Clinical Outcomes and Complications Following Subtotal Cholecystectomy: A Single-Centre Cohort Analysis
General Surgery, Homerton University Hospital, London, GBR
General Surgery, North Middlesex University Hospital, London, GBR
General and Upper Gastrointestinal (GI) Surgery, Ain Shams University, Cairo, EGY
Upper Gastrointestinal (GI) Surgery, Homerton University Hospital, London, GBR
Radiology, Guy's and St Thomas' NHS Foundation Trust, London, GBR
Surgery, Homerton University Hospital, London, GBR
Abstract
Background
Subtotal cholecystectomy (STC) is increasingly used as a safe technique for managing difficult gallbladders to reduce the risk of common bile duct (CBD) injury. However, techniques and outcomes vary across institutions, and standardised reporting remains limited.
Objective
To evaluate peri-operative and post-operative outcomes following STC at a single tertiary centre and to explore pre-operative factors associated with the need for STC, including the frequency of previous gallstone-related admissions and radiologic markers such as impacted infundibular or neck stones, thickened or contracted gallbladder, and imaging features suggestive of a frozen Calot’s triangle.
Methods
Retrospective cohort study of consecutive patients undergoing STC between January 2021 and January 2024. Data included demographics, indications, operative technique (fenestrating vs. reconstituting), intra-operative findings, complications, and long-term biliary outcomes. The primary endpoint was clinically significant bile leak; secondary outcomes were reoperation, endoscopic retrograde cholangiopancreatography (ERCP) requirement, readmission, and mortality.
Results
Thirty-nine patients underwent STC (97% laparoscopic, 3% open). Median age 49 years with a mean BMI of 39 kg/m2. Bile leak occurred in 2.6% (n = 1), reoperation 0%, ERCP 2.6% (n = 1), readmission 0%, and mortality 0%.
Conclusions
STC offers a safe alternative to total cholecystectomy in complex cases, though bile leak remains an important morbidity. Technique type and intra-operative factors influence outcomes, highlighting the need for standardised approaches and careful case selection.
Untitled section
Keywords: bile leak, cholecystectomy outcomes, difficult gallbladder, laparoscopic surgery, subtotal cholecystectomy
Article notes
Untitled section
Accepted 2025 Dec 4; Collection date 2025 Dec.
Introduction
Background
Cholecystectomy is the definitive management for gallstone disease. In cases of severe inflammation or obscured anatomy at Calot’s triangle, STC is employed to prevent bile duct injury [1,2]. More generally, the term difficult gallbladder describes a cholecystectomy which is expected to be more difficult than a routine cholecystectomy. Although the incidence of difficult gallbladders varies among series, it may be estimated that one in six gallbladders is “difficult” [3].
Objectives
To describe the outcomes of STC at our centre, analyse results by technique, and identify predictors of the need for STC.
Materials and methods
Study design and setting
This is a retrospective cohort analytic study conducted at Homerton University Hospital, our tertiary referral centre in London, United Kingdom. The study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [4].
All patients who underwent STC between January 2021 and January 2024 were included. Cases from emergency or elective settings were all included. All cases are performed by experienced upper gastrointestinal or emergency surgeons. A second opinion from another consultant colleague was taken when needed.
Patients <18 years, those undergoing total cholecystectomy, cases performed for malignancy, or those where cholecystectomy formed part of another operation were excluded.
Cases were identified from electronic theatre logs. Data were extracted from the hospital’s electronic patient records and operative notes. Demographic characteristics of patients, including age, sex, body mass index (BMI), and co-morbidities (e.g., diabetes, pancreatitis) were obtained.
Pre-operative data, including the number of previous admissions, were collected. The radiological findings (e.g., gallstones, wall thickness, impacted stones, ductal dilatation, Mirizzi syndrome, perforation) were analysed in detail and reviewed by a consultant radiologist. Detailed information on the intra-operative findings, e.g., frozen Calot’s triangle anatomy, degree of inflammation, adhesions, and conversion to open surgery, was checked to address the reasons for the intra-operative decision to perform a subtotal cholecystectomy as a bailout procedure rather than the planned laparoscopic cholecystectomy.
Operative details regarding the type of subtotal cholecystectomy have been investigated. We followed the Strasberg classification for subtotal cholecystectomy, which divides the procedure into two categories, fenestrating or reconstituting, depending on whether the gallbladder remnant is closed or left open [1]. The stump management technique used in our cases (e.g., suture closure, stapled closure, use of endo-loop, hemo-lock, or open stump), drain placement, as well as intra-operative complications were all analysed.
