expose the lumen of the GB. Confluence stones can be removed by placing an incision on the GB side of the junction of the duct. The incised part is closed with suture. A cystic tube (C-tube) is used to decompress the common bile duct. In more difficult cases in which dissection cannot be started safely at any location, the body and the fundus of the GB are excised, and a drain is placed in the neck of the GB. Dissection must be able to be done from the main surgeon's side and the assistant's side depending on the situation, and cooperation between the two surgeons is mandatory to achieve laparoscopic cholecystectomy in difficult cases. When performing the LC, one must have a low threshold fo converting to open surgery if complications cannot be managed safely.