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 [2]. 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.

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, cystic duct leakage, biliary event recurrence, biliary fistula, readmissions and reinterventions [4,5,6].

Many articles describe the possibility of Calot visualization [7]. In case of severe inflammation of Calot, this maneuver is not easy and should be avoided to prevent severe damages [8] or open conversion [9]. Furthermore, the visualization of Calot triangle is very hazardous in case of severe inflammation and a cautious behavior could be recommended [10].

The first step of the present technique is the most important not only to avoid complications but also to understand if the technique can be finalized or not. As the approach is very high, far from infundibulum, the only risk in this stage is represented by wall perforation. In case of minimal leakage, the procedure can reach the end. On the opposite in case of massive bile leakage in our opinion is better to convert with subtotal cholecystectomy, laparoscopic [2] or open [11]. In the presence of massive adhesion and difficulty to separate the layers, the subtotal cholecystectomy has to be adopted without procrastination.

The bleeding that can affect this procedure is not relevant as for common total cholecystectomy. This is due to the fact that the majority of anterior vessels can be managed easily. The posterior ones between the external layer and the liver, in this technique, are leaved in place with external layer.

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 [12]. 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. [13] with the intent of skeletonizing the wall of the gallbladder and excluding the gallbladder from the bile duct, but the manuscript reports different indications.