Rules and technical tricks in extremely difficult laparoscopic cholecystectomies

We remind you of some technical artifices required in order to resolve difficult cases, such as: antegrade laparoscopic cholecystectomy (LC), subtotal laparoscopic cholecystectomy (SLC) and the “stairs” clipping of the cystic duct. Also we acknowledge the closing of the cystic duct. We analyzed the medical records of 15251 laparoscopic cholecystectomies performed during 1994-2015, with emphasis on: surgical technique, conversion rate, hemorrhage, postoperative bile leaking, iatrogenic MBD injuries and mortality. We divided the cases in 5 study groups, group 1 (1994-2004) N= 5138, group 2 (2005-2015) N= 10113, group 3 (fundus first cholecystectomies, N=2348), group 4 (retrograde cholecystectomies, N=12889) and group 5 (subtotal laparoscopic cholecystectomy-SLC, N=14) which we compared regarding the main parameters. We prefer to perform a “step by step” clipping each time the length of the clip does not cover all the circumference of the cystic duct. This artifices, is a simple laparoscopic gesture easy to perform and has the advantage of avoiding a large excessive and risky laparoscopic dissection in the vicinity of the main biliary duct. More seldom we appeal to the suture of the cystic stump using the intra-corporeal knots or a simple stump ligation with an extracorporeal preformed not. We did not encounter any late or early complications following the implementation of this technical laparoscopic artifice. Laborious laparoscopic cholecystectomies performed by a well-trained surgical team ensure the premises of a good performance even while adopting laparoscopic ingenious and difficile gestures that also respect the intra-operatory rules and principals.