Fundus-first dissection: a salvage technique for the difficult laparoscopic cholecystectomy

Fundus-first dissection (FFD) is an established salvage technique for difficult cholecystectomies when the critical view of safety (CVS) is unachievable. However, it is not widely practised due to perceived risks of dissecting inflamed or contracted gallbladders or fibrosed cystic pedicles. This study aimed to evaluate the safety and outcomes of FFD in a large series of difficult laparoscopic cholecystectomies (LC).

A prospectively maintained database, with retrospective analysis of outcomes of LC performed by a single surgeon between 1992 and 2022. FFD, was employed in Nassar Difficulty Grades 4 and 5 when CVS could not be displayed via antegrade dissection. Patient characteristics, operative findings, operative time, conversion rates and outcomes were described for FFD.

There were 159 FFDs amongst 1065 Grades 4 or 5 LCs (14.9%). Old age, elective presentations, previous biliary episodes and Grade V difficulty were factors associated with FFD utilisation which reflected increased complexity. No bile duct injuries occurred. In the FFD group, subtotal cholecystectomy and open conversion were required in 3.1% each. FFD resulted in a significant decline in conversions over the three decades. Multivariable adjustment for case complexity showed adverse outcomes were driven by patient ASA ≥ 3 and difficulty grade V, whilst FFD technique was not independently associated with increased odds of major complications. Temporal analysis revealed an evolving practice pattern and 35-fold reduction in conversions over three decades.

The FFD salvage approach to difficult LC has an acceptable risk profile when CVS was unachievable. Total cholecystectomy was achieved in 96.9% of FFD cases with acceptable complication rates given the increased anatomical complexity. After adjustment for confounders, adverse outcomes appeared to be driven by case complexity rather than the FFD technique itself. FFD is a viable salvage approach in experienced hands. External validation and specialisation are needed before generalising to broader surgical practice.