Surgery 164 (2018) 419–423

Contents lists available at ScienceDirect

Surgery
journal homepage: www.elsevier.com/locate/surg

Bile duct/Gallbladder

Use of a piece of free omentum to prevent bile leakage after subtotal

cholecystectomy✩
Yoichi Matsui, MD∗, Satoshi Hirooka, MD, Masaya Kotsuka, MD, So Yamaki, MD,
Tomohisa Yamamoto, MD, Hisashi Kosaka, MD, Sohei Satoi, MD, FACS
Department of Surgery, Kansai Medical University, Osaka, Japan

a r t i c l e i n f o a b s t r a c t

Article history: Background: Bile leakage after subtotal cholecystectomy (SC) is clinically serious. To prevent such leakage,
Accepted 18 April 2018 we developed a new surgical technique in which a free piece of omentum is plugged into the gallbladder
Available online 7 June 2018
stump (omentum plugging technique). We evaluated whether the omentum plugging technique prevents
bile leakage after subtotal cholecystectomy.
Methods: Prospectively collected data of patients who had undergone subtotal cholecystectomy with-
out cystic duct closure in the Department of Surgery of Kansai Medical University during the 12 years
from January 2006 to March 2018 were reviewed retrospectively. The outcomes of patients who had un-
dergone subtotal cholecystectomy with the omentum plugging technique (omentum plugging technique
group) were compared with those of patients who had undergone subtotal cholecystectomy without the
omentum plugging technique (Control group). The outcomes of interest were perioperative data and post-
operative complications including bile leakage, necessity for interventions for complications, and duration
of hospitalization.
Results: Fifty of 2,447 consecutive patients (2.0%) had undergone subtotal cholecystectomy. Of these 50
patients, 18 were treated with the omentum plugging technique (omentum plugging technique group)
and 32 were treated without the omentum plugging technique (Control group). One of 18 patients in
the omentum plugging technique group and 14 of 32 in the Control group developed postoperative bile
leakage. One postoperative interventional treatment for complications was performed in the omentum
plugging technique group and 12 in the Control group. The duration of postoperative hospitalization was
less in the omentum plugging technique group.
Conclusion: The omentum plugging technique appears to be an effective operative technique for prevent-
ing postoperative bile leakage in selected situations when a “difficult gallbladder” is encountered.
© 2018 The Author(s). Published by Elsevier Inc.
This is an open access article under the CC BY-NC-ND license.
(http://creativecommons.org/licenses/by-nc-nd/4.0/)

Introduction of Calot’s triangle cannot be safely identified, contraindicating

A “difficult gallbladder” is usually associated with severe
inflammation that has deformed the local anatomy, making dissec-
tion more difficult (eg, dissection for acute cholecystitis, empyema,
gangrene, perforation, xanthogranulomatous change, fistula for-
mation, or Mirizzi syndrome).1,2 Subtotal cholecystectomy (SC),
which involves removal of the body and sometimes part but not
all of the infundibulum of the gallbladder and in which the cystic
duct is not directly closed, may be performed when the structures
✩
The authors declare no funding sources or conflicts of interest.
∗
Corresponding author: Department of Surgery, Kansai Medical University, Hi-
rakata, Osaka, Japan.
E-mail address: matsui@hirakata.kmu.ac.jp (Y. Matsui).
total cholecystectomy.3 This “damage control” technique aims to
decrease risks of complications, such as bile duct injury, hepatic
artery injury, and bleeding from the gallbladder bed. There has
recently been an increasing trend toward performing SC, reflecting
the growing general acceptance of the need to minimize morbid
complications of removing the “difficult gallbladders.”4
Although positive outcomes have been reported, SC has also
been associated with postoperative bile leakage.5-12 Leaving the
cystic duct open or inside a purse-string suture within the gall-
bladder stump would theoretically minimize the risk of bile duct
injury, but such procedures have potential disadvantages; namely,
that they can could lead to greater rates of postoperative bile
leakage through the gallbladder stump, prolonged drainage, and
a more frequent need for percutaneous or endoscopic retrograde

https://doi.org/10.1016/j.surg.2018.04.022
0039-6060/© 2018 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license.
(http://creativecommons.org/licenses/by-nc-nd/4.0/)

