Evaluation of fundus-first laparoscopic cholecystectomy

Laparoscopic cholecystectomy is the gold standard for gallbladder surgery. Cholecystectomy from the fundus to the cystic duct may be advantageous when cystic duct exposure becomes difficult due to adhesions on Calot's triangle. The aim of this study was to compare conventional laparoscopic cholecystectomy with the fundus-first procedure and to evaluate whether the fundus-first technique can prevent conversion in difficult cases.

The study included 145 patients treated over 18 months. The inclusion criterion was the presence of ultrasound proven gallstones. Patients were excluded from the study if there was evidence of common bile duct stones, a bilioenteric fistula, or carcinoma of the gallbladder.

The fundus-first approach was started in 45 patients; all procedures were completed laparoscopically. Conventional laparoscopic cholecystectomy was begun in 100 patients. Twenty-seven of the 100 patients were converted to fundus dissection (adhesions within Calot's triangle). Four of the 27 were further converted to open surgery. One patient had a drop in blood pressure on creation of pneumoperitoneum. Time taken for severely inflammatory and noninflammatory cases was significantly greater (P<0.05) in the fundus-first group. The average hospital stay was 48 hours in both groups. No major complications were observed.

The rate of conversion in the conventional laparoscopic cholecystectomy group decreased from 18.75% (27/144) to 2.08% (3/144). The fundus-first technique has the potential to decrease conversion in difficult cases.