Subtotal Cholecystectomy: Outcomes of a Fenestrated Versus Reconstituted Approach and the Association With Cystic Duct Findings on Cholangiogram.

BACKGROUND: Subtotal cholecystectomy (STC) is a recognised bailout strategy when the critical view of safety cannot be safely achieved. Whether cystic duct findings on intraoperative cholangiogram (IOC) should guide the choice between performing a fenestrated or a reconstituted STC remains unclear. This study evaluates the relationship between IOC results, STC technique and postoperative outcomes over a 17-year period. METHODS: A retrospective cohort study was conducted across the Gold Coast Hospital and Health Service (2006-2023). Variables examined included demographics, cystic duct patency on attempted IOC, STC technique, length of stay, readmission, cost and complications including bile leak, remnant cholecystitis, ERCP, return to theatre and medical complications. RESULTS: Out of 10 964 cholecystectomies, 181 (1.65%) were STC. Reconstituted STC was performed in 157 of these cases (87%) and fenestrated in 24 (13%). 25% of patients had a patent cystic duct on IOC, while the remaining 75% of patients had a non-patent or indeterminate cystic duct. The association between a patent cystic duct and the risk of surgical complications when compared to a non-patent or indeterminate cystic duct did not reach statistical significance (OR 0.69, p = 0.35). Similarly, there was no statistically significant association between STC technique and surgical complications (OR 0.48, p = 0.10). CONCLUSION: Neither cystic duct findings on IOC nor STC technique were associated with a difference in outcomes. Surgeons in our institution were more likely to utilise a reconstituted STC technique in preference to fenestrated. Both approaches represent safe bailout options in these challenging cases.