Reconstituting, Fenestrating, and Cholecystostomy—our approach and surgical technique for difficult gallbladders using three bailout procedures

Authors: Yosuke Miyachi

Abstract

Laparoscopic cholecystectomy (LC) is one of the most frequently performed operations worldwide. Despite advances such as the critical view of safety (CVS), the Tokyo Guidelines, and intraoperative indocyanine green cholangiography, bile duct injury (BDI) remains a major concern. The 2018 Tokyo Guidelines formally endorsed “bailout procedures” to avoid BDI when CVS cannot be achieved, including subtotal cholecystectomy. However, the concept remains ambiguous, as it encompasses both strategies applied before deciding to abandon cystic duct dissection (e.g., fundus-first approach, conversion to open surgery) and techniques performed after that decision has been made (Reconstituting, Fenestrating). We define bailout procedures as interventions performed after abandoning cystic duct dissection, consisting of three Reconstituting, Fenestrating, and Cholecystostomy, corresponding respectively to decreasing levels of gallbladder dissection feasibility. In a retrospective review conducted at our institution, between April 2021 and March 2025, 57 of 593 LCs (9.6%) required a bailout 35 Reconstituting, 19 Fenestrating, and 3 Cholecystostomy. Median operative time was 168 minutes, and postoperative bile leak occurred in only one Reconstituting case. No BDI or mortality within 90 days was observed. While Fenestrating is often associated with higher bile leak rates in the literature, this likely reflects the underlying disease severity rather than the technique itself. Our experience suggests that Cholecystostomy can also be an effective option when dissection is unsafe. In conclusion, proficiency in Reconstituting, Fenestrating, and Cholecystostomy techniques is essential for preventing BDI in difficult gallbladders and for expanding the surgeon’s choice of safe bailout strategies.

Introduction

Background

Laparoscopic cholecystectomy (LC) is now one of the most commonly performed surgical procedures worldwide (1). According to pre-pandemic data from 2019, approximately 90,000 cases were performed annually in Japan (2), 700,000–1,200,000 in the United States (3,4), 110,000–180,000 in Germany (5) and 50,000 in the United Kingdom (6).

The major concern in LC remains intraoperative bile duct injury (BDI) (7). Since the introduction of the Critical View of Safety (CVS) by Strasberg* et al. (8), the publication of the Tokyo Guidelines (9), and the adoption of intraoperative indocyanine green cholangiography (10), the incidence of BDI has steadily declined. Pucher et al. *reported that the incidence of BDI during LC decreased significantly from 0.69% in 1994–1999 to 0.22% in 2010–2015 (7). Nevertheless, BDIs have not been completely eliminated so far.

A noteworthy feature of the Tokyo Guidelines 2018 was the formal recommendation of “bailout procedures”, including subtotal cholecystectomy, as an accepted strategy to avoid BDI in difficult gallbladders where CVS cannot be safely achieved (9). Since then, several studies have supported the effectiveness of bailout procedures in preventing BDI, and further reduction in BDI rates during LC is expected (11-14). However, because TG18 defines bailout procedures broadly as any deviation from standard LC performed to avoid BDI (9), the term has occasionally led to confusion in clinical practice.

Rationale

The extent of dissection during LC varies depending on adhesions around gallbladder, the degree of inflammation or fibrosis of the gallbladder wall, the anatomical relationship between the gallbladder and common bile duct, and the presence of anatomical variations. However, from the standpoint of “how far the gallbladder can be dissected circumferentially”, the surgery can be categorized into the following four

• The cystic duct is fully exposed after confirming CVS.
• The cystic duct cannot be isolated, but the neck or body of the gallbladder can be dissected circumferentially.
• Circumferential dissection is not possible at either the neck or body of the gallbladder.
• Severe adhesions prevent any meaningful exposure of the gallbladder wall.

In pattern I, standard total cholecystectomy with cystic duct division is feasible. In contrast, patterns II–IV require abandoning total cholecystectomy with cystic duct division to avoid BDI.