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420 Y. Matsui et al. / Surgery 164 (2018) 419–423
cholangiographic drainage.13 When SC is performed, the cystic
duct cannot be closed directly and must be closed from within
the open gallbladder stump with a purse-string suture if possible.
This technique has been adopted by numerous surgeons with
minor modifications.10,11 , 14 Regardless of whether the gallblad-
der stump is closed, however, the rate of bile leakage from the
gallbladder stump after SC remains much greater than after total
cholecystectomy, in which the cystic duct is closed directly.12
We developed a new operative technique in which a free piece
of omentum is plugged into the gallbladder stump (omentum
plugging technique [OPT]) to prevent bile leakage through the
cystic duct after SC in patients in whom it is difficult or too
risky to isolate the cystic duct that the surgeon cannot directly
close.15 The aim of the present study was to assess the safety and
efficacy of this new operative technique and determine whether
this procedure prevents postoperative bile leakage.
Methods
In 2011, we developed the OPT to prevent postoperative bile
leakage in patients in whom surgeons cannot safely dissect Calot’s
triangle or directly close the cystic duct because of a “difficult
gallbladder.” Prospectively collected data from patients who had
undergone cholecystectomy in the Department of Surgery of
Kansai Medical University during the 12 years from January 2006
to March 2018 were reviewed retrospectively. In this study, we
defined the term SC as cholecystectomy in which the cystic duct
could not be closed directly and the gallbladder was transected at
its neck because of a “difficult gallbladder,” thereby leaving part of
the infundibulum and the cystic duct in place. Of all patients who
underwent cholecystectomy during the study period, those who
had undergone SC were selected for this study. The outcomes of
patients who had undergone SC with the OPT (OPT group) were
compared with those of patients who had undergone SC without
the OPT (Control group). The outcomes of interest were perioper-
ative data and postoperative complications, including bile leakage,
necessity of interventions for complications related to problems in
the gallbladder fossa, and durations of drainage and hospitaliza-
tion. Bile leakage was defined as macroscopic identification of bile
coming through the intraoperatively placed drain postoperatively.
Postoperative complications were classified according to Clavien
and Dindo.
Operative procedures
Figure 1 demonstrates the OPT procedure, which is described
in the following. The gallbladder is drained and opened with
hook diathermy at the fundus, thus extending the incision to
the neck of the gallbladder without dissecting the cystic duct.
The gallbladder contents are then suctioned or evacuated into an
Endobag and the anterior wall excised with diathermy, leaving
the posterior wall attached to the liver if necessary. The remnant
mucosa is coagulated with diathermy or argon beam coagulation.
For OPT, a piece of omentum that matches the size of the opening
of the gallbladder stump is resected from the greater omentum
and plugged into the gallbladder stump (Fig. 1, A). The maximum
length and width of this piece of omentum are approximately 2
to 3 cm. The tip of the piece is then plugged into the opening
of the stump and oversewn with the edge of the gallbladder
stump, including the surrounding tissues if necessary, thus fixing
the omental tissue that has been plugged into the stump to
Hartmann’s pouch or the inside entry of the cystic duct, similarly
to a cork in a wine bottle (Fig. 1, B). Both sides of the stump
edges are closed near each other using absorbable sutures (coated
VICRYL 3-0 J316H; Johnson & Johnson Medical, North Ryde, NSW,
Australia), but there is no need to completely close both sides of
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Fig. 1. Omentum plugging technique. A, A piece of omentum is plugged into the
gallbladder stump after subtotal cholecystectomy. B, Both sides of the stump edges
are closed near each other by suturing. C, The stump edges are closed using ab-
sorbable suture clips (LAPRATY). Each illustration in the middle panels depicts a
cross section at each of the stages of the procedure shown in the upper panels. The
bottom panels are photographs of actual operative fields.
the stump edges. It is enough to ensure that the plugged omental
tissue forms a watertight seal by ensuring the sides of the stump
edges are in close proximity. If absorbable suture clips (LAPRATY
XC20 0 and KA20 0; Ethicon, Somerville, NJ, USA) are available, the
laparoscopic suturing procedures can be used to fix the omental
plug, as shown in Fig. 1, C. In patients in whom the OPT was not
performed, the gallbladder stump was oversewn, a purse-string
suture was placed from within the gallbladder stump, or the
stump was left open if there was no intraoperative evidence of
bile leakage. A subhepatic drain was placed routinely in both
groups. During the study period, all operative procedures were
performed by experienced surgeons who, as of the beginning of
the study, had performed more than 200 cholecystectomies.
Results
A flowchart of the current study is shown in Fig. 2. During
the 12 years from January 2006 to March 2018, 2,447 consecutive
cholecystectomies, including 2,184 laparoscopic and 263 open pro-
cedures, were performed at our institution for benign gallbladder
diseases and choledocholithiasis.
Fifty of these 2,447 patients (2.0%) had undergone SC because
it was not possible to close their cystic ducts because they had
“difficult gallbladders.” Of these 50 patients, 18 underwent SC
with the OPT (OPT group) and 32 underwent SC without the OPT
(Control group). The clinical characteristics of the study patients
according to their group are shown in Table 1; none differed sig-
nificantly between the 2 groups. The gallbladder stump was closed
with sutures in 20 of the 32 Control patients and left open in
the remaining 12 because of severe inflammatory changes in the
stump edges (Fig. 2, Table 2). Fistulas were identified intraopera-
tively in 14 patients, 11 being fistulas to the duodenum, whereas 2
patients in the Control group had a fistula to the hepatic duct and
one in the Control group had one to the colon.
The various outcomes are displayed in Table 2 according to
study group. In the OPT group, a minor complication (minor
wound infection) occurred in one patient, and another patient
developed postoperative bile leakage that resolved spontaneously
 Y. Matsui et al. / Surgery 164 (2018) 419–423 421

