Artificial intelligence applied to laparoscopic cholecystectomy: what is the next step? A narrative review

Artificial intelligence (AI) is playing an increasing role in several fields of medicine. It is also gaining popularity among surgeons as a valuable screening and diagnostic tool for many conditions such as benign and malignant colorectal, gastric, thyroid, parathyroid, and breast disorders. In the literature, there is no review that groups together the various application domains of AI when it comes to the screening and diagnosis of main surgical diseases. The aim of this review is to describe the use of AI in these settings. We performed a literature review by searching PubMed, Web of Science, Scopus, and Embase for all studies investigating the role of AI in the surgical setting, published between January 01, 2000, and June 30, 2023. Our focus was on randomized controlled trials (RCTs), meta-analysis, systematic reviews, and observational studies, dealing with large cohorts of patients. We then gathered further relevant studies from the reference list of the selected publications. Based on the studies reviewed, it emerges that AI could strongly enhance the screening efficiency, clinical ability, and diagnostic accuracy for several surgical conditions. Some of the future advantages of this technology include implementing, speeding up, and improving the automaticity with which AI recognizes, differentiates, and classifies the various conditions.

Laparoscopic cholecystectomy (LC) is now a common method of treating symptomatic gallstones, and it is increasingly being requested by the informed general public. Our aim was to evaluate the role of LC for cholelithiasis and to establish its outcome and the effect of gender on the results. Between September 1994 and June 1999, all patients who underwent LC for cholelithiasis were retrospectively reviewed. They were classified as having acute or chronic cholecystitis (AC or CC). There were 791 patients with CC (633 females, 158 males) and 204 patients with AC (124 females, 80 males). Conversion to open cholecystectomy was needed in 0.76% and 11.8% of the patients with CC and AC, respectively (P<0.00). Four percent of the female patients with AC needed conversion as compared to 23.8% in the males (P<0.00). The low conversion rate in CC limited gender comparison. Median operation time in the patients with CC was 53+/-16 minutes as compared to 74.5+/-35.7 minutes in those with AC (P<0.00). Operation time in the male patients with CC and AC was significantly higher than in the female patients, even after excluding the converted cases (P<0.00). Median postoperative stay for patients with CC was 1.33+/-0.9 days as compared to 1.9+/-1.34 days in patients with AC (P<0.00). No statistical significance in the hospital stay was found between males and females (in CC and AC). There was no mortality in the series. There were three bile duct injuries in the patients with CC. In patients with successful LC, gallbladder perforation occurred in 18% and 31% of CC and AC patients, respectively (P<0.003). Missed stones occurred in 1.4% and 3.3% of the patients with successful LC for CC and AC, respectively. Bile collection, which was treated with open drainage, occurred in four patients with CC and one patient with AC. LC for symptomatic cholelithiasis is safe and feasible; it should be the first choice before resorting to open surgery. In patients with AC as compared to CC, there is an increased conversion rate, longer operation time, longer hospital stay, and higher incidence of gallbladder perforation without an increase in the incidence of bile duct injuries (BDI). Male patients have a longer operation time and higher conversion rate than female patients.

Randomized trials, observational studies, and the illusive search for the source of truth

