Med. J. Malaysia Vol. 47 No. 1 March 1992 Modified subtotal cholecystectomy: A procedure for the difficult gall bladder T.P. T. Khan Department of Surgery. Hospital Universiti Sains Malaysia. Kubang Kerian. Kelantan Summary Modified subtotal cholecystectomy involves removal ofthe gall bladder after circumferential division of the neck. Either the impacted stone or the surgeons finger was was used as a guide to identify the neck. The stump cavity in the neck is obliterated with interrupted sutures to prevent recurrent stone formation. Indications for this procedure are obscure anatomy, due either to the severe inflammation in acute cholecystitis or dense adhesions in the small fibrosed gall bladder. The decision to perform modified subtotal is taken during the operation. Forty three patients (14%) under- went this procedure during the period between August 85 and April 90. Out of 289 cholecystectomies performed seven were emergency and thirty-six were early cholecystectomies. With the increasing trend towards urgent and early cholecystectomy in acute cholecystitis the author has found this to be a safe and definitive procedure. Key words: Difficult gall bladder, modified cholecystectomy, stump cavity obliteration Introduction A modification of the standard cholecystectomy, which was found to be useful both in the acute inflammatory stage as well as in the small fibrosed gall bladder is described. In such situations access to the junction of the cystic with the common hepatic duct is both difficult and dangerous. Attempting a standard cholecystectomy puts the anatomy at a significant risk of being damaged and cystic duct cannulation is usually not possible. Method The contents of the gall bladder are aspirated through the fundus and sent for culture and sensitivity. If a stone is impacted in the neck, it is not dislodged. The gall bladder is opened with a scissors at the fundus. The incision is extended up to the neck which contains the impacted stone. The neck is then divided circumferentially on the stone exposing almost half the stone (Fig. 1). In the presence of smaller stones, the neck is divided 1 cm from the distal edge of the stone. The presence of the stone beyond the division safeguards the extra hepatic bile ducts. The posterior wall of the neck is divided under vision from within. In this process the cystic artery is also divided as at this point it has entered the wall of the gall bladder and is suture ligated. After the division, the remaining part of the gall bladder is dissected off the liver as in a standard operation. The remnant neck resembles a cup (Fig. 2a), the orifice of the cystic duct is rarely identifiable, thus preoperative cholangiography was not attempted. The cavity in the neck is obliterated with interrupted sutures, taken at a suitable distance from the cut edge (Fig. 2b). These sutures also help in controlling bleeding from the cut edge. The result, after the sutures are tied is illustrated in Fig. 2c. 65