Post-operative outcomes, including 30-day morbidity and mortality, re-operation, post-operative endoscopic retrograde cholangiopancreatography/magnetic resonance cholangiopancreatography (ERCP/MRCP), rate of readmission, and length of stay, were also reviewed in detail. Persistent bilious drainage or imaging evidence requiring intervention is considered a clinically significant bile leak.
Follow-up was conducted between two to four years post-operatively via outpatient visits, virtual clinic notes, and review of hospital records for any gallbladder-related readmissions, interventions, or imaging.
Statistical analysis
Data were analysed using Microsoft Excel 2024 (Microsoft Corp., Redmond, WA, USA). Continuous variables are presented as mean ± standard deviation (SD) or median (interquartile range, IQR). Categorical variables are expressed as number (n) and percentage (%).
Ethical considerations
This study was approved by the hospital research and innovation team. All data were anonymised prior to analysis. No external funding was received, and the authors declare no conflicts of interest.
Results
Cohort overview
Between January 2021 and January 2014, 778 cholecystectomies were performed, of which 39 (5.0%) were subtotal. Median patient age was 49 years (SD 13.7), 21 (53.8%) were female subjects. Mean BMI was 39.0 ± 7.5 kg/m2 (Table 1).
| Variable | Mean ± SD/n (%) | Range/details |
| Age (years) | 49 ± 13.7 | 22 – 77 |
| Sex (male/female) | 18 (46.2%)/21 (53.8%) | — |
| BMI (kg/m2) | 39.0 ± 7.5 | 26 – 55 |
| Diabetes mellitus | 3 (7.7%) | — |
| Previous pancreatitis | 2 (5.1%) | — |
| ≥ 1 previous admission | 16 (41.0%) | 0 – 5 admissions |
Pre-, intra-, and post-operative findings
Many patients who underwent subtotal cholecystectomy had a history of repeated gallstone-related admissions, with a mean of 1.2 admissions (median 1, range 0-5). Overall, 41% of patients had experienced more than one admission prior to their operation. Three patients were diabetic, and two patients had previous pancreatitis.
Pre-operative radiological findings are shown in Table 2. These included gallstones (100%), thick-walled gallbladder (82%), impacted stones at gallbladder neck (20.5%), dilated bile ducts (10.2%), Mirizzi syndrome (7.6%), adenomyomatosis (7.6%), and perforation (2.5%). These radiologic features often correlated with the intra-operative finding of dense adhesions and frozen Calot’s anatomy.
| Imaging finding | n (%) |
| Gallstones | 39 (100%) |
| Thickened gallbladder wall | 32 (82.1%) |
| Impacted neck stone | 8 (20.5%) |
| Dilated bile ducts | 4 (10.3%) |
| Mirizzi syndrome | 3 (7.7%) |
| Adenomyomatosis | 3 (7.7%) |
| Gallbladder perforation | 1 (2.6%) |
The main indications for subtotal cholecystectomy included intra-operative findings of necrotic, emphysematous, perforated, frozen, or contracted gallbladders in which safe dissection of Calot’s triangle was not possible.
Several stump-management techniques were utilised depending on intra-operative findings and the surgeon’s judgement. Laparoscopic suturing was performed in 15 (38.4%) cases, endo-loop ligation in 11 (28.2%), stapler closure was used in 10 (25.6%), large hemo-lock in two (5.1%) and the stump was left open in one case (2.6%). Drains were placed in 33 patients (85%), with six patients left without drainage at the surgeon’s discretion.
Conversion to open surgery occurred in one case (2.6%) due to bleeding from the staple line. This was a tan-coloured tri-stapler reload. At laparotomy, bleeding from the gallbladder stump edge was controlled successfully without further complications. The details are illustrated in Table 3.
| Parameter | n (%) | Notes |
| Frozen Calot’s/dense adhesions | 28 (71.8%) | — |
| Necrotic/perforated gallbladder | 5 (12.8%) | — |
| Contracted gallbladder | 6 (15.4%) | — |
| Laparoscopic suturing | 15 (38.4%) | Reconstituting STC |
| Endoloop ligation | 11 (28.2%) | Reconstituting STC |
| Stapler closure | 10 (25.6%) | Reconstituting STC |
| Hemo-lock clip | 2 (5.1%) | Reconstituting STC |
| Open stump (fenestrating) | 1 (2.6%) | — |
| Drain placement | 33 (84.6%) | — |
| Conversion to open surgery | 1 (2.6%) | Staple-line bleeding |
The mean length of hospital stay was 3.6 ± 3.6 days. Post-operative complications were infrequent and included a single bile leak (2.6%) and three intra-abdominal collections (7.7%), all managed conservatively or with image-guided drainage. Post-operative imaging and endoscopic interventions were required in a small proportion of patients, with ERCP performed in 2.6% for post-operative bile leak and MRCP in 7.7% (Table 4).