Postoperative Pulmonary Changes after Laparoscopic Cholecystectomy

Cholecystectomy is one of the most frequently performed operations. Open cholecystectomy has been the gold standard for over 100 years. Laparoscopic cholecystectomy was introduced in the 1980s. To compare the beneficial and harmful effects of laparoscopic versus open cholecystectomy for patients with symptomatic cholecystolithiasis. We searched TheCochrane Hepato-Biliary Group Controlled Trials Register (April 2004), The Cochrane Library (Issue 1, 2004), MEDLINE (1966 to January 2004), EMBASE (1980 to January 2004), Web of Science (1988 to January 2004), and CINAHL (1982 to January 2004) for randomised trials. All published and unpublished randomised trials in patients with symptomatic cholecystolithiasis comparing any kind of laparoscopic cholecystectomy versus any kind of open cholecystectomy. No language limitations were applied. Two authors independently performed selection of trials and data extraction. The methodological quality of the generation of the allocation sequence, allocation concealment, blinding, and follow-up was evaluated to assess bias risk. Analyses were based on the intention-to-treat principle. Authors were requested additional information in case of missing data. Sensitivity and subgroup analyses were performed when appropriate. Thirty-eight trials randomised 2338 patients. Most of the trials had high bias risk. There was no significant difference regarding mortality (risk difference 0,00, 95% confidence interval (CI) -0.01 to 0.01). Meta-analysis of all trials suggests less overall complications in the laparoscopic group, but the high-quality trials show no significant difference ('allocation concealment' high-quality trials risk difference, random effects -0.01, 95% CI -0.05 to 0.02). Laparoscopic cholecystectomy patients have a shorter hospital stay (weighted mean difference (WMD), random effects -3 days, 95% CI -3.9 to -2.3) and convalescence (WMD, random effects -22.5 days, 95% CI -36.9 to -8.1) compared to open cholecystectomy. No significant differences were observed in mortality, complications and operative time between laparoscopic and open cholecystectomy. Laparoscopic cholecystectomy is associated with a significantly shorter hospital stay and a quicker convalescence compared with the classical open cholecystectomy. These results confirm the existing preference for the laparoscopic cholecystectomy over open cholecystectomy.

In this golden age of rapid development surgeons realized that AI could contribute to healthcare in all aspects, especially in surgery. The aim of the study will incorporate the use of Convolutional Neural Network and Constrained Local Models (CNN-CLM) which can make improvement for the assessment of Laparoscopic Cholecystectomy (LC) surgery not only bring opportunities for surgery but also bring challenges on the way forward by using the edge cutting technology. The problem with the current method of surgery is the lack of safety and specific complications and problems associated with safety in each laparoscopic cholecystectomy procedure. When CLM is utilize into CNN models, it is effective at predicting time series tasks like identifying the sequence of events in the Laparoscopic Cholecystectomy (LC). This study will contribute to show the effectiveness of CNN-CLM approach on laparoscopic cholecystectomy, which will frequently focus on surgical computer vision analysis of surgical safety and related applications. The method of study is deep learning based CNN-CLM to better detect nominal safety as well as unsafe practices around the critical view of safety and AI-based grading scale. The general design flow of AI-recognition of surgical safety is firstly collecting safety surgical videos for frame segmenting and phase according to the image context by surgeon reviewer by CNN-CLM. For this advance research, the dataset is splatted into three main parts where 70% of which is used for training, 15% of which is used for testing and the rest for the cross validation, to achieve the accuracy up to 98.79% of this specific research. For result part, different metrics of CNN-CLM to evaluate the performance of the proposed model of safety in surgery. The study uses one of the top three performing methods CNN-CLM for the evaluation yields and anatomical structures in laparoscopic cholecystectomy surgery.

Laparoscopic or open cholecystectomy in cirrhosis: a systematic review of outcomes and meta-analysis of randomized trials

Introduction: Achalasia is a rare primary esophageal disorder characterized by impaired functioning of the lower esophageal sphincter. The goal of treatment is to reduce symptoms and improve the quality of life. The gold standard of surgical approach is Heller-Dor myotomy. The aim of this review is to describe the use of robotic surgery in patients with achalasia. Methods: The literature review was performed by searching on PubMed, Web of Science, Scopus and EMBASE for all studies on robotic surgery for achalasia, published from January 1, 2001, to December 31, 2022. We focused our attention on randomized controlled trials (RCTs), metaanalysis, systematic reviews, and observational studies on large cohorts of patients. Furthermore, we have identified relevant articles from the reference list. Conclusions: Taking into consideration our review and experience, RHM with partial fundoplication is safe, efficient, comfortable for the surgeon and characterized by a reduction of the intraoperative perforation rate of the esophageal mucosa. This approach may represent the future for the surgical treatment of achalasia especially with a reduction in costs.

