Calot's Triangle Research Articles

“Difficult Gallbladder” Incidence and Management at Speciality Surgical Unit

Laparoscopic cholecystectomy is deemed to common surgical procedure, however 'Difficult Gallbladder' requires modified surgical approach. Aim: 1. To define incidence of "difficult gallbladder“ 2. To review bail out procedures for difficult gallbladder Study period: January 2016 to December 2019. “Difficult gall bladder” defined as: 1. acute cholecystitis with thick walled/necrotic/gangrenous/empyema of gall bladder. 2. chronic cholecystitis (fused calots triangle with thick contracted gallbladder). 3. Mirizzi syndrome. 4. Known/ suspected GB perforation. Subtotal cholecystectomy defined as: 1. constituting type: infundibular stump cleared and suture closed. 2. Fenestrating type posterior wall on GB bed left behind and cystic duct closed. Results: Total 745 patients underwent cholecystectomy. Out of 227 cases of acute cholecystitis, there were 119 cases were “difficult gallbladder”. Etiology of difficult gallbladder was as follows, Empyma gall bladder-46, Gangreneous/necrotic gall bladder-20, Chronic cholecystitis with fused calot's triangle-24, Mirizzi syndrome type I/II-8, Gall bladder perforation-21. Out of 119, difficult gallbladder, subtotal cholecystectomy was done in 74 cases-Fenestrating type in 49 cases while constituting type in 25 cases. There was no bile duct injury reported. Bile leak was encountered in 4 cases of constituting type of subtotal cholecystectomy, which was stopped gradually without any intervention. Conclusion: It is advisable to look for cystic duct identification and close the duct whenever is possible. Subtotal cholecystectomy is viable bail out option in difficult gallbladder surgery to prevent bile duct injury.

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Visual gaze patterns reveal surgeons’ ability to identify risk of bile duct injury during laparoscopic cholecystectomy

BackgroundBile duct injury is a serious surgical complication of laparoscopic cholecystectomy. The aim of this study was to identify distinct visual gaze patterns associated with the prompt detection of bile duct injury risk during laparoscopic cholecystectomy. MethodsTwenty-nine participants viewed a laparoscopic cholecystectomy that led to a serious bile duct injury (‘BDI video’) and an uneventful procedure (‘control video’) and reported when an error was perceived that could result in bile duct injury. Outcome parameters include fixation sequences on anatomical structures and eye tracking metrics. Surgeons were stratified into two groups based on performance and compared. ResultsThe ‘early detector’ group displayed reduced common bile duct dwell time in the first half of the BDI video, as well as increased cystic duct dwell time and Calot's triangle glances count during Calot's triangle dissection in the control video. Machine learning based classification of fixation sequences demonstrated clear separability between early and late detector groups. ConclusionThere are discernible differences in gaze patterns associated with early recognition of impending bile duct injury. The results could be transitioned into real time and used as an intraoperative early warning system and in an educational setting to improve surgical safety and performance.

Xanthogranulomatous cholecystitis: experience in 100 cases.

BackgroundXanthogranulomatous cholecystitis (XGC) is a rare presentation of chronic cholecystitis, characterized by xanthogranuloma, severe foam cells and fibrosis, and can be an inducement of difficulty in cholecystectomy. The purpose of this study was to review the clinical findings and imageology features of XGC and to optimize the treatment option.MethodsThis retrospective study collected clinical symptoms, demographics, imageology, operation records, histopathological findings, and postoperative complications of 100 patients with XGC after evaluating 50005 cholecystectomy specimens between 2009 and 2018 in a single institute. heir clinical symptoms, demographics, imageology, operation records, histopathological findings, and postoperative complications were collected and analyzed.ResultsPatients showed various clinical symptoms, ultrasonography was performed in all patients, CT and MRI were further arranged selectively before the operation, but none of the patients were prediagnosed. Fifty-two patients received open cholecystectomy. Laparoscopic cholecystectomy (LC) was planned in 48 patients within whom 8 cases were converted to open cholecystectomy. No partial cholecystectomy was performed. The intraoperative findings included cholecystolithiasis, choledocholithiasis, thickened gallbladder wall, lesions infiltrating into adjacent tissues, disordered Calot’s triangle anatomy, enlarged regional lymph nodes, internal gallbladder fistula, and hepatic abscesses. Frozen-section analysis was performed in 48 patients under the suspicion of gallbladder carcinoma (GBCa), but only 2 cases were finally confirmed.ConclusionsThe preoperative diagnosis of XGC was challenging. Open cholecystectomy was the most preferred treatment, and conversion to open was often necessary after LC.