Table 1
Clinical characteristics according to study group.

OPT∗ group (n = 18) Control group (n = 32)

Age (years) 65† (36–78)‡ 72 (27–83)

Sex (male / female) 13 / 5 19 / 13
Urgent operation 10 (56%) 20 (63%)
Operative procedures (laparoscopic / open) 6 / 12 12 / 20
Diagnosis (fistula formation / Mirizzi syndrome / Xanthogranuloma / others§ ) 5/2/3/8 9 / 5 / 3 / 15
History of choledocholithiasis 6 (33%) 9 (28%)
History of abdominal surgery 2 (11%) 2 (6%)
ASA|| classification (1 / 2 / 3 / 4) 3 / 13 / 2 / 0 7 / 22 / 2 / 1
Intraoperative hemorrhage (mL) 109 (10–416) 181 (4–2508)
Duration of operation (min) 177 (111–262) 134 (64–334)
∗
Omentum plugging technique.
†
Median.
‡
Range.
§
Severe inflammation, fibrosis with adhesion to surrounding tissues.
||
American Society of Anesthesiologists.

Table 2
Comparison of outcomes of OPT∗ and Control groups.

OPT group (n = 18) Control group (n = 32)

gallbladder stump

closure (n = 20) left open (n = 12)

Total postoperative complications 3 (17%) 10 (50%) 8 (67%)

postoperative bile leakage 1 7 (35%) 7 (58%)
other major complications 1 4 (20%) 1
minor complications 1 1 2
Postoperative intervention† 1 (6%) 6 (30%) 6 (50%)
Duration of drain placement (days) 4‡ (2-10)§ 7 (1-51)
Postoperative hospital stay (days) 9 (4-36) 15 (3-52)
Readmission 0 4
Reoperation 0 1
Clavien–Dindo classification (I / II / III / IV / V) 2/0/1/0/0 2 / 5 / 10 / 2 / 0
∗
Omentum plugging technique.
†
Eight patients underwent endoscopic retrograde cholangiographic with stenting, 3 were treated with percuta-
neous drainage, and 2 required a respirator for lung complications.
‡
Median.
§
Range.

