Background and Aims: Laparoscopic cholecystectomy (LC) is the gold standard operation for gallstones with cholecystitis. However, it is difficult and risky to implement the standard LC in conditions where the Calot’s triangle has a distorted anatomical structure or tightly adheres to the adjoining tissues. Laparoscopic subtotal cholecystectomy (LSC) can reduce the surgical difficulty and the open conversion rate, as well as effectively avoid the bile duct and vascular injuries, but the main problem with this procedure is that the conditions of the gallbladder neck duct are uncertain and it may result in retained stones. This study was to investigate the application value of LSC combined with choledochoscopic exploration of the gallbladder neck duct and treat the stone in treatment of complex cholecystectomy. 
Methods: The clinical data of 36 patients undergoing LSC and choledochoscopic exploration of the gallbladder neck duct from January 2014 to January 2018 were retrospectively analyzed. Of the patients, 22 cases had acute suppurative cholecystitis, 5 cases had acute gangrenous cholecystitis and 9 cases had chronic atrophic cholecystitis. Diagnosis in all patients was confirmed by preoperative ultrasound and CT examinations, and 33 patients underwent MRCP, of whom, 28 cases were found with stones or suspected stones in the gallbladder neck duct, and 2 cases had concomitant Mirizzi syndrome.
Results: All the 36 patients underwent LSC and choledochoscopic exploration the neck of gallbladder. During the operation, bile outflow from the neck of the gallbladder was noted in 8 cases, and was not found in 28 cases. In patients with bile outflow, stones were found in 2 cases through the exploration of the gallbladder neck duct, which were removed by a superfine basket. In those without bile outflow, stones were detected in 26 cases and inflammatory stenosis at the distal end of the cystic duct in one case by the choledochoscopic exploration, and exploration was not completed in one case due to a tortuous cystic duct; the methods for stone extraction included that simple basket extraction in 4 cases, plasma lithotripsy plus basket extraction in 16 cases, and Heister spiral valve incision by a needle knife plus plasma lithotripsy and basket stone removal in 6 cases; after stone extraction, bile outflow was detected in 23 cases, and was still not found in 3 cases, of whom, inflammatory occlusion of the cystic duct due to distal inflammatory stenosis was considered in one case, and further exploration was not completed to determine the cause in the other 2 cases due to bile duct distortion. The gallbladder neck duct was closed with a barbed-wire in 35 cases, and suturing could not be performed in 1 case because of the severe inflammation and edema in the gallbladder neck duct, and drainage tube was placed in the gallbladder neck duct. There was conversion to laparotomy, and no bile duct and vascular injuries occurred during operation. The operative time was 50 to 170 min, the intraoperative blood loss was 50 to 120 mL, and the length of postoperative hospital stay was 5 to 10 d. Complications occurred in 7 patients, including choledocholithiasis cholangitis in one case, bile leakage in 2 cases, Trocar site infection in one case, and other non-surgical related complications in 4 cases; one case underwent ERCP choledocholithotomy. The bile leakage stopped in the 2 case after 2 weeks and one month respectively by keeping the drainage tube patent. The follow-up period ranged from 5 months to one year, and no operation related complications occurred.
Conclusion: The application of LSC combined with choledochoscopic exploration of the gallbladder neck duct can provide information about the condition inside the gallbladder neck duct as much as possible and properly deal with the stone incarceration or escape of the stones. It has certain application value in complex laparoscopic cholecystectomy.