THE COCONUT TECHNIQUE - A NEW METHOD TO PERFORM SAFE CHOLECYSTECTOMY FOR ACUTE CHOLECYSTITIS: Our Initial Experience
Conditions: Cholecystectomy
Sponsor: University of Catania

 
 
 
      
THE COCONUT TECHNIQUE – A NEW METHOD TO PERFORM SAFE 
CHOLECYSTECTOMY FOR ACUTE CHOLECYSTITIS: Our initial experience 
 
Dott.ssa A. Toro 
Adriana TORO, Chiara MAZZONE, Emanuele Gaspare FONTANA, Martina 
RAPISARDA Salomone DI SAVERIO, Luca ANSALONI, Fausto CATENA, Isidoro DI 
CARLO. 
02/02/2023 

 
 
1 
 
TITLE 
THE 
COCONUT 
TECHNIQUE 
– 
A 
NEW 
METHOD 
TO 
PERFORM 
SAFE 
CHOLECYSTECTOMY FOR ACUTE CHOLECYSTITIS: Our initial experience 
 
 
Authors: 
Adriana TORO*, Chiara MAZZONE, Emanuele Gaspare FONTANA, Martina RAPISARDA 
Salomone DI SAVERIO**, Luca ANSALONI***, Fausto CATENA****, Isidoro DI CARLO. 
 
 
Institutional affiliations: 
Department of Surgical Sciences and Advanced Technologies "G.F. Ingrassia", University of 
Catania, Cannizzaro Hospital, General Surgery, Catania, Italy. 
* General Surgery, Augusta Hospital, Syracuse, Italy. 
** La Sapienza University, Rome, Italy. 
*** Department of Surgery, University of Pavia. Italy 
**** Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy.  
 
 
E-mail address: 
Adriana Toro: atoroct@gmail.com  
Chiara Mazzone: chiaramazzone1995@gmail.com  
Emanuele Gaspare Fontana: emanuelegaspare@libero.it  
Martina Rapisarda: martinarapi96@gmail.com 
Salomone Di Saverio: salo75@inwind.it 
Luca Ansaloni: aiace63@gmail.com  
Fausto Catena: faustocatena@gmail.com 
Isidoro Di Carlo: idicarlo@unict.it 
 
 
Address for correspondence: 
Isidoro Di Carlo, MD, PhD, FACS, Professor of Surgery, Department of Surgical Sciences and 
Advanced Technologies “GF Ingrassia”, University of Catania, Cannizzaro Hospital, Via Messina 
829, 95126 Catania, Italy. Tel: +39 095 7264863. Fax: +39 095 7263020. E-mail: idicarlo@unict.it 

 
 
2 
 
 

 
 
3 
 
ABSTRACT 
Introduction 
The aim of this manuscript is to illustrate a new method permitting safe cholecystectomy in terms of 
complications with respect to the common bile duct (CBD). 
Methods 
The core of this new technique is identification of the continuity of the cystic duct with the 
infundibulum. The cystic duct can be identified between the inner gallbladder wall and inflamed outer 
wall. 
Results 
In the last 2 years, 3 patients have been treated with the reported technique without complications. 
Conclusions 
Among the various cholecystectomy procedures, this is a new approach that ensures the safety of the 
structures of Calot’s triangle while providing the advantages gained from total removal of the 
gallbladder. 
 
KEY WORDS 
acute cholecystitis, cholecystectomy, cystic duct 
 
 
 

 
 
4 
INTRODUCTION 
Elective surgery for gallbladder stones is usually easy; however, when the indication is acute 
cholecystitis, with or without stones, the procedure duration, techniques and results are often 
unpredictable (1). 
Many techniques have been described to prevent the various complications of surgery for 
cholecystitis, particularly damage to the CBD. 
Among the techniques used, subtotal cholecystectomy is the safest to avoid CBD damage; however, 
this procedure is also associated with some complications (2). 
The aim of this manuscript is to illustrate a new method permitting total cholecystectomy while 
maintaining safety with respect to CBD. 
 
METHOD 
To avoid subtotal cholecystectomy, we recently developed a simple but effective laparoscopic 
technique to approach and ligate the cystic duct in cases of difficult acute cholecystitis. 
The general rules adopted for the laparoscopic cholecystectomy technique have been well 
standardized over many decades. The patients were positioned supine in the French position, and 
three ports were used to perform the procedure. The umbilical port was first created through open 
surgery under direct vision, through which the camera was inserted. After establishing a 
pneumoperitoneum, two other ports were created to permit a perfect manipulation angle between the 
tips of the instruments. 
 