bile leakage. In the Control group, bile leakage occurred in 7 of

Fig. 2. Flowchart of the study. ∗ Omentum plugging technique.
within 3 days of operation without any interventional treatment
necessary. Another patient in the OPT group developed a sub-
hepatic abscess without bile leakage, which was treated with an
ultrasonographically guided percutaneous intervention.
In contrast, 18 of 32 patients developed postoperative com-
plications in the Control group; 14 of these were postoperative
20 patients with closed gallbladder stumps and 7 of 12 with
open gallbladder stumps (Fig. 2, Table 2). Major complications
other than bile leakage occurred in 5 patients in the Control
group and were treated as follows. Reoperation was performed
laparoscopically on one patient because of an impacted stone in
the remnant gallbladder stump. Two patients required percuta-
neous interventions because of subhepatic abscesses. One patient
required prolonged mechanical ventilation in the intensive care
unit for 10 days because of atelectasis, and another with bile leak-
age required mechanical ventilation for 7 days because of severe
postoperative pneumonitis. A minor complication (minor wound
infection) occurred in 2 patients in the Control group (Table 2).
As shown in Table 2, postoperative interventions were required
in 12 of 32 patients in the Control group and 1 of 18 in the OPT
group. Postoperative endoscopic retrograde cholangiography was
performed to manage biliary leakage from the gallbladder stump
by stenting in 8 patients in the Control group but none in the OPT
group. The mean duration of drain placement was less in the OPT
than in the Control group, as was the duration of postoperative
hospitalization. There was no perioperative mortality during the
follow-up period in either group. The median duration of follow-
up was 12 months (range, 2–82 months) in the OPT group and 26
months (range, 2–121 months) in the Control group.
In comparison, postoperative bile leakage developed in only
6 of 2,397 patients (0.25%) whose cystic ducts had been closed
directly (total cholecystectomy; Fig. 2). One of these 6 patients
developed postoperative bile leakage because the cystic duct had
been closed with an unsecured metal clip, another leak was from