In this paper, we define “bailout procedures” as any surgical intervention performed after the decision to abandon cystic duct division. Then, Reconstituting (or Fenestrating) is applicable for pattern II, Fenestrating for pattern III, and Cholecystostomy for pattern IV.

Each bailout procedure was defined based on the classification proposed by Strasberg (15). Reconstituting refers to closure of the gallbladder wall at the level of the body or neck, leaving a small remnant gallbladder. Fenestrating involves resection of the gallbladder wall as completely as possible except for the portion attached to the liver bed, followed by closure of the cystic duct from inside of gallbladder; therefore, no gallbladder remnant with a lumen remains. Cholecystostomy is defined as a procedure in which most of the gallbladder is left* in situ *and a drainage tube is placed into the gallbladder lumen, typically via a percutaneous approach.

In some cases of pattern I, a small portion of the gallbladder wall may intentionally be left attached to the liver bed due to dense adhesions. According to our definition, such cases are not classified as bailout procedures.

Objective

In this article, we aim to clarify the definition of bailout procedures in LC and to describe the specific techniques of Reconstituting (reconstituting subtotal cholecystectomy), Fenestrating (fenestrating subtotal cholecystectomy), and Cholecystostomy as practiced in our institution. Our hospital (St. Luke’s International Hospital, Tokyo, Japan) is a large tertiary care, academic medical center providing advanced emergency and surgical services. The operation was performed in a dedicated operating theatre under standard sterile conditions. The operating room meets high-level cleanliness standards corresponding to Class I cleanliness. This article is presented in accordance with the SUPER reporting checklist (available at https://jovs.amegroups.com/article/view/10.21037/jovs-2025-1-52/rc).

Preoperative preparations and requirements

All procedures described in this study were conducted in accordance with the ethical standards of the institutional and/or national research committees and complied with the principles of the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patients for the publication of this study and the accompanying videos. A copy of the written informed consent is available for review by the editorial office of this journal.

The surgical team consisted of one primary surgeon and two assistants, one of whom was responsible for camera handling, together with one anesthesiologist, one scrub nurse, and one circulating nurse. An attending surgeon with extensive experience in gastrointestinal surgery and LC was always involved in the operation to supervise and ensure procedural safety. The remaining surgical team members were typically residents within 4–5 years after graduation. Even in cases requiring bailout procedures, the operation was often performed by a resident as the primary surgeon under the direct supervision of the experienced attending surgeon.

The operation was performed under general anesthesia with endotracheal intubation.

Anesthesia was induced intravenously, followed by administration of a neuromuscular blocking agent to facilitate tracheal intubation, and maintained with inhalational anesthetics throughout the procedure.

In our standard LC, we employ a standard four-port technique as shown in Figure 1A. When a bailout procedure is anticipated or deemed necessary, the epigastric port is replaced with a 12-mm port to allow the surgeon’s right hand to introduce a suture needle or linear stapler (Figure 1B). Additionally, a 5-mm port is inserted to the right of the umbilicus and used by the assistant’s right hand for exposure and suction.

All three bailout procedures—Reconstituting, Fenestrating, and Cholecystostomy—can be performed laparoscopically. However, if the procedure becomes technically demanding or unsafe, conversion to open surgery should not be hesitated.

Step-by-step description

Case Reconstituting (Video 1)

A male patient in his 30s underwent emergency surgery for grade II acute cholecystitis.

In this case, the gallbladder wall was circumferentially dissected at the body, allowing adequate exposure. Dissection was then continued from the fundus toward the neck; however, the cystic duct could not be safely identified. Therefore, subtotal cholecystectomy was selected (pattern II).

After leaving an adequate portion of the gallbladder wall for closure, the gallbladder was opened and the impacted stone at the neck was removed with forceps. The remnant stump was then closed using a linear stapler. A drain was placed in the foramen of Winslow or beneath the liver.

The operative time was 155 minutes and estimated blood loss was 50 mL. The drain was removed on postoperative day (POD) 2 after confirming the absence of bile leakage, and the patient was discharged without complications on POD 3.

