Gallstone disease poses a growing public health challenge in India affecting an estimated 4% to 7.1% of the population. The burden is particularly pronounced in the northern and northeastern regions (stone belt area) where prevalence rates surpass those reported in many Western nations (1). In the United States, approximately 20 million people have gallstones, and between 300,000 and 750,000 cholecystectomies are performed annually [2, 3]. In Europe, approximately 900,000 cholecystectomies are conducted each year [4].Laparoscopic cholecystectomy is most commonly performed operation in general surgery worldwide. Although most cases are easy but a significant chunk is difficult, reported in up to 26% of large series[5], leading to higher chances of Bile Duct Injury. Bile duct injury is almost twice as probable in laparoscopic vis-à-visopen cholecystectomy (0.4–1.5% vs 0.2–0.3%)[6,7]. Mortality following bile duct injury (BDI) remains significant, with reported rates ranging from 1.8% to 4.6%. Long-term data further suggest that BDI patients may experience an elevated mortality of up to 8.8% compared with the expected age-adjusted death rate over a 20‑year period[8]. Associated vascular injury,

level of BDI, sepsis, and postoperative bile leakage have been shown to be associated with worse outcomes[9]. Addressing the difficult gallbladder is of primary importance given that the significant number of complications arising from an ill addressed problem. The Critical View of Safety (CVS) constitutes a fundamental component of the culture of safety in cholecystectomy (COSIC), with the adoption of reliable bailout strategies representing an equally indispensable element. In circumstances where CVS cannot be attained during complex laparoscopic cholecystectomy, the surgeon should employ a bailout technique that ensures safety,by minimizing the risk of bile duct injury (BDI), and efficacy by obviating the need for subsequent reoperation. [10]In principle, bailout procedures are predicated on avoiding dissection within Calot’s triangle and instead favoring subtotal cholecystectomy (STC). A variety of techniques have been described to facilitate safe mobilization of the gallbladder in this context, including the fundus-first approach, the middle-first approach, and posterior infundibular dissection. Of these, the posterior infundibular technique was originally outlined by Song et al. In the present study, we report our experience with a modified posterior infundibular approach. These modifications not only streamline the operative process but also reduce operative time, thereby contributing to both technical ease and procedural efficiency in challenging cases [11].

We conducted a retrospective analysis of prospectively collected data from 45 patients who underwent difficult cholecystectomy in the Department of General Surgery, Government Medical College, Anantnag, between April 2025 and January 2026, and ultimately required subtotal cholecystectomy (STC). Scientific and ethical approval for the study was obtained from the institutional committees. Inclusion criteria comprised patients with preoperative predictors of a difficult gallbladder as well as intraoperative findings consistent with difficult cholecystectomy. Only cases that culminated in STC were analyzed.

Statistical analysis was performed using SPSS version 25.0. Data collected included patient demographics (age, sex, postoperative histopathology), preoperative imaging findings from ultrasonography and magnetic resonance cholangiopancreatography (MRCP), and perioperative variables. Perioperative parameters encompassed timing of surgery (elective or emergency), conversion rates, infundibulum management technique (fenestrating or reconstituting), incidence of bile leak, retained stones, operative duration, intraoperative blood loss, length of hospital stay, and follow-up outcomes.

 Surgical Technique and Intraoperative Strategy

Initial Access and Exposure

Port placement followed the conventional laparoscopic cholecystectomy technique, with supplementary ports integrated as required by the clinical presentation. The procedural complexity was initially assessed via visual inspection. Preliminary dissection utilized a harmonic scalpel or suction-irrigation cannula to expose the gallbladder, typically initiating at the fundus. Omental and pericholecystic adhesions were divided using ultrasonic energy.

When adhesions along the serosal surface were amenable to blunt or energy-based dissection (ultrasonic, electrosurgical, or suction-assisted), progressive exposure of the gallbladder, Calot’s triangle, and the common bile duct (CBD) was pursued to maintain the laparoscopic approach. If safe visualization could not be achieved, the procedure was converted to open surgery or managed via intraoperative cholecystostomy. Gallbladder decompression was performed as needed to facilitate atraumatic retraction.

