partial cholecystectomy , whether open ( 1,2 ) or laparoscopic ( 3 ) , has been described as a safe and effective operation .
it is indicated in cases of severe acute cholecystitis , gangrenous cholecystitis or necrotizing cholecystitis , where the degree of inflammation precludes safe visualization of biliary structures .
partial cholecystectomy removes the majority of the gallbladder , leaving a portion of the neck , and occasionally the posterior wall of the gallbladder , in place .
( 4 ) it is reportedly tolerated well , with few minor postoperative complications , however the issues that do occur include recurrent symptoms , choledocholithiasis and persistent biliary fistula . ( 5 ) historical accounts have documented partial cholecystectomy performed in the 1950s with washout and removal of gallbladder contents with placement of a drain in the orifice of the cystic duct when dissection of the hilar structures would be too dangerous , or the gallbladder was densely adherent to the liver bed .
( 6 ) it should be noted that even though technically possible , partial cholecystectomy is less than the ideal procedure , which is a complete cholecystectomy , with total removal of the gallbladder and closure of the cystic duct remnant .
partial cholecystectomy may not provide a cure in all patients because leaving a portion of the gallbladder in situ in connection to the common bile duct may contribute not only to the formation of new stones , but also leaves a path intact for continued biliary colic and obstruction .
we review a case in which partial cholecystectomy was performed due to severe inflammation in a young otherwise healthy patient .
a 22 year - old male presented with a history of several months of nausea , vomiting , right upper quadrant abdominal pain and in the last two weeks , jaundice .
seven months prior , he had undergone a partial cholecystectomy at an outside institution for severe acute cholecystitis .
the case was attempted laparoscopically , however due to lack of visualization , it was converted to an open approach .
the gallbladder was dissected from the fundus in a retrograde fashion , but extended far posteriorly , and was noted to be beyond surgical reach , secondary to the acute inflammation .
a partial cholecystectomy was done with a surgical ta stapler across the infundibulum leaving approximately 25% of the gallbladder , including the entire cystic duct .
mrcp shows the residual gallbladder (  x  ) , and the dilated common bile duct with stones ( white arrows ) over seven months , he had continued frequent recurrent attacks of acute cholecystitis , and choledocholithiasis .
his symptoms included frequent nausea , vomiting , persistent sharp right upper quadrant pain , fever , and jaundice , which precipitated multiple emergency department visits to multiple institutions .
the patient presented to our institution with an outside ultrasound that demonstrated multiple residual stones , a sonographic murphy s sign , and dilated common bile duct of 9 mm .
. 1 ) and gallstones were visualized in the remaining portion of the gallbladder by ct , ( fig .
preoperatively , an ercp with sphincterotomy was performed to extract the remaining common bile duct stones ( fig .
ct of the abdomen demonstrates the residual portion of the gallbladder , marked by an 
the staple line , indicated by a black arrow , is seen best on the coronal imaging at operation , the previous transverse right upper quadrant incision was reentered , and dissection continued down to the liver .
the previously stapled remnant of gallbladder was identified as partially intrahepatic , and located at the most inferior portion of the liver .
the cystic duct and artery were then each ligated and a completion cholecystectomy was performed . due to the still severe inflammation , the estimated blood loss was 1800 cc . on pathology ,
the patient tolerated the surgery well and was discharged home the following day , and made a full recovery with no further symptoms .
ercp shows a residual cystic duct ( black arrow ) , and choledocholithiasis ( white arrows )
in patients with acute cholecystitis , partial cholecystectomy can be performed , when the severity of inflammation precludes safe dissection of the hilar structures .
depending on the extent of the resection and the structures left in situ , there is a definite risk of recurrence of symptoms , including recurrent acute cholecystitis ( 7 ) , gallstone pancreatitis ( 8) and choledocholithiasis .
the morbidity of recurrent gallbladder issues will require further endoscopic and/or surgical interventions in at least some patients , as the underlying pathophysiologic process responsible for the acute cholecystitis has not been definitively managed .
all efforts should be made to remove remaining gallstones from the remaining portion of the gallbladder ; as this was not done in our patient it explains the lack of recovery from the partial cholecystectomy .
analogous to a cholecystostomy tube placement , partial cholecystectomy should therefore be considered another option for temporizing the patient experiencing severe acute cholecystitis .
however , there needs to be an awareness that the patient will need to be considered for definitive surgical management with a completion cholecystectomy . in our case , this was done via an open approach due to the adhesions and the posterior position of the remnant gallbladder , but in more favorable cases it has been performed laparoscopically .
 partial cholecystectomy has been documented in the literature as a safe alternative in the management of patients with acute cholecystitis when the degree of inflammation prevents a safe dissection to identify the biliary structures for complete removal of the gallbladder . 
 partial cholecystectomy however is not without risk of recurrence , and the need for further surgical or endoscopic intervention in management of complications . 
 we review a case in which partial cholecystectomy was performed without any relief of symptoms , to review the possible postoperative complications , and caution that these patients will need to be considered for a completion cholecystectomy . 
INTRODUCTION
CASE REPORT
DISCUSSION