Safe laparoscopic subtotal cholecystectomy in the face of severe inflammation in the cystohepatic triangle: a retrospective review and proposed management strategy for the difficult gallbladder

Roderick H. Purzner

2019

We proposed 3 tenets as the foundation of the management of severe cholecystitis: early identification of a severely inflamed and possibly fused cystohepatic triangle resulting in a decision to avoid further dissection and prepare for Laparoscopic subtotal cholecystectomy; mobilization of the GB off of the liver bed in a counterclockwise direction well above the vasculobiliary pedicle using what we call the top-around technique; this is followed by opening of the GB at the level of Hartmann’s pouch and leaving a remnant without approaching the cystohepatic triangle at all; and removal of all stones from the GB remnant and identification of the cystic duct orifice to determine if there is bile leakage

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