---
title: Surgeons stopped escaping difficult gallbladders by opening the abdomen. What they do instead is safer for the bile duct and harder on everything else
publication: Medical Insights Korea
section: news
category: Gallbladder
canonical_url: https://medicalinsightskorea.com/news/difficult-gallbladder-bailout-subtotal-vs-conversion
author: David Seo
published: 2026-09-01T14:20:00+09:00
modified: 2026-09-01T14:20:00+09:00
content_type: reporting
license: Quotation permitted with attribution to Medical Insights Korea and a link to the canonical URL.
---

# Surgeons stopped escaping difficult gallbladders by opening the abdomen. What they do instead is safer for the bile duct and harder on everything else

A society review of subtotal cholecystectomy puts bile duct injury at 0.3 percent and overall complications at 24.7 percent. That trade needs stating whenever a low conversion rate is offered as proof of surgical quality.

## Answer

In a Society for Surgery of the Alimentary Tract systematic review and meta-analysis, subtotal cholecystectomy — the bailout used when the critical view of safety cannot be achieved — carried a bile duct injury rate of 0.3 percent alongside a bile leak rate of 13.5 percent, overall complications of 24.7 percent, readmission of 17.8 percent and reoperation of 6.3 percent.

## Key takeaways

- In a Society for Surgery of the Alimentary Tract systematic review, subtotal cholecystectomy carried bile duct injury in 0.3 percent of patients, bile leak in 13.5 percent, retained stones in 6.1 percent, overall complications in 24.7 percent, readmission in 17.8 percent, reoperation in 6.3 percent and mortality in 0.8 percent.
- Compared with total cholecystectomy, subtotal cholecystectomy had significantly higher rates of bile leak, retained stones, overall complications, readmission, reoperation and postoperative ERCP, with no significant difference in mortality, intensive care admission or length of stay.
- An earlier meta-analysis of 85 studies covering 3,645 subtotal cholecystectomies reported bile duct injury in 7 patients (0.2 percent) and bile leak in 506 (13.9 percent), closely matching the newer figures.
- A meta-analysis of preoperative risk factors for conversion to open surgery found the largest odds ratios for acute cholecystitis (5.475) and age over 60 (4.324), followed by previous upper abdominal surgery (3.301) and heart disease (2.947).
- At one German secondary referral centre, 1,534 laparoscopic cholecystectomies over ten years produced a 2.0 percent conversion rate, with 84 percent of conversions occurring in emergency cases.

## Full article

There is a moment in a gallbladder operation when the surgeon cannot see well enough to proceed. The tissue is inflamed to the point where the cystic duct and the bile duct are no longer distinguishable, and the discipline of the operation says that nothing may be divided until they are.

For thirty years the answer to that moment was to make a larger incision and finish the operation by hand. Increasingly it is not. The gallbladder is left partly in place instead — its neck and a rim of wall abandoned where the danger is — and the operation ends laparoscopically. That change is well justified by what it prevents. It is less often described by what it costs.

### What subtotal cholecystectomy actually produces

The Society for Surgery of the Alimentary Tract published a state-of-the-art systematic review and meta-analysis of the procedure in 2026, synthesising studies from 2010 to mid-2025.

**Pooled single-arm outcomes after subtotal cholecystectomy**

| Outcome | Rate |
| --- | --- |
| Bile duct injury | 0.3% |
| Bile leak | 13.5% |
| Retained stones | 6.1% |
| Overall complications | 24.7% |
| Readmission | 17.8% |
| Postoperative ERCP | 16.2% |
| Reoperation | 6.3% |
| Percutaneous drainage | 5.7% |
| Mortality | 0.8% |

**0.3% vs 24.7%** — bile duct injury rate against overall complication rate after subtotal cholecystectomy, in pooled analysis  
_Source: Nadeem MA et al., Journal of Gastrointestinal Surgery, 2026_

Those two numbers are the whole argument. The procedure exists to avoid the injury that ruins a life, and it does that well. It achieves it by leaving behind a structure that leaks, retains stones, and sends one patient in six back for an endoscopic procedure afterwards.

Set against total cholecystectomy, the review found subtotal significantly worse for bile leak, retained stones, overall complications, readmission, reoperation and postoperative ERCP — and no different for mortality, intensive care admission or length of stay. The morbidity is real and it is mostly the kind that is fixed with another procedure rather than the kind that kills.

> **The figures have been stable for a decade**  
> An independent meta-analysis of 85 studies published between 1985 and 2020, covering 3,645 subtotal cholecystectomies, reported bile duct injury in seven patients (0.2 percent) and bile leak in 506 (13.9 percent). Two reviews with different authors, different periods and different inclusion criteria arrived at the same shape.

### The technique variant that matters

Subtotal cholecystectomy is done in two ways. The reconstituting version closes the gallbladder remnant so that it holds; the fenestrating version leaves it open and drains. Both reviews found the choice consequential in the same direction: the 2026 analysis reported significantly higher bile leak and longer stay after the fenestrating technique, and the earlier review found the reconstituting approach associated with lower risk across eleven of the outcomes it examined.

