Linear stapler-assisted subtotal cholecystectomy in portal cavernoma: A novel technical approach to a hostile Calot’s triangle

Abstract

Extrahepatic portal vein obstruction (EHPVO) with portal cavernoma (PC) presents a significant technical challenge during cholecystectomy due to extensive collateralization in the hepatoduodenal ligament. We report a novel technique of stapled subtotal cholecystectomy (SC) performed for symptomatic cholelithiasis in a 62-year-old female with longstanding EHPVO and prior proximal splenorenal shunt. Pre-operative imaging demonstrated extensive periportal, perigastric, and peripancreatic cavernomas. In view of the high risk of intraoperative hemorrhage, an open approach was undertaken. Intraoperatively, dense cavernomatous collaterals involving Calot’s triangle precluded safe dissection. A fundus-first SC was performed, and a linear stapler was applied across the Hartmann’s pouch to achieve simultaneous transection and closure of the gallbladder neck. The procedure was completed without bleeding or bile leak, and the post-operative course was uneventful. Stapled SC avoids dissection and suturing in a vascular field, thereby minimizing the risk of hemorrhage in the presence of PC. Although experience remains limited, this technique appears to be a safe and practical bailout strategy in selected patients where conventional dissection is not feasible. To our knowledge, this is the first report describing the use of a linear stapler for SC in this setting.