Difficult acute cholecystitis frequently precludes attaining the critical view of safety during minimally invasive cholecystectomy. Established bail-out options—subtotal cholecystectomy (fenestrating/reconstituting), cholecystostomy drainage with delayed cholecystectomy, or conversion to open—remain widely accepted with distinct limitations. We present an operative framework and a technical description of subserosal cholecystectomy (SSC), supported by an operative video. The technique dissects the edematous, avascular subserosal plane between the outer fibrofatty serosal layer and the inner perimuscular fibrous serosal-lamina-propria-mucosal layer. Preserving the outer serosal rind theoretically allows for full dissection and control of the cystic structures in an otherwise inflamed and a scarred, adherent surgical field. Intact cystic duct and artery are clipped in this plane; if cystic duct disrupts during the subserosal dissection, it is managed like in subtotal cholecystectomy —ligation by needle suturing or left open/fenestration with surgical drain. Patient selection is critical: SSC is suitable in early phase of stage II acute cholecystitis (per our pathophysiological staging below, with corresponding intraoperative findings like hyperemia or distended gallbladder). In advanced stage II or stage III, where brawny fibrosis obliterates the plane, subserosal dissection is unfeasible, and subtotal cholecystectomy is the best approach. We propose SSC as a conceptual complement to the bail-out armamentarium based on limited experience and pending comparative outcome data relative to established bail-out techniques. Further prospective or multi-case studies are warranted to define its safety, outcomes, complications, and role as an effective bail-out technique.
Ravichandran et al. (Fri,) studied this question.