The 2026 review also identified patient factors that shift the risk. Diabetes was linked to higher rates of leak, complications and ERCP; male sex to more surgical site infection.

### Which gallbladders become difficult

The conditions that force a bailout are largely known before the operation begins. A systematic review and meta-analysis of preoperative risk factors for conversion to open surgery pooled the published odds ratios.

**Preoperative factors increasing the odds of conversion to open surgery**

| Factor | Odds ratio | 95% CI |
| --- | --- | --- |
| Acute cholecystitis | 5.475 | 2.959–10.130 |
| Age over 60 | 4.324 | 3.396–5.506 |
| Previous upper abdominal surgery | 3.301 | 1.965–5.543 |
| Heart disease | 2.947 | 1.047–8.296 |
| Diabetes | 2.576 | 1.687–3.934 |
| Obesity | 2.228 | 1.162–4.271 |
| Hypertension | 1.931 | 1.018–3.662 |
| Male sex | 1.907 | 1.254–2.901 |

None of these is modifiable on the morning of surgery. What they permit is planning: knowing before the first incision which operations are likely to become difficult, and staffing and scheduling them accordingly.

### Why a low conversion rate is an incomplete boast

A German secondary referral centre reported its ten-year record in 2026: 1,534 laparoscopic cholecystectomies, 31 conversions to open, a rate of 2.0 percent, and bile duct injury in 0.26 percent. Eighty-four percent of the conversions were emergency cases. The authors propose that a low conversion rate together with a low complication rate can serve as a marker of surgical quality.

As stated, with both halves attached, that is defensible. The half that cannot be dropped is the second one. A conversion rate can be driven toward zero by finishing difficult operations subtotally instead, and the pooled evidence says that route carries a 24.7 percent complication rate and returns one patient in six for an endoscopic procedure. A unit reporting its conversion rate alone is reporting the denominator of its own choice.

### What is missing here

1. None of these figures is Korean. Published Korean series reporting conversion rates or subtotal cholecystectomy outcomes at national scale were not available; the Korean number this publication has is a bile duct injury rate of 0.7 percent across 18 academic institutions, which is not the same measurement.
2. The subtotal figures are pooled across studies with different definitions of a difficult gallbladder and different thresholds for abandoning a total cholecystectomy, so the 24.7 percent complication rate describes a heterogeneous group of operations.
3. Comparisons of subtotal against total cholecystectomy are comparisons between patients who were selected into each, not between randomised arms. Subtotal is performed on the worst gallbladders by definition, and no adjustment removes that.
4. The German series is one centre and 1,534 operations, which is a description of that unit rather than a benchmark other units are obliged to meet.

> **The reading that survives the caveats**  
> Subtotal cholecystectomy is a rational response to a gallbladder that cannot be safely removed whole, and the evidence supports its central claim: it very rarely injures the bile duct. It is not a free alternative to converting, and a surgical unit that reports one rate without the other has not described its practice.

## Sources

- Nadeem MA, Awan AR, Wehrle CJ, Tsutsumi A, Darby F, Bhandarkar S, et al. Operative strategies for the acute difficult gallbladder: a Society for Surgery of the Alimentary Tract state-of-the-art systematic review and meta-analysis of subtotal cholecystectomy outcomes. Journal of Gastrointestinal Surgery 2026;30(4):102345. doi:10.1016/j.gassur.2026.102345. PMID:41644007. https://doi.org/10.1016/j.gassur.2026.102345
- Nzenwa IC, Mesri M, Lunevicius R. Risks associated with subtotal cholecystectomy and the factors influencing them: A systematic review and meta-analysis of 85 studies published between 1985 and 2020. Surgery 2021;170(4):1014-1023. doi:10.1016/j.surg.2021.03.036. PMID:33926707. https://doi.org/10.1016/j.surg.2021.03.036
- Magnano San Lio R, Barchitta M, Maugeri A, Quartarone S, Basile G, Agodi A. Preoperative Risk Factors for Conversion from Laparoscopic to Open Cholecystectomy: A Systematic Review and Meta-Analysis. International Journal of Environmental Research and Public Health 2022;20(1):408. doi:10.3390/ijerph20010408. PMID:36612732. https://doi.org/10.3390/ijerph20010408
- Schwarz J, Reithmann C, Rothe M, Allescher HD, Vogelsang H. Conversion Rate in Laparoscopic Cholecystectomy as a Critical Benchmark. Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A 2026;36(5):356-359. doi:10.1177/10926429261421340. PMID:41733426. https://doi.org/10.1177/10926429261421340
- Lee H, Han IW, Choi JE, Lee HK. Surgical risk calculator development for postoperative outcomes after laparoscopic cholecystectomy: a multicenter prospective cohort study. Annals of Surgical Treatment and Research 2025;108(6):352-361. doi:10.4174/astr.2025.108.6.352. PMID:40503269. https://doi.org/10.4174/astr.2025.108.6.352

## Citation

David Seo (2026). "Surgeons stopped escaping difficult gallbladders by opening the abdomen. What they do instead is safer for the bile duct and harder on everything else". Medical Insights Korea. https://medicalinsightskorea.com/news/difficult-gallbladder-bailout-subtotal-vs-conversion

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