Is subtotal cholecystectomy a safe strategy for difficult cases? Long-term outcomes in a high-volume center.

Background: Subtotal cholecystectomy (SC) is a bailout strategy for difficult gallbladders in which standard dissection may pose high risk of bile duct injury (BDI). However, concerns remain about postoperative complications.

Methods: This retrospective, observational study included 347 patients who underwent SC between February 2015 and September 2023 at a high-volume hepatobiliary center. A total of 7778 cholecystectomies were performed during the study period. SC was indicated intraoperatively based on severe inflammation or unclear anatomy of the hepatocystic triangle. The Pribram technique, defined by removal of the anterior wall, mucosal ablation, and preservation of the posterior wall, was used in 82.4% of cases. Intraoperative cholangiography was systematically performed. Outcomes included complications (Clavien-Dindo), bile leak, ERCP, reoperation, and follow-up.

Results: Median operative time was 117 min (range 88-150), and median hospital stay was 2 days (range 1-4). Most procedures were completed laparoscopically (96.5%). The incidence of major complications (Clavien-Dindo ≥ III) was 3.4%, bile leak occurred in 1.4%, and no BDI or mortality were observed. Postoperative ERCP was required in 5.2%, and reoperation in 1.4% of cases. At a median follow-up of 23.2 months (range 11.4-37.6), no cases of stump lithiasis or cancer recurrence were recorded.

Conclusions: Subtotal cholecystectomy, when combined with systematic intraoperative cholangiography, is a safe and effective strategy for managing difficult gallbladders. In our series, it was not associated with bile duct injury or mortality. These results suggest that even non-hepatobiliary surgeons can safely resolve complex cases by adopting subtotal techniques as a standardized bailout approach.