Case Fenestrating (Video 2)

A male patient in his 60s underwent elective surgery following percutaneous transhepatic gallbladder drainage for grade III acute cholecystitis.

Marked fibrosis was observed throughout the gallbladder wall, making circumferential dissection at the body or neck impossible (pattern III). Therefore, a Fenestrating was performed.

The gallbladder wall was excised as widely as possible from the neck to the fundus. From within the lumen, the opening of the cystic duct was identified. As shown in Video 2, grasping and gently lifting the mucosa near the cystic duct orifice with forceps helps to visualize the opening clearly. The cystic duct orifice was closed with interrupted sutures.

Because the common bile duct runs along the left side of the closure line, particular care must be taken when placing sutures on that side. The right side, however, allows safer needle passage with sufficient tissue bites for secure ligation. Usually, two or three sutures are sufficient for complete closure. As in the Reconstituting procedure, a drain was placed before completion.

The operative time was 155 minutes, and blood loss was 10 mL. The drain was removed on POD 2 after confirming no bile leakage, and the patient was discharged on POD 3. Postoperatively, an intra-abdominal abscess developed, which was managed successfully with antibiotics.

Case Cholecystostomy (Video 3)

An 80-year-old man who had previously received conservative treatment for grade III acute cholecystitis developed recurrent inflammation and underwent emergency surgery.

In this case, severe adhesions involving the duodenum and colon made dissection of the gallbladder impossible (pattern IV). To prevent iatrogenic injury, Cholecystostomy was selected.

A small area of the gallbladder wall that could be identified was incised, and stones within the lumen were removed. A 16 Fr Foley catheter was inserted into the gallbladder through the abdominal wall (Cholecystostomy tube). The residual incision on the gallbladder wall was closed with running sutures using 3-0 V-Loc™.

We prefer a Foley catheter because its balloon can be inflated within the gallbladder to prevent accidental dislodgement after closure. An additional drain was placed under the right diaphragm.

The operative time was 165 minutes, and blood loss was 150 mL. The cholecystostomy tube was removed on POD 4, and the subdiaphragmatic drain on POD 6. The patient was discharged on POD 8 without biliary complications.

The patient later died of multiple myeloma eight months postoperatively, with no gallbladder-related adverse events during that period.

Postoperative considerations and tasks

In all three bailout procedures, oral intake is usually resumed on the day after surgery.

The nature of the fluid drained from the abdominal cavity should be carefully observed, and the bilirubin concentration in the drainage fluid should be measured if a bile leak is suspected.

For Reconstituting and Fenestrating procedures, if the absence of bile leakage is confirmed, the drain is removed on POD 2, and the patient is discharged the following day.

In Cholecystostomy cases, if bile continues to drain through the cholecystostomy tube, a cholangiography using Amidotrizoic Acid is performed at least four weeks postoperatively to confirm that there is no contrast leakage outside the tract before catheter removal. If, as in Case 3, there is no bile drainage after surgery, it can be assumed that the cystic duct is already occluded, and early catheter removal is possible.

Postoperative follow-up was conducted in the outpatient clinic, similar to that for standard cholecystectomy. Patients were routinely evaluated within 1–2 weeks after discharge, including clinical assessment and blood tests. If no abnormalities were detected and the patient had no specific complaints or requests, routine follow-up was concluded.

Tips and pearls

In Reconstituting cholecystectomy, residual stones left within the gallbladder remnant may lead to recurrence of cholecystitis or the development of choledocholithiasis and cholangitis (16). Therefore, the gallbladder lumen must be carefully inspected before closure of the stump.

In cases with a markedly thickened gallbladder wall, stump closure using a stapler or intracorporeal suturing may be technically difficult. In such situations, conversion to the Fenestrating approach is a reasonable alternative. Successful Reconstituting cholecystectomy requires that a segment of gallbladder wall with sufficient thickness and tensile strength is circumferentially preserved to allow secure closure. Although Reconstituting is often preferred over Fenestrating because of concerns about postoperative bile leakage (16,17), its indication should be determined carefully.

