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Literature Selections

Subtotal Cholecystectomy Technique Drives Distinct Complications

Selection prepared by Christopher DuCoin, MD, FACS

October 21, 2025

acs-store-journalperiodical.jpg

Johnson P, Mullens CL, Picart JK, et al. Fenestrating or Reconstituting? The Impact of Subtotal Cholecystectomy Technique on Postoperative Outcomes and Subsequent Procedures. J Am Coll Surg. October 6, 2025.

Subtotal cholecystectomy is a bailout technique that can be utilized for difficult cholecystectomies. There are several different techniques for subtotal cholecystectomies, including fenestrating and reconstituting. This prospective study across 11 hospitals captured data from 369 subtotal cholecystectomies over 5 years, classifying operations as fenestrating or reconstituting and tracking downstream interventional radiology and ERCP use. 

Technique choice varied by site, with fenestrating technique ranging from 45 to 95%. Risk-adjusted results showed the trade-off: fenestrating had more bile leaks (22.0% vs 6.9%; aOR 4.34), while reconstituting had more retained common bile duct stones (14.3% vs 4.2%; aOR 4.72). 

Fenestrating technique prompted more postoperative procedures from IR and ERCP (36.3% vs 19.4%, p=0.01), with ERCPs clustered early at 71% completed by postoperative day 2. 40% of ERCPs yielded no leak or retained stones, suggesting routine rather than selective use at many centers.

Resource utilization patterns should inform technique selection and pathways. For difficult gallbladders, this means accepting a potentially higher early leak with fenestration versus need for surveillance for choledocholithiasis after reconstitution. Local endoscopy access and surgeon comfort should drive the choice.

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