The critical view of safety during laparoscopic cholecystectomy: Strasberg Yes or No? An Italian Multicentre study

BackgroundLaparoscopic cholecystectomy is considered the gold standard for the treatment of gallbladder lithiasis; nevertheless, the incidence of bile duct injuries (BDI) is still high (0.3–0.8%) compared to open cholecystectomy (0.2%). In 1995, Strasberg introduced the "Critical View of Safety" (CVS) to reduce the risk of BDI. Despite its widespread use, the scientific evidence supporting this technique to prevent BDI is controversial.MethodsBetween March 2017 and March 2019, the data of patients submitted to laparoscopic cholecystectomy in 30 Italian surgical departments were collected on a national database. A survey was submitted to all members of Italian Digestive Pathology Society to obtain data on the preoperative workup, the surgical and postoperative management of patients and to judge, at the end of the procedure, if the isolation of the elements was performed according to the CVS. In the case of a declared critical view, iconographic documentation was obtained, finally reviewed by an external auditor.ResultsData from 604 patients were analysed. The study population was divided into two groups according to the evidence (Group A; n = 11) or absence (Group B; N = 593) of BDI and perioperative bleeding.The non-use of CVS was found in 54.6% of procedures in the Group A, and 25.8% in the Group B, and evaluating the operator-related variables the execution of CVS was associated with a significantly lower incidence of BDI and intraoperative bleeding.ConclusionsThe CVS confirmed to be the safest technique to recognize the elements of the Calot triangle and, if correctly performed, it significantly impacted on preventing intraoperative complications. Additional educational programs on the correct application of CVS in clinical practice would be desirable to avoid extreme conditions that may require additional procedures.

Transillumination of Calot's Triangle on Laparoscopic Cholecystectomy: A Feasible Approach to Achieve a Critical View of Safety.

BackgroundLaparoscopic cholecystectomy is currently one of the most commonly performed procedures globally. Morbidity of laparoscopic cholecystectomy is low; however, bile duct injury is still a feared complication. Despite worldwide efforts, the global incidence of bile duct injury remains higher for laparoscopic cholecystectomy compared with open cholecystectomy. Despite the general belief that the learning curve and lack of laparoscopic skills represent the most common causes of bile duct injuries, the principal cause is the misidentification of biliary anatomy. The aim of our study is to determine if laparoscopic transillumination is a feasible approach to bile and vascular structures visualization during laparoscopic cholecystectomy because the only other method for real-time visualization is fluorescent cholangiography, which can be cost-prohibitive and requires specialized equipment and training.Materials and methodsWe performed a retrospective comparison of outcomes between the transillumination approach in 10 patients receiving laparoscopic cholecystectomy (group A) and a control group of 50 conventional laparoscopic cholecystectomy patients (group B). We compared demographic data, type of surgery, operative time, bleeding, intraoperative and postoperative complications, and hospital stay. We used a conventional four-port positioning for laparoscopic cholecystectomy, and a 5-mm/30° scope was used as a light source and placed behind the area identified as Calot’s triangle.ResultsGroup A consisted of 10 patients (9 women, 1 man), with a mean age of 50.7 (± 17.4) years. The mean body mass index (BMI) in group A was 26.8 (± 0.65) kg/m2. In group A, three of the cholecystectomies were conducted as emergency procedures. Group B consisted of 50 patients (40 women, 10 men), with a mean age of 49.7 (±15.2) years. The mean BMI in group B was 27.5 (±4.5) kg/m2, and two cholecystectomies were emergency procedures. In comparing the transillumination approach with conventional cholecystectomy, we found no statistical differences in operative time, bleeding, complications, or mean hospital stay.ConclusionsLaparoscopic transillumination is a feasible method for real-time visualization of Calot’s triangle structures. Our initial experience with transillumination did not provide better outcomes than conventional cholecystectomy.

