Is Subtotal Cholecystectomy a Breach of Duty?

Introduction

Cholecystectomy — the surgical removal of the gallbladder — is one of the most commonly performed operations worldwide. In the vast majority of cases it is completed without complication. However, when the gallbladder is severely inflamed, the anatomy of the cystic triangle (Calot's triangle) can become obscured to the point where the critical structures — the cystic duct, cystic artery, and common bile duct — cannot be safely identified.

In such circumstances, the operating surgeon faces a pivotal decision. Persisting with attempts to achieve a total cholecystectomy risks catastrophic injury to the bile duct. The alternative is to perform a subtotal cholecystectomy — deliberately leaving behind a portion of the gallbladder wall in order to avoid dissection in the danger zone.

This article considers whether the decision to perform a subtotal cholecystectomy, in the context of a difficult and inflamed gallbladder, represents a departure from the expected standard of care.

The Clinical Scenario

The typical scenario encountered in medicolegal practice involves a patient who undergoes cholecystectomy — whether as an emergency or elective procedure — in the setting of significant gallbladder inflammation. At operation, the surgeon finds dense adhesions, oedematous tissue, or fibrosis in the region of the cystic triangle. The anatomy is distorted and the cystic duct and artery cannot be clearly delineated. In the language of modern biliary surgery, the critical view of safety cannot be achieved.

Rather than continuing to dissect in this hazardous area, the surgeon elects to perform a subtotal cholecystectomy. This involves opening the gallbladder, evacuating its contents (including stones), and removing as much of the gallbladder wall as can be safely excised — whilst leaving behind a cuff or remnant of the gallbladder wall, typically the portion adherent to the liver and the area adjacent to the biliary structures.

What Is the Standard of Care?

The standard of care in biliary surgery has evolved considerably over the past two decades. A body of surgical literature now firmly supports the principle that when the critical view of safety cannot be safely obtained, the surgeon should adopt an alternative strategy rather than persist with dissection that risks bile duct injury.

Subtotal cholecystectomy is the most widely recognised of these bail-out strategies. Gupta and Jain (2019) described subtotal cholecystectomy as a key component of a universal culture of safety in cholecystectomy, placing it alongside the critical view of safety itself and intraoperative cholangiography as methods to reduce the incidence of bile duct injury (doi:10.4240/wjgs.v11.i2.62).

Strasberg and colleagues (2016) have defined two technical variants of the procedure — the fenestrating subtotal cholecystectomy and the reconstituting subtotal cholecystectomy — and described their indications, technique, and expected outcomes in detail (doi:10.1016/j.jamcollsurg.2015.09.019).

The Evidence Base

The published evidence supports the safety of subtotal cholecystectomy as a damage-limitation strategy. Several key findings from the literature are relevant to the medicolegal assessment.

First, the rate of bile duct injury following subtotal cholecystectomy is very low. Lucocq et al. (2022) reported in a large series that the rate of bile duct injury following subtotal cholecystectomy was 0.08%, significantly lower than the rates historically associated with persisting with difficult dissections (doi:10.1007/s00268-022-06737-0).

Second, whilst subtotal cholecystectomy does carry a higher rate of certain postoperative complications compared to total cholecystectomy — notably bile leak, which may require postoperative endoscopic retrograde cholangiopancreatography (ERCP) — these complications are generally self-limiting or amenable to minimally invasive management. They are widely regarded as acceptable when weighed against the devastating consequences of a major bile duct injury, which may require complex reconstructive surgery and carry long-term morbidity.

The Medicolegal Analysis: Is It a Breach of Duty?

In my opinion, where a surgeon encounters severe inflammation that obscures the biliary anatomy and prevents safe achievement of the critical view of safety, the decision to perform a subtotal cholecystectomy does not, in itself, represent a breach of duty. On the contrary, it represents the application of a recognised, evidence-based bail-out strategy that prioritises patient safety.

The Bolam test requires that a surgeon acts in accordance with a practice accepted as proper by a responsible body of surgical opinion. The practice must also withstand logical analysis (Bolitho). The published surgical literature overwhelmingly supports subtotal cholecystectomy as an appropriate response to a difficult gallbladder. Multiple professional societies and expert consensus statements recognise it as a legitimate and prudent surgical strategy.

It could be argued that continuing to dissect in the hazardous area, when the anatomy cannot be safely identified, is itself more likely to represent a departure from accepted practice than the decision to stop and adopt a safer alternative. A surgeon who recognises the limits of safe dissection and adjusts their operative plan accordingly is exercising sound surgical judgement.

Important Caveats

There are, however, important qualifications to this general position. The assessment of breach of duty always depends on the specific facts of the individual case. Several factors may influence the medicolegal analysis.

First, the documentation of intraoperative findings is critical. The surgeon should record the reasons for converting to a subtotal cholecystectomy — including the specific inflammatory findings that prevented safe identification of the anatomy. Contemporaneous, detailed operative notes provide the strongest evidence that the decision was clinically appropriate.

Second, the management of stones within the gallbladder remnant deserves attention. Where stones are visible within the remnant or at the neck of the gallbladder, every reasonable effort should be made to remove them. Retained stones in a gallbladder remnant can cause ongoing symptoms, recurrent cholecystitis, or choledocholithiasis — and a failure to extract accessible stones during subtotal cholecystectomy may attract criticism.

Third, the surgeon's experience and the appropriateness of the clinical setting matter. Early recognition of a difficult gallbladder, appropriate consultant involvement, and the availability of intraoperative cholangiography or other imaging may be relevant considerations.

Finally, the patient's consent and the preoperative discussion should, where possible, have included mention of the possibility that a subtotal cholecystectomy may be required, particularly in patients with predictors of a difficult cholecystectomy (recurrent cholecystitis, previous percutaneous cholecystostomy, ERCP, or known dense inflammatory changes on imaging).

Conclusion

Subtotal cholecystectomy is a well-established, evidence-based surgical technique designed to manage the difficult gallbladder safely. When severe inflammation obscures the biliary anatomy and the critical view of safety cannot be achieved, its use represents sound surgical judgement rather than a departure from the expected standard of care. The surgeon who stops dissecting in a dangerous area and adopts a recognised bail-out strategy is, in my opinion, acting in the patient's best interest.

Each case must, of course, be assessed on its own facts — including the operative findings, the surgeon's documentation, the management of any retained stones, and the adequacy of the consent process. Nonetheless, the decision to perform a subtotal cholecystectomy, in appropriate clinical circumstances, should not in itself be regarded as a breach of duty.