Reconstituting, Fenestrating, and Cholecystostomy-our approach and surgical technique for difficult gallbladders...

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 techniques: 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 procedure: 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.