Laparotomy causes a significant reduction of pulmonary function, and atelectasis and pneumonia occur after open cholecystectomy. In this prospective, randomized study, we evaluated the hypothesis that pulmonary function is less restricted after laparoscopic cholecystectomy (LC) than after open cholecystectomy (OC). Sixty patients underwent laparoscopic (n = 30) or open (n = 30) cholecystectomy. The two groups did not differ significantly in age, sex, intraoperative findings, and preoperative pulmonary function. Pulmonary function tests, arterial blood-gas analysis, and chest radiographs were obtained in both groups before operation and on postoperative day 1. The forced expiratory volume in 1 s (mean +/- SD values; OC, 1.49 +/- 0.77 L/s; LC, 2.33 +/- 0.80 L/s; p > 0.0001) and the forced vital capacity (OC, 2.40 +/- 0.66 L; LC, 2.93 +/- 1.05 L; p > 0.01) were more suppressed in patients having OC than in those having LC. Similar results were found for the peak expiratory flow (OC, 3.51 +/- 1.35 L/s; LC, 4.27 +/- 1.66 L/s; p > 0.05), expiratory reserve volume (OC, 0.73 +/- 0.34 L; LC, 0.92 +/- 0.43 L; p > 0.05), and the midexpiratory phase of forced expiratory flow (FEF25-75) (OC, 1.45 +/- 0.54 L/s; LC, 1.60 +/- 0.73 L/s; NS). Laparoscopic cholecystectomy was associated with a significantly lower incidence of (30 vs 70%) and less severe atelectasis and better oxygenation. Pulmonary function is better preserved after LC than after OC.

Background: Open cholecystectomy (OC) may still be necessary in surgical training to perform safe conversions of laparoscopic cholecystectomy (LC). Our aim was to study the outcome of LCs and OCs performed by surgical trainees. Methods: All consecutive cholecystectomies (1,581 LCs and 984 OCs) were retrospectively analyzed from 1995 until 2008. Operative complications were compared between the cholecystectomies performed by 20 trainees alone (n = 822), assisted operations (n = 754, trainees/specialist surgeons) and 9 specialists alone (n = 989). Results: Surgical trainees performed 787 (50%) LCs and 789 (80%) OCs either alone or assisted. The conversion rate of LC for trainees and specialist surgeons were 34 (7.0%) and 44 (5.5%), respectively. Complication rates and mortality were similar between the trainees and specialist surgeons. No bile duct injuries were associated with LCs or OCs performed by trainees alone. LCs were associated with 9 (0.57%) cases of bile leakage from cystic stump and 2 (0.13%) other bile duct injuries. Conclusion: Surgical trainees performed over half of our cholecystectomies with good results. The patient selection for LC versus OC was good, because no total transection of the common bile duct was observed in over 1,500 LC operations.

Artificial intelligence (AI) systems have witnessed notable advancements, revolutionizing various fields of research and medicine. Specifically, advancements of AI and the rapid growth of machine learning hold immense potential to significantly impact emergency medicine. This narrative review aimed to summarize AI applications in prehospital emergency care, emergency radiology, triage and patient classification, emergency diagnosis and interventions, pediatric emergency care, trauma care, outcome prediction, as well as the legal and ethical challenges and limitations of AI use in emergency medicine. A comprehensive literature search was conducted in Web of Science, Scopus, and Medline using a wide range of artificial intelligence and machine learning-related keywords combined with terms related to emergency medicine to identify relevant published studies. The findings show that AI-powered tools can assist clinicians in emergency departments in improving the management of prehospital emergency care, emergency radiology, triage, emergency department workflow, complex diagnoses, treatment, clinical decision-making, pediatric emergency care, trauma care, and the prediction of admissions, discharges, complications, and outcomes. However, the majority of these applications have been reported in retrospective studies, whereas randomized controlled trials (RCTs) are essential to determine the true value of AI in emergency settings. These applications can serve as effective tools in emergency departments when they are continuously supplied with high-quality real-time data and are adopted through collaboration between skilled data scientists and clinicians. Implementing these AI-assisted tools in emergency departments requires adequate infrastructure and machine learning operation systems. Since emergency medicine involves various clinical decision-making scenarios based on classifications, flowcharts, and well-structured approaches, future well-designed prospective studies are necessary to achieve the goal of replacing conventional methods with new AI and machine learning techniques.

