P-BN53 The ‘Difficult Gallbladder’: do no harm!

Background Laparoscopic cholecystectomy (LC) for a ‘difficult gallbladder’ can incur increased risk of biliary complications. In these challenging conditions where anatomical delineation (commonly through the critical view of safety) is unachievable, it is important to recognise when to proceed and when to consider a bail-out strategy. Subtotal cholecystectomy (SC), cholecystostomy insertion, conversion to open or abandoning the procedure are accepted solutions. In this study we review the outcomes of patients who underwent LC following previous intervention. Methods We retrospectively reviewed patients who underwent LC under a single surgeon between January 2009 to July 2020 following a previous intervention with LC, SC or cholecystostomy tube insertion. Data was collected with regards to demographics, clinical presentation, intraoperative details, imaging, conversion to open, length of hospital stay and complications. Results 40 patients with previous intervention underwent LC. Previous intervention included abandoned LC in 24(60%), on-table cholecystostomy in 8 (20%) and SC in 8 (20%), with 5(13%) converted to open. Reasons for referral included adhesions, intrahepatic gallbladder, possible malignancy, empyema and abnormal anatomy.  Laparoscopic approach attempted in 39/40 (98%), conversion to open in 25%. Reasons for conversion included cholecystoduodenal fistula, and suspected malignancy. Median hospital stay was 4 days (1 – 22). Morbidity was seen in 2(4%) with no biliary complications. Completion of treatment, from previous intervention to definitive LC was 9 months (1-48). Conclusions In patients with previously attempted cholecystectomy, LC is feasible and can be performed with low morbidity. When faced with a difficult gallbladder intra-operatively, aborting the procedure and re-attempting at a later date, locally or referral to a specialist Unit, should be considered.