Body First Approach of Laparoscopic Cholecystectomy for Difficult Gallbladder

Laparoscopic cholecystectomy for difficult gallbladders is risky because severe inflammation obscures local anatomy. We investigated the usefulness of "the body-first approach" with laparoscopic cholecystectomy for acute cholecystitis at our institution.

Two hundred and five patients were diagnosed with acute cholecystitis and underwent cholecystectomy at our hospital between January 2017 and December 2024. Eight cases were excluded due to severe adhesions from previous surgery. From July 2022, we have performed the body-first approach for difficult surgical cases until bailout surgery was required. To evaluate the usefulness of the body-first approach, the period was divided into before and after the start of the body-first approach. The patient characteristics, conversion rate to laparotomy, and total cholecystectomy rates were examined.

There were no significant differences in terms of age, gender, BMI, or the operative difficulty grading between the two periods. The operative time was significantly longer in the later period than in the early period (p = 0.0346). There were no cases requiring blood transfusion. The conversion rate to open surgery was significantly lower in the later period than in the early period (p = 0.000629). The total cholecystectomy rate was significantly higher in the later period than in the early period (p = 0.00012). No cases of vasculobiliary injury were observed in either period.

It was suggested that even in difficult gallbladder cases, the body-first approach may reduce the rate of conversion to laparotomy and increase the rate of total cholecystectomy without vascular-biliary injury.