Difficult Laparoscopic Cholecystectomy: Current Evidence and Strategies of Management

Laparoscopic cholecystectomy is the treatment of choice for gall bladder stone disease. Difficult cholecystectomy is associated with serious complications and a high conversion rate. The aim of this study was to review the current strategies to manage difficult cholecystectomy. Methods: A Medline search was conducted to review all published English literatures relevant to difficult cholecystectomy through 1993 to 2009. The search words were laparoscopic cholecystectomy, difficult cholecystectomy, difficult laparoscopy, subtotal laparoscopic cholecystectomy, fundus first cholecystectomy, and causes of conversion of laparoscopic cholecystectomy. Results: Ninety-one studies, which included 324,553 patients, were selected for this review. Five major categories of difficulty were identified. Conversion rate and iatrogenic injuries during laparoscopic cholecystectomy are still high despite significant improvement over the last 10 years. Depending on the technique of cholecystectomy, the degree of gall bladder inflammation, patient comorbidities, and surgical experience, the conversion rate was reported between 0.18% and 30%, whereas the incidence of iatrogenic injuries was from 0% to 0.6%. Subtotal cholecystectomy, antegrade and fundus first techniques, and peroperative cholangiogram were associated with lower complications and conversion rate. Risk factors for difficulty were male sex, increased age, acute and thick wall chronic cholecystitis, wide and short cystic duct, cholecystodigestive fistula, previous upper abdominal surgery, obesity, liver cirrhosis, anatomic variation, cholangiocarcinoma, and low surgeon's caseload. Conclusions: No consensus is found among surgeons on how to manage difficult laparoscopic cholecystectomy. Iatrogenic injuries and conversion rate can be reduced depending on the surgeon's experience, special techniques, and intraoperative investigations. Subtotal cholecystectomy, antegrade or fundus first techniques, and peroperative cholangiogram significantly reduced the complications and conversion rate.