SURGICAL AUDIT - LAPAROSCOPIC CHOLECYSTECTOMY IN A FREE CAMP AT PRIVATE SECTOR HOSPITAL

BACKGROUND & OBJECTIVE: Laparoscopic Cholecystectomy is usual method for the treatment of gall bladder stone disease and is practiced all over the world due to many benefits like fasten the recovery time. Furthermore, it reduced the post-operative pain and period of hospital stay. To conduct Surgical Audit and evaluate safety of Laparoscopic cholecystectomy.
 METHODOLGY: This prospective study was conducted in a private hospital at Hyderabad during free camps of Laparoscopic Cholecystectomy. Four camps were arranged in 2016 - 2019. Total number of 190 patients underwent Laparoscopic Cholecystectomy during the study period. The patient's age falls between 12–65 years. A detailed history, relevant investigation and Cardiac fitness were evaluated. All patients underwent four ports Lap-Chole. Data was collected assessed and audit was performed and safety was evaluated.
 RESULTS: Total 190 patients operated females 88.45% and males 11.55%. 115 (60.50%)were in the range of 30-35 years followed by 55 (28.95%)patients in the range of 40-50 years.8 (4.20%) patients were converted to open cholecystectomy, 4 due to bleeding from liver bed, 3 patients due to difficult dissection in calots triangle and 1 due to Empyema of gall bladder.10 patients (5.50%) had Trocar site bleeding, 10 patients (5.50%) had gall bladder injury, in 4 cases had spillage of stones and 72 patients (38.50%) developed umbilical port site infection 1 patient develop port site hernia. No mortality was recorded in this study.
 CONCLUSION: Our Surgical Audit proves that Laparoscopic Cholecystectomy is a safe procedure on the basis of only 4.2% intra operative and 5.5% postoperative complications and gaining wide spread popularity among our population due to less pain, less hospital stay. We recommend other private hospitals to extent such services to our poor population with symptomatic cholelithiasis.

Three-dimensional versus two-dimensional imaging during laparoscopic cholecystectomy: a systematic review and meta-analysis of randomised controlled trials.

To evaluate the comparative outcomes of three-dimensional (3D) versus two-dimensional (2D) imaging during laparoscopic cholecystectomy. We conducted a systematic search of electronic information sources and bibliographic reference lists and applied a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators and limits. Procedure time, Calot's triangle dissection time, gallbladder removal time, gallbladder perforation, intraoperative bleeding, postoperative complications, conversion to open and intraoperative errors were the evaluated outcome parameters. We identified 6 randomised controlled trials (RCT) reporting a total of 577 patients who underwent laparoscopic cholecystectomy using 3D (n = 282) or 2D (n = 295) imaging. The 3D imaging was associated with significantly shorter procedure time (MD - 4.23, 95% CI - 8.14 to - 0.32, p = 0.03), Calot's triangle dissection time (MD - 4.19, 95% CI - 6.52 to - 1.86, p = 0.0004) and significantly lower risk of gallbladder perforation (RR 0.50, 95% CI 0.28-0.88, p = 0.02) compared to the 2D approach. No significant difference was found in gallbladder removal time (MD - 0.79, 95% CI - 2.24 to 0.66, p = 0.28), intraoperative bleeding (RR 1.14, 95% CI 0.68-1.90, p = 0.61), postoperative complications (RD - 0.01, 95% CI - 0.06 to 0.05, p = 0.85), conversion to open (RD 0.00, 95% CI - 0.02 to 0.03, p = 0.70) or intraoperative errors (RR 0.96, 95% CI 0.79-1.17, p = 0.70) between the two groups. Although our findings suggest that the use of 3D imaging during laparoscopic cholecystectomy may be associated with significantly shorter procedure time, Calot's triangle dissection time and gallbladder injury compared to the 2D imaging, the differences seem to be clinically insignificant. Moreover, both approaches carry s similar risk of postoperative morbidities. The impact of the surgeon's level of experience and difficulty of the procedure on the outcomes of each imaging modality remains unknown.

Comparison of 3-port with standard 4-port laparoscopic cholecystectomy: A clinical trial

Introduction: Since the laparoscopic cholecystectomy was introduced first in 1990, the 4-port laparoscopic cholecystectomy was the gold standard. The 4-port (lateral) is used to hold gallbladder fundus and observe Calot's triangle. It is discussed that the 4-port technique is not required in many patients. Therefore, this study aimed to make a comparison between 3-port and 4-port laparoscopic cholecystectomy methods in the treatment of gallstone disease. Methods: A double-blind clinical trial was performed on patients admitted to Imam Reza Hospital, Birjand, Iran. The patients with gallstone disease (n=60) were randomly assigned into the case (3-port) and control (4-port) groups using balanced block randomization and underwent 3- or 4-port laparoscopic cholecystectomy. Postoperative pain was measured by a visual analog scale four h after surgery. The amount of pain-killer, duration of surgery, as well as length of stay and scars were measured in this study. Data were analyzed statistically in SPSS software (version 18) through the Chi-square test and t-test. A p-value less than 0.05 was considered statistically significant. Results: The groups were compared in terms of demographic characteristics. There were 24 females (80%) and 6 males (20%) in the control group and 25 females (83.4%) and 5 males (16.7%) in the case group (P=0.739). Moreover, the mean ages of the control and case groups were 59.823±7.8 and 61.10±4.7, respectively, and there was no significant difference between the groups in this regard (P=0.348). Furthermore, length of operation (P=0.001) and analgesic consumption (P=0.001) in the 3-port laparoscopic cholecystectomy group were lower than those in the 4-port group; however, the hospital stay (P=0.896) was the same in both groups. Conclusions: The 3-port laparoscopic cholecystectomy is a safe, reliable, and cost-effective method in patients who underwent laparoscopic cholecystectomy.