In Fenestrating cholecystectomy, there are rare cases in which the opening of the cystic duct cannot be identified, for example, when the orifice is adherent to the dorsal side of the hepatoduodenal ligament. In such cases, a “lay-open” technique without closure of the cystic duct orifice can be an acceptable option (18-20). If no active bile flow is observed intraoperatively, the cystic duct is likely already obstructed, and postoperative bile leakage is unlikely. Even if minor bile drainage persists, spontaneous closure can often be achieved by percutaneous drainage or endoscopic intervention (18). Blind suturing of the presumed ductal orifice should be strictly avoided, as it carries the risk of bile duct stricture or injury.

In cases requiring Cholecystostomy, severe adhesions around the gallbladder often limit its mobility, making it difficult to visualize the gallbladder lumen using the standard camera position. In such situations, shifting the camera from the umbilical port to the 12-mm epigastric port can provide a better view of the intraluminal field (see Video 3).

For cholecystostomy, a “lay-open” technique without placement of a cholecystostomy tube has also been reported, similar to the Fenestrating (21). In our third case, the cholecystostomy tube was successfully removed on POD 4, which was likely attributable to preexisting closure of the cystic duct caused by severe inflammation at the time of surgery. In some cases, placing a cholecystostomy tube and suturing the remaining gallbladder wall can be technically challenging. Under such circumstances, a lay-open approach may represent a feasible alternative option.

As mentioned earlier, these bailout procedures should not be performed with excessive insistence on maintaining a laparoscopic approach. When the procedure becomes technically challenging or unsafe, conversion to open surgery should be made without hesitation.

As described above, intracorporeal suture and ligation is a critical technical component of all three bailout procedures to prevent postoperative bile leakage. When these bailout procedures are performed by surgical trainees, adequate proficiency in suturing and ligation techniques is considered a prerequisite and should be established through preoperative training.

Particularly for precise intracorporeal suturing in Reconstituting, Fenestrating or Cholecystostomy, robot-assisted surgery may offer significant technical advantages and is expected to become increasingly useful in the future (22).

Discussion

As mentioned above, the Tokyo Guidelines 2018 state that “a bailout procedure should be considered when the CVS cannot be achieved”, and list Reconstituting and Fenestrating subtotal cholecystectomy, along with fundus-first approach and open conversion, as potential options (9). However, after selecting a fundus-first approach or open conversion, some cases allow cystic duct dissection and completion of total cholecystectomy, whereas in others, cystic duct management remains impossible and a Reconstituting or Fenestrating procedure is required. In other words, among the bailout procedures defined by the Tokyo Guidelines 2018, some techniques (fundus-first and open conversion) are applied before determining whether the cystic duct can be managed, while others (Reconstituting and Fenestrating) are applied after concluding that cystic duct management is impossible. The lack of clear hierarchy between these has contributed to conceptual confusion (9). In fact, Strasberg* et al. *have stated that “open conversion is not a bailout procedure” (15). Similarly, the fundus-first approach should not be categorized as a bailout technique; rather, the term “bailout procedure” should be reserved for interventions performed after abandoning total cholecystectomy to avoid BDI.