| Outcome | n (%) | Management |
| Bile leak | 1 (2.6%) | Managed conservatively with drain and ERCP |
| Intra-abdominal collection | 3 (7.7%) | Image-guided drainage |
| ERCP performed | 1 (2.6%) | For post-operative bile leak |
| MRCP performed | 3 (7.7%) | For follow-up imaging |
| Conversion to open surgery | 1 (2.6%) | Controlled bleeding |
| Readmission | 0 (0%) | — |
| Reoperation | 0 (0%) | — |
| Mortality | 0 (0%) | — |
| Mean length of stay (days) | 3.6 ± 3.6 | Range 1 – 19 |
Discharge criteria included clinical stability, normal liver function test and minimal drain output. Histopathological analysis predominantly demonstrated chronic cholecystitis in 30 patients (approximately 77%), with occasional acute-on-chronic inflammation or mild dysplastic changes. During follow-up, a small number of patients experienced transient abdominal pain or small remnant collections; all resolved spontaneously or normalised on subsequent imaging.
There were no bile duct injuries, readmissions, bile duct injuries or mortality cases in our series. Details of histopathological results are demonstrated in Table 5.
| Histopathology result | n (%) |
| Chronic cholecystitis | 30 (76.9%) |
| Acute-on-chronic inflammation | 7 (17.9%) |
| Mild dysplastic changes | 2 (5.1%) |
| Malignancy | 0 (0%) |
Discussion
Laparoscopic subtotal cholecystectomy (STC) seems to be seen frequently in current surgical practice, with an average of one case per month in our series of 39 patients in three years. There was no special correlation with pre-operative history of diabetes or pancreatitis. However, our study suggested that the majority of the patients were at the high BMI side, classified as class 2 obesity (Mean BMI is 39 kg/m2).
Principal findings
Conversion to open surgery was required in only 2.6% of cases. Morbidity was low, with a bile leak rate of 2.6% and intra-abdominal collections in 7.7%. These outcomes compare favourably with published series [5-7]. The patient who needed conversion to open surgery had his gallbladder stump managed with a tan-coloured linear stapler. He bled more than 1 litre of blood, where conversion to open surgery was needed to get a better view and put an overstitch on the stapler edge where the bleeding point was. The single patient who developed post-operative bile leak had his gallbladder stump managed with a laparoscopic suturing technique. The bile leak was controlled by the presence of the sub-hepatic drain. The patient was treated with post-operative ERCP successfully. However, he remained in the hospital for a longer period (19 days). The mean length of stay for the cohort was 3.6 days; excluding the single patient with a prolonged 19-day admission due to bile leak, the mean was 3.1 days. Both values exceed the usual same-day discharge associated with routine laparoscopic cholecystectomy. Histology confirmed predominantly chronic inflammation, consistent with “frozen” Calot’s anatomy [1,6].
Comparison with the literature
Systematic reviews report bile leak rates between 10% and 20% and conversion rates of around 7% [5-8]. Fenestrating techniques carry a higher leak risk (odds ratio ≈ 2.5) than reconstituting techniques [6,9]. Our low bile leak rate may reflect careful intra-operative decision-making, secure stump closure, and tailored gallbladder stump management techniques to individual cases.
Multicentre studies and meta-analyses [9-11] confirm similar trends (Table 6).
Strengths and limitations
Strengths include real-world single-centre data reflecting NHS practice, a clearly defined classification of stump management techniques, and near-complete follow-up. Limitations include retrospective design, lack of standardised long-term imaging, and limited generalisability beyond a single institution.
Clinical implications
Frequent readmissions, high BMI and imaging findings such as an impacted infundibular stone, a thick-walled or contracted gallbladder, should alert surgeons to the likelihood of requiring STC. Awareness of these predictors can improve pre-operative counselling, intra-operative planning, and post-operative bed management. Structured follow-up, including liver-function monitoring, drain assessment, and early ultrasound or MRCP, when indicated, facilitates timely detection of bile leaks [9,11] [10,12].
Future directions
Future studies should focus on prospective multicentre registries to standardise definitions, techniques, and long-term outcome reporting [6,12].
