Title: Endo-loop or Interrupted Suture Closure of Gallbladder Remnant During Laparoscopic
Subtotal Cholecystectomy- a Retrospective Analysis of Our Experience at a High-Volume
Centre of Eastern Nepal
Version: 4 Date: 13 Mar 2025
Reviewer:  Muthukumaran Rangarajan
Reviewer's report:
1. “In our centre, we prefer endo-loop over interrupted suture if the remnant stump is
mobilized to such an extent that it’s all sides (including posterior) are intact and of adequate
length.  Meanwhile, we prefer interrupted suture closure if the posterior side is not adequately
mobilizable or if any side has inadequate length.” : Authors must explain the very basis of this
study, as it appears to be flawed: because your indications for both the techniques are different.
So would it be fair to compare the efficacy of one over the other?
2. Authors mention: “The absence of any stone in the gallbladder remnant is confirmed under
direct vision, then the remnant stump is closed by either interrupted sutures with 2-0 polyglactin
or pre-knotted endo-loop of PDS, based on operating surgeon’s preference.” : so there is no
standardization?
3. Please delete this from METHODS section: "Subtotal cholecystectomy consists of the
removal of most of the organ, usually with dissection at the infundibulum.4 According to the
classification by Henneman et al.1,3, there are four types of subtotal cholecystectomy, depending
on the preservation of the posterior wall, the area of the dissection and the management of the
remaining structures. Type A is based on preserving the posterior wall, which would be attached
to the gallbladder bed, without closing the gallbladder remnant; type B involves preserving the
posterior wall by closing the gallbladder remnant; type C involves making the dissection at the
infundibulum of the gallbladder, with closure of the gallbladder remnant; similarly, in type D,
the division is made at the area of the infundibulum of the gallbladder, although it is not closed"
4. Avoid using references in METHODS section
5. Regarding intraoperative blood loss: was the 200ml blood loss (quite high) was during the
stump closure?
6. TABLE 2: the numbers depicted under “Complications” are confusing – are they percentages
or actual patient numbers? For example, you mention “CBD stricture is 52 & 68” – does
that mean all the patients developed stricture?? Also you mention “Early postoperative
complications: None – 32 & 68”: please explain
7. Is there any evidence for this: “This implies an extra waiting period of around 14 years by
patients with gall bladder disease before they seek the definitive treatment. The more one with
gall stone waits for the definitive treatment, more is the chance that one needs laparoscopic
subtotal cholecystectomy than laparoscopic classic cholecystectomy.”
8. This is not relevant here, so please delete “Patients with gall bladder stone has female
preponderance because oestrogen increases biliary cholesterol secretion causing supersaturation
of bile. In this study among patients who underwent laparoscopic subtotal cholecystectomy,
a slight male predominance may be because of higher tolerance and delayed health seeking
behavior among male than female patients in our parts of the world.”
9. In TABLE 2, you mention “CBD stricture is 52 & 68” but in DISCSUSSION you mention
“We were fortunate to have none of the late complications such as CBD stricture, recurrent/
residual stone in the remnant stump till date.” – Please clarify
Title: Endo-loop or Interrupted Suture Closure of Gallbladder Remnant During Laparoscopic
Subtotal Cholecystectomy- a Retrospective Analysis of Our Experience at a High-Volume
Centre of Eastern Nepal
Version: 4 Date: 13 Mar 2025
Reviewer:  Muthukumaran Rangarajan
Reviewer's report:
1. “In our centre, we prefer endo-loop over interrupted suture if the remnant stump is
mobilized to such an extent that it’s all sides (including posterior) are intact and of adequate
length.  Meanwhile, we prefer interrupted suture closure if the posterior side is not adequately
mobilizable or if any side has inadequate length.” : Authors must explain the very basis of this
study, as it appears to be flawed: because your indications for both the techniques are different.
So would it be fair to compare the efficacy of one over the other?
2. Authors mention: “The absence of any stone in the gallbladder remnant is confirmed under
direct vision, then the remnant stump is closed by either interrupted sutures with 2-0 polyglactin
or pre-knotted endo-loop of PDS, based on operating surgeon’s preference.” : so there is no
standardization?
3. Please delete this from METHODS section: "Subtotal cholecystectomy consists of the
removal of most of the organ, usually with dissection at the infundibulum.4 According to the
classification by Henneman et al.1,3, there are four types of subtotal cholecystectomy, depending
on the preservation of the posterior wall, the area of the dissection and the management of the
remaining structures. Type A is based on preserving the posterior wall, which would be attached
to the gallbladder bed, without closing the gallbladder remnant; type B involves preserving the
posterior wall by closing the gallbladder remnant; type C involves making the dissection at the
infundibulum of the gallbladder, with closure of the gallbladder remnant; similarly, in type D,
the division is made at the area of the infundibulum of the gallbladder, although it is not closed"
4. Avoid using references in METHODS section
5. Regarding intraoperative blood loss: was the 200ml blood loss (quite high) was during the
stump closure?
