General Surgery
What is a total cholecystectomy?
‘Cholecystectomy’ is a medical term. It refers to the surgical removal of the diseased gallbladder. To emphasise the completeness of this surgical procedure, surgeons often use the term ‘total cholecystectomy’.
What is a ‘difficult gallbladder’?
Although ‘key-hole’ (medically called laparoscopic) total cholecystectomy is the gold standard for symptomatic and complicated gallbladder stone disease, it is not safe to perform when acute or chronic inflammation of the gallbladder distorts the anatomy of the gallbladder, bile ducts, liver vessels and surrounding intestine.
Surgeons often use the term ‘difficult gallbladder’ to describe difficult anatomical conditions in a simple but informative way. It does not mean that every difficult gallbladder cannot be removed. However, the principles of medical and surgical safety require reducing the risk of accidental injury to the main bile duct, bowel, and vessels to nil, even in difficult cases.
That is why the concept of subtotal cholecystectomy is paramount in extraordinary surgical situations. The phrase ‘less is more’ perfectly captures its meaning.
What is ‘subtotal cholecystectomy’?
It is a less-than-complete cholecystectomy, either laparoscopic (‘keyhole’) or open, and the removal of biliary stones from the gallbladder’s cavity. Partial cholecystectomy is the alternative term for this surgical procedure.
It is the removal of part of the gallbladder (usually, 70-90%, but variations are possible) when the important anatomical structures around the gallbladder—the gallbladder’s duct and artery—cannot be identified and exposed with certainty. In other words, subtotal (partial) cholecystectomy means that a piece of the gallbladder, firmly attached to vital anatomical structures (liver, main bile duct, vessels, intestine), is left inside the tummy.
This operation is performed in patients with symptomatic or complicated (e.g., infected) gallbladder stone disease who are at high risk of injury to the main bile ducts, liver vessels, or intestine due to severe acute or chronic inflammation, or to non-typical anatomical features of the gallbladder or bile ducts.
At Aintree University Hospital, a centre for acute surgical diseases, including cholecystitis, this surgical procedure is common. Approximately 8-10% of patients listed for gallbladder surgery undergo a subtotal cholecystectomy.
How is a subtotal cholecystectomy performed?
A surgeon performs a subtotal cholecystectomy through four ‘key-holes’ (laparoscopic surgery) or via one large incision (open surgery). The decision to choose one approach or another depends on many factors.
However, surgeons believe that in difficult cases, laparoscopic subtotal cholecystectomy and stone removal from the gallbladder are preferable to an open traditional gallbladder operation.
There are a few technical variants and types of subtotal cholecystectomy. The decision to opt for a particular surgical technique and a type of subtotal cholecystectomy depends mainly on the anatomy of the gallbladder and the severity of the pathology. If you would like to discuss your surgery in detail, please ask your Consultant Surgeon to answer your questions about the operation.
What are the early side effects of subtotal cholecystectomy?
There are five early surgical side effects.
First, drainage of the spaces around the liver is the most common side effect of subtotal cholecystectomy. The aim of drainage is to control bile leakage from the remnant of the gallbladder if it occurs.
Second. Bile leakage through the drain is a very common side effect of this operation, occurring in approximately 20–30% of patients. It is an expected side effect of subtotal cholecystectomy for the same reason – a piece of the gallbladder is left inside the abdominal cavity, and for some patients, it is not possible to close (or reliably close) that piece of inflamed gallbladder tissue.
In most cases, a bile leak stops and bile resolves spontaneously within a week or two. For other patients, especially those with a significant bile leak, further surgical intervention, such as ERCP with insertion of a plastic or metallic stent into the main bile duct, laparoscopy, radiological drainage, or, in infrequent cases, open surgery, may be required.
Third. Collection of physiologic fluids (bile, blood, or serous fluid) in the not-drained areas of the tummy is another common side effect of subtotal cholecystectomy. Treatment options, including a watch-and-wait plan, depend on the size of the fluid collection and clinical symptoms.
Fourth. Infection of the fluid (abscess) around the liver or the remnant of the gallbladder is a possibility after subtotal cholecystectomy.
Fifth. It may sound paradoxical, but injuries to the main duct, the intestine and blood vessels are possible even during subtotal cholecystectomy.
What are the late side effects of subtotal cholecystectomy?
There is no straightforward answer to this question, as it depends on the size of the portion of the gallbladder removed, the method used to complete a subtotal cholecystectomy, the presence or absence of residual gallstones within the residual gallbladder or within the bile ducts, and the histology of the gallbladder’s tissues. Therefore, it is always advisable to discuss the possibility of late side effects with your Consultant Surgeon.
Besides, it is important to understand that possible side effects (or their absence) depend on the specific characteristics of your gallstone disease. For example, residual bile duct stones that have not been detected on preoperative imaging or during surgery.
First example: When the cause of inflammation and infection of the gallbladder is a large gallstone, and when it is possible to remove 80-90 per cent of the gallbladder, late side effects of subtotal cholecystectomy are rare or absent.
Second example: When multiple (often hundreds) small or very small gallstones are the cause of inflammation and infection of the gallbladder, late side effects in the form of pain or even obstructive jaundice are possible due to residual gallstones in the remnant of the gallbladder, its duct (the cystic duct), or the main bile duct.