Background: Globally, gallstone disease (GS) is a significant health issue, especially for adults although cholecystitis is common, there is an evidence of variance in its diagnosis and course of therapy, including surgery. In place of open cholecystectomy, laparoscopic cholecystectomy is now the preferred course of treatment for symptomatic cholelithiasis. In situations where laparoscopic cholecystectomy is dangerous; a surgeon may be forced to change from laparoscopy to an open procedure. The aim of the study was to clarify the benefits and role of minimally invasive surgery in comparison to the open conventional method of cholecystectomy, with a focus on the postoperative phase and to compare the ratio of Laparoscopic and open cholecystectomy between male and female genders. Methods: 185 Patients of cholecystitis aged between 10 years to 80 years (86.5% males and 13.5% females) were presented to Zawia Medical Center during the period from March 2005 till April 2006 that randomly get an open or laparoscopic cholecystectomy. They were divided into open and laparoscopic Cholecystectomy group. Results: In this study, a total of 185 patients were included: 160 females (86.5% of the total) and 25 males (13.5% of the total). Whereas, 86 females (53.7%) were operated on by laparoscopic cholecystectomy, and 74 females (46%) were operated on by open cholecystectomy. In comparison, of a total of 25 males, 12 (48%) underwent laparoscopic cholecystectomy and 13 (52%) underwent open cholecystectomy. The conversion rate was eight cases (8.2%) due to technical, bleeding, or massive adhesion. Conclusion: From this study, we concluded that the laparoscopic cholecystectomy versus open cholecystectomy ratio (female: male ratio) was 86.5% to 13.5% of the total 185 patients, and laparoscopic cholecystectomy appears to be a safe procedure with quick recovery, early discharge from the hospital, and less postoperative pain as compared to open cholecystectomy.

Background: Laparoscopic cholecystectomy has become the gold standard in the treatment of symptomatic gallstones. In spite of the advantages of a distinctly faster recovery and better cosmetic results, the laparoscopic approach bears a higher risk for iatrogenic bile duct injury and injury of the right hepatic artery. Bile leak after laparoscopic cholecystec-tomy is uncommon but can occur in 0.3-2.7% of patients. A bile leak may result in a biliary fistula, a subhepatic/subphrenic collection and localised or generalised peritonitis. Despite the widespread notion that the risk of bile leak is higher after LC, there is a scarcity in the published literature that directly compared the risk of bile leak after LC versus open cholecys-tectomy. Aim of Study: To provide cumulative data about the outcome of biliary leakage after laparoscopic versus open cholecystectomy. Patients and Methods: In the present study, we searched Medline via PubMed, SCOPUS, Web of Science, and Cochrane Central Register of Controlled Trials (CENTRAL) from their inception till December 2018. The search retrieved 12157 unique records. We then retained 45 potentially eligible records for full-texts screening. Finally, 17 studies were included in the present systematic review and meta-analysis. Data Extrac-tion: If the studies did not fulfill the inclusion criteria, they were excluded. Study quality assessment included whether ethical approval was gained, eligibility criteria specified, appropriate controls, and adequate information and defined assessment measures. Results: In terms of the primary outcomes of the present study, the overall effect estimates showed that LC significantly increased the risk of bile leak compared to OC (OR 2.01, 95% CI [1.3-3.09]; p=0.002); the pooled studies showed no signif-icant heterogeneity (p=0.74; I2=0%). Conclusion: Surgeons experienced a very low rate of postoperative bile leak following laparoscopic or open chole-cystectomy; however, the risk of bile leak appears to be higher with laparoscopic compared to open cholecystectomy. The present systematic review and meta-analysis showed that the laparoscopic cholecystectomy significantly increased the risk of bile leak compared to open cholecystectomy. These data draw attention to the importance of early identification of patients, at high risk of bile leak, as it may allow specific measures or conversion to open cholecystectomy.