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422 Y. Matsui et al. / Surgery 164 (2018) 419–423
the repaired hepatic duct, 2 were from the duct of Luschka, and 2
from unknown origin.
Discussion
Madding16 first reported SC in 1955 as an alternative for
conventional total cholecystectomy as a rescue procedure in cases
of a technically difficult total cholecystectomy that minimized the
potential for injury to the bile duct and vascular structures when
they were severely inflamed. SC was performed by piecemeal
excision of the gallbladder, transecting the gallbladder neck or
Hartmann’s pouch, and leaving a rim of the posterior wall attached
to the liver bed. The cystic duct was closed indirectly from within
the gallbladder stump with a purse-string suture or left open.12,13
SC is usually performed in patients with a “difficult gallbladder”
in whom inflammation, fibrosis, and adhesions increase the risk of
complications with dissection of the cystic duct.17 The rate of fatal
complications is similar to that reported for total cholecystectomy,
indicating that it is as safe to perform SC in patients with a “dif-
ficult gallbladder” as it is to perform simple total cholecystectomy
in patients without a “difficult gallbladder.” This is especially true
regarding common bile duct injuries and hemorrhage, which occur
less frequently during SC than during total cholecystectomy,18,19
definitely achieving the aims of SC. As predicted, common bile
duct injury does not occur in the subgroup in which Hartmann’s
pouch or the gallbladder stump is left open to avoid performing
hazardous dissection of the cystic duct in patients with difficult
Calot’s triangles.20-24
A recent systematic review12 showed that regardless of whether
the gallbladder stump is closed, postoperative bile leakage occurs
more frequently after SC than after total cholecystectomy. That
systematic review also showed that there is no clinically relevant
difference in the incidence of postoperative bile leakage and
subhepatic collections when the stump is closed versus left open.
Likewise, in the Control group of the present study, 7 of 12 pa-
tients whose stumps were left open developed bile leakage, as did
7 of 20 whose gallbladder stumps were closed. These leakage rates
are similar to those in the aforementioned systematic review.12
It is likely that in “difficult gallbladders,” the edematous tissues
of the cystic duct and gallbladder stump increase the risk of bile
leakage once the edema has resolved and the suture loses the
watertightness that was achieved when the gallbladder stump
was closed.25 Alternatively, bile leakage from the unsecured stump
can occur postoperatively when the gallbladder stump is closed
inadequately or purposely left open.
We used non-vascularized, free omental tissue rather than a
vascularized omental pedicle for the following 3 reasons. First,
when an omental pedicle is used, it is difficult to completely
secure the omental plug to the dorsal part of the gallbladder
stump because dorsal vision of the stump is obstructed by the
pedicle, especially in patients with “difficult gallbladders.” Second,
the key point of this plugging technique is creation of a watertight
seal with the omental tissue, like a cork in a wine bottle. Even
if a vascularly predicled piece of omentum is used to ensure a
blood supply, watertight suturing cuts off the blood supply to the
plugged omental tip. Third, in patients with “difficult gallbladders”
there is little normal, soft omentum surrounding the gallbladder
because of severe inflammatory changes. Therefore, it is almost
impossible to reach and insert the tip of a vascularized piece of
omentum into the stump. Given the few postoperative complica-
tions including subhepatic abscess formation in the OPT group,
we believe that a non-vascularized plug of omental tissue helps to
form a scar despite it undergoing fat necrosis.
The absence of bile leakage in the OPT group in this study
means that OPT is preferable to leaving the cystic duct open or
attempting to close the stump with either an inner purse-string
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suture or a simple oversewing suture technique. Moreover, the lack
of a difference in the duration of the operation or the amount of
hemorrhage between the OPT and Control groups means that the
OPT is an easier and safer technique. Our results show that this
technique can reliably prevent postoperative bile leakage and other
postoperative complications. In addition, the OPT is advantageous
in terms of decreasing the duration of postoperative drainage,
minimizing the need for percutaneous intervention or endoscopic
retrograde cholangiography drainage, and decreasing the duration
of hospitalization. Direct cystic duct closure is the best procedure
for prevention of postoperative bile leakage,26 but when a difficult
Calot’s triangle is encountered and the cystic duct cannot be
approached safely, OPT is helpful for completing a SC safely and
minimizing postoperative complications, including bile leakage.
We recommend the OPT regardless of whether SC is performed
laparoscopically or as an open procedure. Surgeons who encounter
difficulties when attempting to perform the OPT laparoscopically
can convert to an open procedure. Indeed in this study, conversion
to open surgery was required in 10 patients in the OPT group.
Our study does have some limitations when considering the
results. The small number of patients who underwent the OPT
(N = 18) limits the generalizability of our conclusions. It is rel-
atively rare to be unable to neatly close the cystic duct when
performing SC and this would likely be the case even in a high-
volume center. Indeed, in our institution, the rate of SC without
closure of the cystic duct was only 50 of 2,447 (2%) cholecys-
tectomies over the 12 years of the study, thus only 4 of the 200
cholecystectomies performed each year in our institute. Thus, our
findings could only validly be generalized if a multicenter study
of many of these relatively rare cases achieved similar outcomes.
Moreover, in this study, only 6 patients who underwent OPT
did so by laparoscopic surgery without conversion. Some recent
reports have demonstrated the advantages of laparoscopic SC for
patients with “difficult gallbladders.”5,13 , 17,27 , 28 Therefore, the OPT
should be evaluated through laparoscopic SC in larger numbers of
patients with “difficult gallbladders.”
In conclusion, when a “difficult gallbladder” is encountered
and SC is required during cholecystectomy, OPT seems to be a
safe and more feasible alternative for prevention of postoperative
bile leakage than conventional procedures for management of the
gallbladder stump, such as an inner purse-string suture or no
closure, both in open and laparoscopic SC.
Acknowledgments
We would like to express our sincere appreciation to sec-
retaries Ayaka Fujimoto and Kumi Sakamoto of the Depart-
ment of Surgery, Kansai Medical University. We also thank
Dr Jun Yamao, MD, for editing the supplemental videos of this
manuscript and Dr Trish Reynolds, MBBS, FRACP, from Edanz Group
(www.edanzediting.com/ac) for editing a draft of this manuscript.
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ABS

RRC APDS

Yeah. They are residents signaling “since surgeons end up

doing only ten operations when they get in practice, why
does it take ten years after high school to get there?”

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