You will receive a follow-up appointment 8-12 weeks after your surgery. If you are well and pain-free, the Consultant Surgeon will discharge you from the general surgery clinic. If you are in pain, a Consultant Surgeon will consider additional investigations, such as a US scan, an endoscopic US scan, a CT scan, an MRI, and an ERCP.
For most patients (80%), there will be no late side effects, as the non-removed part of the gallbladder becomes atrophic.
Is there a risk of new gallstones developing in the left part of the gallbladder?
A patient is at a small risk of developing new gallstones in the gallbladder remnant over the next few decades.
Is there a risk of cancer in the remnant of the gallbladder?
In general, the incidence of cancer of the non-operated gallbladder in the UK is low.
Regarding the incidence of cancer in the operated gallbladder, we do not yet have statistics.
However, we know that gallbladders containing stones and/or infectious agents develop malignant disease due to irritative trauma, chronic inflammation, and carcinogenic derivatives of bile acids. That is why surgeons believe that patients who have undergone subtotal cholecystectomy for gallstone disease remain at the same minimal risk, or even lower, of developing a malignancy in the residual gallbladder tissue.
What is the impact of subtotal cholecystectomy on chronic gastrointestinal disease?
A combination of gallstones and a chronic gastrointestinal disease or syndrome (gastro-oesophageal reflux disease, gastritis, IBS, IBD, etc.) is common.
Symptoms of these syndromes and diseases may worsen temporarily because up to 1 litre of bile secreted by the liver per day reaches the gut directly through the system of bile ducts, irritating the mucosa of the gastrointestinal tract.
For example, symptoms of irritable bowel syndrome (IBS) may worsen after a patient has had a cholecystectomy.
Other considerations
The authors of this patient information leaflet have noticed that, even after a thorough explanation and discussion of subtotal cholecystectomy and its side effects, patients still like to be reassured one more time and ask personalised questions. Below are examples of these frequently asked questions.
Frequently asked questions
Q1. Why was a small piece of the gallbladder left?
A1. That piece of the gallbladder was in firm contact with your main bile duct and liver vessels (or with the bowel). It was safer to leave it in place, as its disconnection from the bile ducts or major vessels may result in severe injury, temporary or permanent disability, or even death from bleeding.
Q2. Why was half of the gallbladder left in place?
A2. It was left in situ because of dense adhesions to the intestine and/or solid attachment to the liver tissue. Please read A1.
Q3. Why was almost all of the gallbladder left inside?
A3. It was left in place because of a solid inflammatory mass around your gallbladder and the extremely high likelihood of fistulae (connections) between the gallbladder, the main bile duct, and the small and large intestines. In such circumstances, excising a small part of the gallbladder (i.e., the dome) and removing gallstones from the gallbladder’s cavity is a reasonable and appropriate procedure, as the symptoms are mainly caused by the gallstones.
Q4. Will a piece of the gallbladder left inside cause me pain?
A4. No, it will not. However, a small residual gallstone or gallstones in the gallbladder’s remnant and/or its bile duct (so-called cystic duct) migrating to the main bile duct can cause biliary pain or even infection or jaundice. If you are in pain, the Consultant Surgeon will discuss all other diagnostic and treatment modalities with you.
Q5. What is the chance of the development of new gallstones in the left portion of the gallbladder?
A5. You are at a small risk of developing new stones in the remnant of the gallbladder over the next few decades.
Q.6. Is the risk of other general surgical complications higher after subtotal cholecystectomy?
A6. Yes, it is. This increased risk of general complications is related to the early side effects of subtotal cholecystectomy. On the other hand, laparoscopic subtotal cholecystectomy is associated with lower morbidity than open subtotal cholecystectomy.
When should you return to the hospital?
We know that most people recover well and do not experience complications. Call your doctor or attend the Accident & Emergency Department if you have:
- Increased or persistent pain not relieved with pain relief medications
- Jaundice (yellowing of the whites of the eyes and the skin)
- Persistent fever
- Temperature above 38.5°C
- Shakes, swelling, chills, rigours
- Uncontrolled vomiting
- Persistent bloating of the stomach
- Redness or swelling around the wound.
- Discharge of bile, pus, or blood from the wound
- Blood in your vomit, urine, or stool
- Blood in couth
- Swollen leg or both legs
Follow-up appointments
It is crucial that you do not miss any of your follow-up appointments.
Who should I contact if I have questions or concerns?
- Secretary of your Consultant Surgeon during working hours, 8am to 5pm, Monday to Friday, via the Contact Hospital Switchboard on 0151 525 5980. Leave a message for the surgical team.
- Nursing staff on the Surgical Assessment Unit via the Contact Hospital Switchboard on 0151 525 5980. To note, the Hospital Switchboard service is available seven days a week.
- If you think your condition is serious, it is best to come straight to Aintree Accident & Emergency Department*.
- Please seek advice from your GP.
*When you come to the hospital, please bring this and any other relevant discharge documents you may have been given at the time of discharge to help the A&E doctors decide on your management.
Are there any other sources of information about subtotal cholecystectomy for patients?
Unfortunately, there is no comprehensive information available on subtotal cholecystectomy for patients in the UK. Only research papers are available online (keyword ‘subtotal cholecystectomy’ to use).
General information about gallbladder removal is available at
https://
This patient information leaflet can be provided together with another information leaflet entitled ‘Laparoscopic cholecystectomy’.
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Authors: General Surgery
Document ref: 1972
Review date: March 2029