6. TABLE 2: the numbers depicted under “Complications” are confusing – are they percentages
or actual patient numbers? For example, you mention “CBD stricture is 52 & 68” – does
that mean all the patients developed stricture?? Also you mention “Early postoperative
complications: None – 32 & 68”: please explain
7. Is there any evidence for this: “This implies an extra waiting period of around 14 years by
patients with gall bladder disease before they seek the definitive treatment. The more one with
gall stone waits for the definitive treatment, more is the chance that one needs laparoscopic
subtotal cholecystectomy than laparoscopic classic cholecystectomy.”
8. This is not relevant here, so please delete “Patients with gall bladder stone has female
preponderance because oestrogen increases biliary cholesterol secretion causing supersaturation
of bile. In this study among patients who underwent laparoscopic subtotal cholecystectomy,
a slight male predominance may be because of higher tolerance and delayed health seeking
behavior among male than female patients in our parts of the world.”
9. In TABLE 2, you mention “CBD stricture is 52 & 68” but in DISCSUSSION you mention
“We were fortunate to have none of the late complications such as CBD stricture, recurrent/
residual stone in the remnant stump till date.” – Please clarify
Please review this paper.
user
Title: Endo-loop or Interrupted Suture Closure of Gallbladder Remnant During Laparoscopic
Subtotal Cholecystectomy- a Retrospective Analysis of Our Experience at a High-Volume
Centre of Eastern Nepal
Version: 4 Date: 13 Mar 2025
Reviewer:  Muthukumaran Rangarajan
Reviewer's report:
1. “In our centre, we prefer endo-loop over interrupted suture if the remnant stump is
mobilized to such an extent that it’s all sides (including posterior) are intact and of adequate
length.  Meanwhile, we prefer interrupted suture closure if the posterior side is not adequately
mobilizable or if any side has inadequate length.” : Authors must explain the very basis of this
study, as it appears to be flawed: because your indications for both the techniques are different.
So would it be fair to compare the efficacy of one over the other?
2. Authors mention: “The absence of any stone in the gallbladder remnant is confirmed under
direct vision, then the remnant stump is closed by either interrupted sutures with 2-0 polyglactin
or pre-knotted endo-loop of PDS, based on operating surgeon’s preference.” : so there is no
standardization?
3. Please delete this from METHODS section: "Subtotal cholecystectomy consists of the
removal of most of the organ, usually with dissection at the infundibulum.4 According to the
classification by Henneman et al.1,3, there are four types of subtotal cholecystectomy, depending
on the preservation of the posterior wall, the area of the dissection and the management of the
remaining structures. Type A is based on preserving the posterior wall, which would be attached
to the gallbladder bed, without closing the gallbladder remnant; type B involves preserving the
posterior wall by closing the gallbladder remnant; type C involves making the dissection at the
infundibulum of the gallbladder, with closure of the gallbladder remnant; similarly, in type D,
the division is made at the area of the infundibulum of the gallbladder, although it is not closed"
4. Avoid using references in METHODS section
5. Regarding intraoperative blood loss: was the 200ml blood loss (quite high) was during the
stump closure?
6. TABLE 2: the numbers depicted under “Complications” are confusing – are they percentages
or actual patient numbers? For example, you mention “CBD stricture is 52 & 68” – does
that mean all the patients developed stricture?? Also you mention “Early postoperative
complications: None – 32 & 68”: please explain
7. Is there any evidence for this: “This implies an extra waiting period of around 14 years by
patients with gall bladder disease before they seek the definitive treatment. The more one with
gall stone waits for the definitive treatment, more is the chance that one needs laparoscopic
subtotal cholecystectomy than laparoscopic classic cholecystectomy.”
8. This is not relevant here, so please delete “Patients with gall bladder stone has female
preponderance because oestrogen increases biliary cholesterol secretion causing supersaturation
of bile. In this study among patients who underwent laparoscopic subtotal cholecystectomy,
a slight male predominance may be because of higher tolerance and delayed health seeking
behavior among male than female patients in our parts of the world.”
9. In TABLE 2, you mention “CBD stricture is 52 & 68” but in DISCSUSSION you mention
“We were fortunate to have none of the late complications such as CBD stricture, recurrent/
residual stone in the remnant stump till date.” – Please clarify
assistant