Comparative Assessment Between the Fundus-First Technique and Standard Laparoscopic Technique in Difficult Laparoscopic Cholecystectomy

Background: Laparoscopic cholecystectomy is a standard minimally invasive technique for the treatment in gallstone disease. In difficult laparoscopic cholecystectomies, bailout strategies have been developed of which the fundus-first technique is one. The present study aims to compare the outcomes of the fundus-first technique against the standard laparoscopic approach in managing difficult cholecystectomy cases by focusing on intraoperative factors such as bleeding, bile duct injury, operative time, and postoperative complications like biliary leakage.

Methods: A prospective comparative study was conducted over a period of two years (June 2022-May 2024) with 200 consecutive patients. All patients were classified as difficult cases based on the Tokyo 2018 guidelines. Detailed data collection included patient history, physical examination, laboratory investigations, and operative findings. The study's follow-up period was six weeks.

Results: The fundus-first technique demonstrated significant advantages, with a reduction in operative time, fewer intraoperative complications, and better operative outcomes compared to the standard approach. Patients in the fundus-first group had a mean operative time of 91.50 minutes as compared to 143.75 minutes in the standard group (p < 0.001) and 88% completed operative outcome vs 51%(p < 0.001). No significant differences were observed in postoperative complications such as bile leakage and bleeding between the two groups.

Conclusion: The fundus-first technique offers a safer and more efficient alternative to the standard approach in difficult laparoscopic cholecystectomy cases. By allowing better access to Calot's triangle, this method proves to be an effective bailout strategy, despite its steep learning curve. Further studies are needed to validate these findings and explore the broader application of the fundus-first technique in gallbladder surgeries.