Dissection and Subtotal Cholecystectomy (STC)

Following initial adhesiolysis, dissection was directed superior to Rouviere’s sulcus, extending posteriorly along the gallbladder body and infundibulum. The gallbladder was mobilized from the cystic fossa via subserosal dissection. In cases where the subserosal plane was obliterated, the gallbladder was incised along the infundibular surface, leaving the posterior wall in situ and treating the remaining mucosa with electrocautery.

Critical emphasis was placed on the spatial relationship between the infundibulum and the bile duct confluence. Impacted stones within the infundibulum were extracted using forceps; the cystic cavity was subsequently explored via endoscopy or choledochoscopy to ensure clearance and confirm anatomical landmarks.

Final Procedural Determination

Depending on the degree of inflammation and anatomical clarity, two subtotal strategies were employed:

Fenestrating STC: Performed when the infundibulum could be further mobilized circumferentially. Cystic duct is closed by a purse-string sutures from within.

Reconstituting STC: Utilized when the hepatocystic triangle remained obscured; in these instances, the gallbladder remnant was closed with sutures.

In all complex cases, a subhepatic drain was placed to manage potential postoperative biliary leak or serosanguinous drainage

We retrospectively analyzed 72 patients who underwent surgery for difficult laparoscopic cholecystectomy (Table-1). The cohort comprised 21 men (29.16%) and 51 women (70.83%), with a mean age of 55.1 years (range: 34–87 years)

Postoperative histopathological examination confirmed acute cholecystitis in 30 patients (41.6%), of whom 18 (25%) had gangrenous cholecystitis. All patients underwent preoperative ultrasonography and magnetic resonance cholangiopancreatography (MRCP). Ultrasonography demonstrated gallbladder wall thickening of 4–10 mm in 62 patients (86.11%) and >10 mm in 10 patients (13.89%).

Elective surgery was performed in 66 patients (91.66%), while 6 patients (8.33%) required emergency intervention. Conversion to open surgery was necessary in one patient (1.38%). The described surgical technique was successfully completed in 65 patients (90.27%). Fenestrating subtotal cholecystectomy (STC) was performed in 2 patients (2.7%), and reconstituting STC in 5 patients (6.94%).

Postoperative bile leakage occurred in two patients (2.7%), one following fenestrating STC and one after reconstituting STC. Both cases were managed successfully with endoscopic retrograde cholangiopancreatography (ERCP), with complete resolution within 1–2 weeks. No retained common bile duct stones were detected postoperatively.

The mean operative duration was 85.5 ± 21.5 minutes, with a mean estimated blood loss of 134.2 ± 48.2Ml(Figure-1). The average length of hospital stay was 8.6 ± 3.2 days. There were no intraoperative vascular or bile duct injuries, no reoperations, no readmissions, and no mortality. Consensus guidelines from the 2018 Boston Conference and the Tokyo Guidelines recommended standardized safety procedures, emphasizing the exposure of Rouviere’s sulcus and efforts to create CVS. If the CVS cannot be achieved due to scar formation or severe fibrosis during the operation, or if the Calot’s triangle is shrinking and the boundary is unclear, a bail-out approach should be considered, including conversion, STC, or the fundus-first technique. The common point of both STC and the fundus-first technique is the retention of the infundibulum.

The advantages of the technique include no dissection of Calot’s triangle, reduced bleeding, shorter operation time, and avoidance of BDI. However, the disadvantages of both the fenestrating and reconstituting techniques include postoperative bile leaks

Table.1 CLINICAL PARAMEETERS STUDIED

With the global adoption of laparoscopy, even highly complex cases are now routinely undertaken and successfully completed, many of which would previously have required conversion to open surgery. However, emerging reports suggest a gradual decline in surgeons’ proficiency with open procedures, prompting renewed calls to formally re-emphasize open surgical skills within training curricula [12].

Consensus guidelines from the 2018 Boston Conference and the Tokyo Guidelines [13] advocate standardized safety protocols during laparoscopic cholecystectomy, particularly emphasizing identification of Rouviere’s sulcus and the creation of the critical view of safety (CVS). When CVS cannot be achieved because of dense adhesions, severe fibrosis, or a contracted Calot’s triangle with obscured anatomical boundaries, a bail-out strategy should be adopted. These include conversion to open surgery, subtotal cholecystectomy (STC), or the fundus-first approach. A common feature of both STC and the fundus-first technique is preservation of the infundibulum. Their advantages include avoidance of dissection in Calot’s triangle, reduced intraoperative bleeding, shorter operative duration, and a lower risk of bile duct injury (BDI). However, both fenestrating and reconstituting STC techniques are associated with a higher incidence of postoperative bile leakage. Bile leaks and common bile duct injuries impose a substantial economic burden and are associated with significant morbidity and mortality.