While numerous studies have examined the detailed classification of subtotal cholecystectomy (23-25), reports describing the practical selection criteria of each bailout procedure remain limited. Given that the frequency of bailout procedures inevitably increases as the technical difficulty of cholecystectomy escalates (26), establishing appropriate criteria for selecting the most suitable bailout technique is of critical importance. Strasberg* et al. recommended tube cholecystostomy when less than one-third of the gallbladder fundus can be exposed, and Reconstituting or Fenestrating subtotal cholecystectomy when Calot’s triangle is identifiable, but CVS cannot be achieved (15). That is, their recommendations do not explicitly delineate the criteria for selecting between Reconstituting and Fenestrating techniques. Sunagawa et al. *proposed three anatomical checkpoints during (A) removal of the gallbladder from the cystic plate on the right side above the ventral aspect of the Rouviere’s groove; (B) separation of the ventral side of the gallbladder neck from the cystic plate on the right side of the hepatic hilum; and (C) exposure of the cystic duct from the gallbladder neck (27). They recommended Fenestrating when both (A) and (B) cannot be achieved, and Reconstituting when (A) and (B) are achieved but (C) is not (27). Although their strategy is quite similar to ours, two main differences exist between their approach and ours. First, their method is based on right-sided dissection of the gallbladder body; therefore, it may not be applicable in cases requiring other approaches, where the described anatomical landmarks cannot always be identified. Second, their classification does not include cases in which gallbladder exposure itself is difficult (our pattern IV). Therefore, we consider our approach to be more versatile and broadly applicable.

As mentioned above, several authors consistently reported that Fenestrating is associated with a higher incidence of postoperative bile leakage than Reconstituting (16,17,23-25). Nevertheless, the choice between Reconstituting and Fenestrating largely depends on the intraoperative gallbladder condition, and surgeons rarely have the freedom to select one purely by preference. Therefore, the difference in bile leak rates likely reflects the severity of the gallbladder pathology that necessitated each technique, rather than inherent shortcomings of the techniques themselves. Accordingly, even in cases corresponding to pattern II, when the condition of the gallbladder wall is deemed unsuitable for Reconstituting, we do not hesitate to proceed with the Fenestrating technique.

Our clinical outcomes for bailout procedures were as follows. Among 593 LC performed between April 2021 and March 2025, 57 (9.6%) required bailout 35 Reconstituting, 19 Fenestrating, and 3 Cholecystostomy cases. The median postoperative hospital stay was 3 days for Reconstituting, 6 days for Fenestrating, and 8 days for Cholecystostomy. Median operative time and blood loss were 168 minutes/30 mL for Reconstituting, 168 minutes/90 mL for Fenestrating, and 145 minutes/100 mL for Cholecystostomy. Only one postoperative bile leak occurred, in the Reconstituting group. Endoscopic retrograde cholangiopancreatography was required in seven cases due to the retained gallstones in the common bile duct, all in the Reconstituting group (none in the Fenestrating or Cholecystostomy groups). Perihepatic fluid collection occurred in four cases (one Reconstituting, three Fenestrating), and percutaneous drainage was needed in one case. In one Fenestrating case, the cystic duct stump could not be identified, and the “lay-open” technique was used; no postoperative bile leak occurred. Although Cholecystostomy leaves almost the entire gallbladder remnant, potentially predisposing to residual cholecystitis, none of the three cases (including Case 3 described above) developed such complications during 1–2 years of follow-up. With proper patient selection, Cholecystostomy can therefore be an effective bailout option. No cases of BDI, postoperative death, or reoperation occurred within 90 days.

Several limitations of this surgical technique should be acknowledged. First, the applicability of this bailout procedure may be limited in cases with extreme inflammation or unfavorable anatomy and it is still dependent on the surgeon’s experience. Second, this report is limited by a small number of cases and a relatively short follow-up period, and long-term outcomes remain to be clarified. Third, among our 57 bailout cases, one incidental gallbladder carcinoma was detected in a Reconstituting case. Such lesions are often difficult to identify preoperatively, yet bile contamination during surgery is unavoidable, raising concerns about postoperative recurrence. Therefore, in elderly patients with severe inflammation and marked wall thickening, the risk of incidental carcinoma should be kept in mind.

Conclusions

To avoid BDI in difficult gallbladder cases, surgeons should be proficient not only in one specific bailout procedure but also in all three—Reconstituting, Fenestrating, and Cholecystostomy—and apply them judiciously according to intraoperative findings.

In the future, subtotal cholecystectomy and other bailout procedures may increasingly be performed using robotic platforms. Robotic assistance could facilitate precise suturing, particularly in Fenestrating techniques or Cholecystostomy, and may further reduce the risk of postoperative bile leakage.

Supplementary