 
After releasing the gallbladder from the intraperitoneal adhesions and exposing the entire organ, the 
upper part of the fundus was identified and lifted up. Three to four centimeters of the inflamed 
gallbladder wall was then cut using an electrocautery hook (Figure 1). 
An incision was made in a safe zone, under direct vision, at the junction of the infundibulum and the 
body of the gallbladder. After the incision, the separation between the outer layer and inner layer was 
searched. If a space was found between the two layers, tension was created through traction of the 
inner layer up towards the gallbladder using forceps. No traction was placed on the outer layer, and 
in this way, it was possible to gradually maneuver it downwards and progressively separate it from 
the inner layer. This maneuver was time intensive and must be done very gently. Step by step, the 
outer layer was detached from the inner layer, highlighting the cystic duct origin. 
This clear identification of the confluence between the cystic duct and the body of the gallbladder 
represents the way to determine if the procedure was safely completed using the current technique, 
avoiding damage to the common biliary duct. 

 
 
5 
This maneuver to identify the continuity of the cystic duct with the infundibulum was mandatory 
(Figure 2). If this identification was not absolutely clear, another bail-out technique must be applied 
to complete the procedure safely. 
After successful identification, the cystic duct was clipped. It was fundamental to check for a robust 
inner layer because the mucosa only can be so thin, and the clip positioned on the cystic duct can be 
released, causing complications. 
The gallbladder can then be lifted and turned over, leaving the unidentified CBD untouched, and 
cholecystectomy can be carefully performed as usual. The inflamed posterior wall remained attached 
to the gallbladder bed of the liver. At the end of the procedure, a scrupulous check for biliary leakage 
and hemostasis was performed. A suction drainage tube was placed. 
 
RESULTS 
In the last 2 years, 3 patients have been treated with the reported technique. Two females and 1 male 
with a mean age of 50 years were diagnosed by CT scan with stage II acute cholecystitis according 
to the Tokyo guidelines and were operated on within three days of symptom onset. The abdominal 
drainage tube was left in place for 1 day, and following negative US findings, the patients were 
discharged on the 2nd postoperative day. No complications have been reported. Pathological 
examination of the specimen never showed only the mucosa layer, and the mucosa was associated 
with muscular layers of the gallbladder wall. 
 
 
 
DISCUSSION 
Total cholecystectomy represents the best method to cure all gallbladder diseases, and the Strasberg 
indications surely represent the basic guidelines to prevent the various complications associated with 
difficult cholecystectomies (3). 
Four types of subtotal cholecystectomies have been proposed. In types A and B, part of the posterior 
wall remains attached to the liver; however, in type A, the remaining gallbladder stump remains open, 
whereas in type B, it is closed. Types C and D include resection of both the anterior and posterior 
gallbladder walls; however, in type C, the pouch is closed, and drains are not routinely used, whereas 
in type D, the stump remains open (2). 
Despite the many techniques used, ligature of the cystic duct, when possible, remains the gold 
standard for cholecystectomy. When subtotal cholecystectomy is performed, complications can 
occur; for example, some studies have shown a higher incidence of postcholecystectomy syndrome, 

 
 
6 
cystic duct leakage, biliary event recurrence, biliary fistula, readmissions and reinterventions (4) (5) 
(6). 
Safe dissection of Calot's triangle to obtain a sufficient surgical view and minimize vascular or biliary 
injury is not easy. Our technique differs from that of Calot exposure because the cystic duct is 
identified from inside the inner gallbladder wall and externally from the inflamed outer wall, similar 
to dissecting a coconut shell. In this way, the continuity between the cystic duct and the infundibulum 
ensures that no other structures can be injured. The thickness of the gallbladder wall due to 
inflammation makes Calot exposure very challenging; in contrast, with our technique, the 
differentiation between the layers of the gallbladder permits safe identification of the cystic duct. This 
differentiation represents the safety of the presented technique, which is based on the identification 
of the junction of the cystic duct origin from the infundibulum after separation of the outer and inner 
layers of the inflamed gallbladder wall. This visualization represents the fundamental step of the 
technique because in this way, all catastrophic complications can be avoided, such as immediate 
direct clipping of the common bile duct or unnecessary traction and late complications such as 
secondary biliary cirrhosis (7). This technique is reproducible and can represent another useful option 
that can be useful in cases of acute cholecystic complications that make it difficult to operate. This 
procedure requires care from the surgeon side, but the advantage is that the affected zone of 
confluence of the cyst into the common bile duct is not approached from outside the peritoneum that 
covers these zones, avoiding the related risks. 
Among the various cholecystectomy procedures, this is a new approach that ensures the safety of the 
structures of Calot’s triangle while providing the advantages gained from total removal of the 
gallbladder. 
To the best of our knowledge, there are no similar techniques in the literature. A mucosectomy has 
been described by Gagner M. et al. (8) with the intent of skeletonizing the wall of the gallbladder and 
excluding the gallbladder from the bile duct, but the manuscript reports different indications. 
This technique represents a new technique in the armamentarium of surgeons in cases of very difficult 
cholecystitis. All patients who undergo surgery for acute cholecystitis could be treated with this 
technique, when possible. This approach should be tentatively attempted. If the technique can be 
completed, a safe cholecystectomy can be achieved, avoiding all the complications of subtotal 
cholecystectomy. This technique may fail if separating the two layers of the gallbladder wall is 
impossible, as a safe dissection plane to safely demonstrate the conjunction of the cystic duct with 
the infundibulum of the gallbladder would not be obtained. 
The technique can be very useful, but surgeons should remember that is not mandatory, and in cases 
of difficulties, a bail-out procedure is needed for the benefit of both the patients and surgeons. 

