LC is a standard and well-established procedure; however, its application in difficult cases, such as severe AC, is controversial [4]. TG18 shows and specifies clear indications for employing LC depending on the severity of cases [1, 5]. For safety, bailout procedures are recommended by TG18 for performing LC; subtotal cholecystectomy is also an important treatment option, which avoids VBI. However, detailed guidelines for LSC have not been reported, and well-advanced skills of the surgeon are required.
Previous reports have shown various LSC procedures for GB stumps, including the use of large clips, endoloops, linear staplers, laparoscopic suturing of remnant GB, and simple drainage without closing the stump [2]. The thickened and fragile GB walls due to severe inflammation and/or fibrosis often make it difficult to deal with the stump of the remnant GB. In such cases, surgeons must choose either laparoscopic suturing, open conversion, or simple drainage [4]. Previous systematic reviews and meta-analyses have shown that LSC has a higher risk of bile leakage than open conversion, but perioperative complications including bile duct injury and mortality rate are low compared to the open conversion approach [2, 3]. Laparoscopic suturing may decrease the risk of bile leakage. Laparoscopic suturing is a feasible option for GB stumps even when the GB wall is thickened and fragile because of inflammation and when other devices cannot be utilized. However, it requires advanced skills of highly experienced surgeons. To the best of our knowledge, our technique of performing LSC using barbed sutures has not been reported before in PubMed’s databases. Furthermore, this technique is simple and enables an easy endoscopic suture of the cystic duct with minimum remnant GB. Only one previous Japanese case report presented LSC using barbed suture for chronic cholecystitis [6]. They could dissect GB from liver bed and encircle the cystic duct using GB body as a handle. However, our cases were difficult and severer AC cases; we could not even dissect GB from liver bed. In comparison to their procedure, our procedure can be applicable to the difficult AC cases and versatile procedure.
This technique is based on laparoscopic suturing, anastomosis, and reconstructions using barbed sutures in various fields of surgery. Some studies have reported the utilization of barbed sutures in repairing bile duct injuries and laparoscopic common bile duct exploration [7, 8]. Previous report suggested the barbed suture technique is well established and offers significant benefits in laparoscopic suturing, such as shortening of the operative and suturing durations [9, 10]. Systematic reviews and meta-analyses have previously shown this technique to be safe and beneficial, without increasing the incidence of complications related to suturing [11]. However, we have to consider some trouble due to barbed sutures; it may be extremely difficult to repair it if local damage or erroneous operation around biliary tract or vessels occurs. To prevent these troubles, suture line should be above the line between the base of Segment 4 and the roof of Rouviere’s sulcus [1]. Furthermore, we should be careful not to be bite size too much during suture. These principles minimize the incidence of troubles. These data may support the effectiveness and safety of the technique used in this study for difficult AC cases.
Our study has some limitations. First, this report does not discuss long-term outcomes of the LSC. LSC has been associated with the risk of GB cancer and GBS recurrence; however, the probability of these risks is low [2, 3]. In this study, we resected almost the entire GB, and the cystic duct with minimum remnant of the GB neck was sutured in order not to leave space for the stump, which differed from conventional reconstituting LSC procedures. The features of remnant GB in our study were similar to those in fenestrating LSC [12]. This may contribute to the decreased risk of GB cancer and GBS recurrence. Second, even though this technique enables easy suturing, we did not evaluate the suturing time compared with that of conventional suturing techniques. The procedures for the two cases in this study were performed by a sixth-year postgraduate fellow, and there were no technical interruptions during the procedures. Moreover, reports have already demonstrated the effectiveness of the barbed suture technique in shortening the suturing time in various fields of surgery [9, 10, 13, 14].