Conclusions
Subtotal cholecystectomy remains a safe and reliable bailout procedure for difficult gallbladders, associated with low rates of bile leak and conversion to open surgery. Our study reported zero rate of readmission, reoperation, bile duct injury or mortality. Careful technique selection, secure stump closure whenever possible, and structured post-operative monitoring are key to optimising outcomes.
Disclosures
Footnote Group
References
Untitled section
References
- 1.Subtotal cholecystectomy-"fenestrating" vs "reconstituting" subtypes and the prevention of bile duct injury: definition of the optimal procedure in difficult operative conditions. Strasberg SM, Pucci MJ, Brunt LM, Deziel DJ. http://doi: 10.1016/j.jamcollsurg.2015.09.019. J Am Coll Surg. 2016;222:89–96. doi: 10.1016/j.jamcollsurg.2015.09.019.
- 2.Laparoscopic subtotal cholecystectomy without cystic duct ligation. Sinha I, Smith ML, Safranek P, Dehn T, Booth M. Br J Surg. 2007;94:1527–1529. doi: 10.1002/bjs.5889.
- 3.Challenging situations in cholecystectomy and strategies to overcome them. Függer R. https://doi.org/10.1007/s10353-020-00687-4 Eur Surg. 2021;53:106–113.
- 4.Strengthening the reporting of observational studies in epidemiology (STROBE): explanation and elaboration. Vandenbroucke JP, von Elm E, Altman DG, et al. PLoS Med. 2007;4:297. doi: 10.1371/journal.pmed.0040297.
- 5.A systematic review on laparoscopic subtotal cholecystectomy for difficult gallbladders: a lifesaving bailout or an incomplete operation? Al-Azzawi M, Abouelazayem M, Parmar C, et al. https://doi.org/10.1308/rcsann.2023.0008. Ann R Coll Surg Engl. 2024;106:205–212. doi: 10.1308/rcsann.2023.0008.
- 6.State of the art in subtotal cholecystectomy: an overview. Ramírez-Giraldo C, Torres-Cuellar A, Van-Londoño I. http://doi: 10.3389/fsurg.2023.1142579. Front Surg. 2023;10:1142579. doi: 10.3389/fsurg.2023.1142579.
- 7.Fenestrating versus reconstituting subtotal cholecystectomy: systematic review and meta-analysis on bile leak, bile duct injury, and outcomes. Ravendran K, Elmoraly A, Thomas CS, Job ML, Vahab AA, Khanom S, Kam C. http://doi: 10.7759/cureus.72769. Cureus. 2024;16:0. doi: 10.7759/cureus.72769.
- 8.Subtotal vs total cholecystectomy for difficult gallbladders: a systematic review and meta-analysis. Koo SS, Krishnan RJ, Ishikawa K, Matsunaga M, Ahn HJ, Murayama KM, Kitamura RK. http://10.1016/j.amjsurg.2023.12.022. Am J Surg. 2024;229:145–150. doi: 10.1016/j.amjsurg.2023.12.022.
- 9.A comparison of outcomes including bile duct injury of subtotal cholecystectomy versus open total cholecystectomy as bailout procedures for severe cholecystitis: A multicenter real-world study. Dhanasekara CS, Shrestha K, Grossman H, et al. http://doi: 10.1016/j.surg.2024.03.057. Epub 2024 May 22.PMID: 38777659. Surgery. 2024;176:605–613. doi: 10.1016/j.surg.2024.03.057.
- 10.Fenestrating vs reconstituting laparoscopic subtotal cholecystectomy: a systematic review and meta-analysis. Motter SB, de Figueiredo SM, Marcolin P, Trindade BO, Brandao GR, Moffett JM. http://doi: 10.1007/s00464-024-11225-8. Epub 2024 Sep 12. Surg Endosc. 2024;38:7475–7485. doi: 10.1007/s00464-024-11225-8.
- 11.Meta-analysis of fenestrating versus reconstituting subtotal cholecystectomy in the management of difficult gallbladder. Hajibandeh S, Hajibandeh S, Parente A, Laing RW, Bartlett D, Athwal TS, Sutcliffe RP. https://doi.org/10.1016/j.hpb.2023.09.005. HPB (Oxford) 2024;26:8–20. doi: 10.1016/j.hpb.2023.09.005.
- 12.Short- and long-term outcomes after a reconstituting and fenestrating subtotal cholecystectomy. van Dijk AH, Donkervoort SC, Lameris W, et al. J Am Coll Surg. 2017;225:371–379. doi: 10.1016/j.jamcollsurg.2017.05.016.