Fundus-first laparoscopic cholecystectomy - A safe means of reducing the conversion rate

Background: Fundus-first dissection (FFD) is an established technique to deal with difficult open cholecystectomies. Although the indications for such an approach are similar for laparoscopic cholecystectomy (LC), FFD is not widely practiced because of difficulties that arise with liver retraction, the dissection of dense adhesions, or obscured cystic peptides, often necessitating conversion to an open procedure. Methods: The aim of this study was to evaluate the indications for FFD and the technical aspects of the procedure in cases with a difficult cystic pedicle. Prospectively collected data and video recordings of cases of fundus-first laparoscopic cholecystectomy (FFLC) were analyzed. The great majority were difficult cases, so we also reviewed the safety aspects of this approach and assessed its effect on the conversion rate. Results: FFLC was resorted to in 35 cases (5%) of 710 consecutive LCs with difficulty grade II (two cases), III (13 cases), or IV (20 cases). There were 16 male patients (46% vs 9% males in the whole), and the mean age was 56 years (ranges, 28-87). The reasons for FFD were dense adhesions preventing the exposure of the cystic pedicle in 14 cases, large Hartmann's pouch stones in 10 cases, short dilated cystic ducts in six cases, and Mirizzi syndrome in three cases. Two cases had contracted "burn-out" gallbladders. Intraoperative cholangiography (IOC) was possible in 24 patients, failed in 10 (29%), and was not attemped in one. Seven patients had bile duct stones and required bile duct exploration. FFLC was completed in 31 patients, 28 of whom were seriously considered for conversion prior to commencing FFD. Conversion was still necessary after trial FFD in four cases (11%) two with Mirizzi abnormalities, one with bile duct stones, and one with dense adhesions. The mean operative time was 125 min, (range, 50-230). There were no operative or technique-related complications. Conclusion: FFLC is feasible and is a safe option for cases with a difficult cystic pedicle. Its use reduced the conversion rate of the series from a potential 5.2% to 1.2%, However, subtotal cholecystectomy or conversion must not be delayed if, after the neck of the gallbladder is reached the anatomy is still unclear.