 
 
7 
In conclusion, the indications of this technique need to be validated with a greater number of cases, 
but it represents an option that can be attempted in all patients suffering from acute cholecystitis. 
Related to the starting point of the surgery in the gallbladder wall, the technique itself does not present 
any risk related to lesions in structures, and for this reason, it can be applied to all patients. The 
limitations of the procedure can be represented by the presence of necrotic or frail inner layers. This 
situation cannot permit the separation of the layers and can represent the starting point of spillage of 
stones or bile into the peritoneal cavity. In this case, subtotal cholecystectomy must be adopted 
without hesitation to avoid any dramatic complications. 
 
 
DECLARATIONS:  
- Ethical Approval and Consent to participate: The requirement of informed consent was not 
necessary because the data used were anonymous and identified. 
- Consent for publication: All authors have read and approved the submitted manuscript.  
- Availability of data and materials: The datasets used and/or analyzed during the current study are 
available from the corresponding author upon reasonable request. 
- Competing interests: All authors declared no competing interest.  
 
- Funding: None 
 
- Authors' contributions: 
A.T., C.M., E.G.F.  wrote the main manuscript text;  
A.T. and C.M. prepared figures 1-2; 
S.D.S., F.C., and L.A. critically revised the manuscript.  
I.D.C. have the idea of this new technique and definitively revised the manuscript.  
All the Authors reviewed the manuscript before the submission. 
REFERENCES 
1. Franklin ME Jr, George J, Russek K. Needlescopic cholecystectomy. Surg Technol Int 2010; 
20:109-13.  
2. Toro A, Teodoro M, Khan M et al. Subtotal cholecystectomy for difficult acute cholecystitis: 
how to finalize safely by laparoscopy-a systematic review. World J Emerg Surg 2021; 16: 45.  

 
 
8 
3. Mayumi T, Okamoto K, Takada T et al. Tokyo Guidelines 2018: management bundles for acute 
cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci 2018; 25: 96-100.  
4. Walsh RM, Ponsky JL, Dumot J. Retained gallbladder/cystic duct remnant calculi as a cause of 
postcholecystectomy pain. Surg Endosc 2002; 16: 981-4.  
5. Michael Brunt L, Deziel DJ, Telem DA et al. Prevention of Bile Duct Injury Consensus Work 
Group. Safe cholecystectomy multi-society practice guideline and state-of-the-art consensus 
conference on prevention of bile duct injury during cholecystectomy. Ann Surg 2020; 272: 3-23.  
6. Strasberg SM, Pucci MJ, Brunt LM, Deziel DJ. Subtotal Cholecystectomy-"Fenestrating" vs 
"Reconstituting" Subtypes and the Prevention of Bile Duct Injury: Definition of the Optimal 
Procedure in Difficult Operative Conditions. J Am Coll Surg 2016; 222: 89-96.  
7. Chiche L, Guieu M, Bachellier P, Suc B, Soubrane O, Boudjema K, Navarro F, Adam R, Vaillant 
JC, Salame E, Heyd B, Truant S, Adam JP, Laurent C. Liver transplantation for iatrogenic bile duct 
injury during cholecystectomy: a French retrospective multicenter study. HPB (Oxford) 2022; 24: 
94-100.  
8. Gagner M, Blanco R, Rossi RL. Ultrasonic mucosectomy of the gallbladder. A histological 
analysis. HPB Surg 1993; 6: 169-73.  
 
 

 
 
9 
Figure 1: Schematic drawing of the intraoperative view 
 
 
 
 
 
 
 
 

 
 
10 
Figure 2: Schematic drawing of the intraoperative view