e16616 Background: Within the field of medicine, artificial intelligence (AI) is used to optimize diagnostic capacity, treatment planning, and prognostic evaluation. Research on AI has advanced significantly, but a comprehensive evaluation of the utility of AI in genitourinary (GU) oncology remains underexplored. We sought to conduct a bibliometric study of existing literature and a systematic review of randomized controlled trials (RCTs) to describe the state of the science regarding the use and applications of AI in GU oncology. Methods: We searched MEDLINE (Ovid), Embase (Ovid), and CINAHL Ultimate databases using search terms relevant to the concepts of GU oncology and AI. We excluded non-English papers, non-human studies, review articles, and articles using AI in manuscript writing. Our bibliometric study described articles from 2013-2023 using the term AI, and we categorized manuscripts by study type and cancer type. We also conducted a systematic review of RCTs assessing the use of AI in GU oncology. We used Covidence for screening and data extraction. Two authors independently reviewed all papers and Cochrane Risk of Bias (RoB) Tool 2.0 was used to assess for bias in the RCT studies. Results: The initial search identified 2,409 articles. After abstract review, 1,220 articles remained: 962 retrospective articles, 175 prospective studies, 79 with combined retrospective/prospective methods, and 4 RCTs. We also categorized studies by cancer type: 923 prostate, 274 renal, 194 urothelial, 8 testicular, and 2 penile cancers. AI-related articles grew exponentially from 14 in 2013 to 362 in 2023, with substantial growth starting in 2019 (92 that year). For our systematic review, we identified 4 RCTs: 1 in bladder cancer (BCa) and 3 in prostate cancer (PCa). Among the 4 RCTs, 2 focused on AI-based diagnostics, and the other 2 analyzed AI’s role in prognosis prediction and treatment planning. Of the diagnostic studies, 1 demonstrated that a neural network analyzing urinary biomarkers outperformed traditional methods in BCa diagnosis. The other demonstrated AI-enhanced imaging’s superior efficiency in detecting PCa. The third article demonstrated AI’s prognostic value in automated bone scan index for evaluating bone metastasis in PCa. The fourth study showed improved operational efficacy of AI-generated treatment plans compared to conventional brachytherapy planning in PCa. The 4 RCTs had varying levels of risk of bias, primarily due to the randomization process and deviations from intended interventions. Conclusions: Our bibliometric analysis of AI in GU oncology demonstrates the growing recognition of AI’s potential to enhance cancer care. Our systematic review identified four RCTs that highlight the diverse applications of AI and showcase AI’s ability in diagnostics and treatment planning. Collectively, this work provides information about the promise of AI in oncology while improving clinical outcomes.

Background: Acute cholecystitis is one of the most common occurring gall bladder conditions requiring surgical removal. Objective: To assess the efficacy of laparoscopic cholecystectomy in patients suffering from acute cholecystitis. Study Design: Prospective comparative study Place and Duration of Study: Department of Surgery Unit-2, Gulab Devi Hospital, Lahore from 1st March 2023 to 31st August 2023. Methodology: One hundred and ten patients were enrolled. Those patients within the age group of 20-65 and suffering from acute cholecystic were included. A total of 80 patients under went laparoscopic procedure while 20 patients undergo open cholecystectomy (initially 30 but later converted to laparoscopic cholecystectomy). The clinical diagnosis was based on the physical finding’s pf right upper quadrant tenderness, leukocytosis ≥12,000/ml, guarding/rebound, as well as the gross morphological diagnosis intraoperatively. The patients were divided into two groups as laparoscopic and open cholecystectomy. In each patient’s outcome comparison between open a laparoscopic cholecystectomy was performed on the basis of the mean patient age, operative time, hospital stay, complication rate. Results: The mean age of laparoscopic cholecystectomy and open cholecystectomy group patients was 42.41 and 46.39 years respectively. The female’s ratio was way above males with 93.75% in laparoscopic cholecystectomy group and 85% in open cholecystectomy group. The Complication comparison within the two groups presented increased risk of respiratory and gastrointestinal complications in open cholecystectomy group verses laparoscopic cholecystectomy group. There was increased bleeding risk at operation theatre table in open cholecystectomy group in addition to the urinary and wound infection. However, the open cholecystectomy group has significantly lower risk of intra operative bleeding as well as common bile duct injury in comparison to the laparoscopic cholecystectomy group. The comparison of operational time and hospital stay showed within laparoscopic and open cholecystectomy showed a significant decrease in the operational time (129±38 vs 157±34 min) as well as length of hospital stay (2.81±2.17 vs 9.29±6.55 days) in laparoscopic surgery than open surgical protocol for acute cholecystectomy. Conclusion: Laparoscopic cholecystectomy is emerging as a reliable, safe, and cost-effective procedure for treating acute cholecystitis. Complications and mortality rates are generally lower for laparoscopic cholecystectomy compared to open cholecystectomy Keywords: Efficacy, Laparoscopic cholecystectomy, Open cholecystectomy, Acute cholecystitis