The infundibular technique involves dissection away from the hepatocystic triangle, thereby avoiding the most critical anatomical zone. Dissection proceeds in a subserosal plane close to the gallbladder, allowing circumferential mobilization of the infundibulum toward the cystic duct in most cases through slow and meticulous technique, often facilitating achievement of CVS. When this is not feasible, STC serves as an appropriate alternative.

Preoperative planning and thorough investigations are fundamental to achieving optimal surgical outcomes. Detailed imaging is particularly important in difficult gallbladder cases, including Mirizzi syndrome, anomalous cystic duct or hepatic duct anatomy, and rare malignancies. Ultrasonography remains the first-line imaging modality, providing information on gallstones, gallbladder distension, and wall thickness. However, magnetic resonance cholangiopancreatography (MRCP) is considered the most informative modality for evaluating the severity of inflammatory changes and the extrahepatic biliary anatomy [14].

Magnetic resonance imaging (MRI) allows accurate assessment of gallbladder enlargement, common bile duct calculi, and gallbladder wall characteristics, including stratification, early edema, necrosis, or late fibrotic changes. Modern rapid acquisition protocols provide excellent soft-tissue contrast. Importantly, MRCP delineates the spatial relationship between the gallbladder, common hepatic duct, and common bile duct, and reliably identifies cystic duct and biliary anatomical variations. This comprehensive preoperative mapping enables a systematic understanding of biliary anatomy, thereby reducing the risk of BDI. MRCP plays a critical role in diagnosis, operative planning, and prognostication in acute cholecystitis and should be performed whenever feasible, even prior to emergency surgery [15].

Endoscopic retrograde cholangiopancreatography (ERCP) is reserved for patients in whom MRI is contraindicated or when therapeutic intervention for common bile duct stones is required. Contrast-enhanced computed tomography may further aid in excluding malignancy and in evaluating vascular anatomy within the hilar region.

Limitation

This study has several limitations that merit consideration. First, its retrospective nature and single-center design may limit the generalizability of the findings and introduce inherent selection bias. Second, the absence of a control group undergoing alternative bailout strategies such as fundus-first dissection or primary conversion to open cholecystectomy precludes direct comparative assessment of outcomes. Third, the sample size, although reflective of real-world difficult gallbladder cases, remains relatively small and may limit the statistical power to detect less frequent complications. Additionally, operative outcomes may be influenced by surgeon experience and institutional expertise, which may not be uniformly reproducible across all practice settings. Finally, long-term follow-up data regarding remnant gallbladder–related complications, recurrent biliary symptoms, or late bile duct strictures were not systematically evaluated. Larger, prospective, multicenter studies with standardized definitions of difficulty and longer follow-up are required to validate these findings and further define the role of the lateral dorsal infundibular approach in difficult laparoscopic cholecystectomy

Difficult laparoscopic cholecystectomy continues to pose a significant challenge, with bile duct injury representing the most feared complication. When the critical view of safety cannot be achieved, adherence to a structured bailout strategy is essential to ensure patient safety. The lateral dorsal infundibular approach described in this study offers a practical and anatomically sound method for managing complex gallbladders without entering Calot’s triangle.

This technique allows controlled subserosal dissection above Rouviere’s sulcus, facilitates safe mobilization of the gallbladder infundibulum, and provides a clear pathway to subtotal cholecystectomy when definitive identification of cystic structures is not possible. Our results demonstrate low conversion rates, acceptable operative times, minimal postoperative bile leakage, and most importantly an absence of bile duct or vascular injuries.

Incorporation of this approach into the armamentarium of hepatobiliary surgeons aligns with contemporary safety guidelines and reinforces the culture of safety in cholecystectomy. With appropriate patient selection, meticulous technique, and thorough preoperative imaging, the lateral dorsal infundibular approach represents an effective and reproducible bailout option for difficult laparoscopic cholecystectomy.

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