Complications of Laparoscopic Cholecystectomy in a Sample of Patients Admitted to Al-Ramadi Teaching Hospital, Anbar-Iraq

Laparoscopic cholecystectomy is currently thought as a surgical procedure that can be done with less risk of complications. However, intraoperative and postoperative complications were existing in 56 (15.01%) patients. Open surgery is the case when laparoscopic cholecystectomy fails to be proceeded with due to many causes such as difficult Calot triangle dissection and empyema of gallbladder. The high occurrence of cholecystitis in the group of patients aged 40-60 (56%) with 151 female and 59 males initiating the floor to many arguments that may help give a good understanding for such a problem. Iatrogenic perforation of gallbladder was the most common cause of intraoperative complications. Wound infection was the most cause of postoperative complications. Difficult Calot triangle dissection was the most common cause to convert to open surgery.

Perioperative complications of laparoscopic cholecystectomy: a cross-sectional observational study

Background: Laparoscopic cholecystectomy (LC) has now become the gold standard in treatment of benign gall bladder disease. The intraoperative and immediate postoperative complication cannot be disregarded and remain of concern. The study aims to evaluate the perioperative complications of LC in patients undergoing the surgery.Methods: A total of 100 patients were included in this prospective analytical study from a June 2017 to September 2019. They were adequately evaluated and underwent LC in General surgery department of Geetanjali Medical College and Hospital, Udaipur. The relevant clinical details of all the patients were recorded and analysed.Results: Among the patients who underwent LC, majority were females. In case of 86 patients, LC was done due to chronic calculous cholecystitis. The conversion rate from laparoscopic to open was 6%. The most frequent intraoperative complication was trocar site bleeding and liver bed injury, 7%, followed by bile leakage from gallbladder 6%, bleeding from calots triangle in 4% and spilled gallstones in 2% cases. There was no case of injury to common bile duct, bowel injury or major vascular injury. Amongst the post-operative complications, wound infection was in 1% case. No perioperative mortality was present. The overall rate of complication was 18%.Conclusions: LC is a safe and effective procedure in almost all patients presenting with symptomatic gallbladder disease and remains one of the most frequently performed laparoscopic operations. It has a low rate of mortality and morbidity making this operation a safe procedure with favourable results.

Development of an artificial intelligence system using deep learning to indicate anatomical landmarks during laparoscopic cholecystectomy

BackgroundThe occurrence of bile duct injury (BDI) during laparoscopic cholecystectomy (LC) is an important medical issue. Expert surgeons prevent intraoperative BDI by identifying four landmarks. The present study aimed to develop a system that outlines these landmarks on endoscopic images in real time.MethodsAn intraoperative landmark indication system was constructed using YOLOv3, which is an algorithm for object detection based on deep learning. The training datasets comprised approximately 2000 endoscopic images of the region of Calot's triangle in the gallbladder neck obtained from 76 videos of LC. The YOLOv3 learning model with the training datasets was applied to 23 videos of LC that were not used in training, to evaluate the estimation accuracy of the system to identify four landmarks: the cystic duct, common bile duct, lower edge of the left medial liver segment, and Rouviere’s sulcus. Additionally, we constructed a prototype and used it in a verification experiment in an operation for a patient with cholelithiasis.ResultsThe YOLOv3 learning model was quantitatively and subjectively evaluated in this study. The average precision values for each landmark were as follows: common bile duct: 0.320, cystic duct: 0.074, lower edge of the left medial liver segment: 0.314, and Rouviere’s sulcus: 0.101. The two expert surgeons involved in the annotation confirmed consensus regarding valid indications for each landmark in 22 of the 23 LC videos. In the verification experiment, the use of the intraoperative landmark indication system made the surgical team more aware of the landmarks.ConclusionsIntraoperative landmark indication successfully identified four landmarks during LC, which may help to reduce the incidence of BDI, and thus, increase the safety of LC. The novel system proposed in the present study may prevent BDI during LC in clinical practice.

Fluorescent Cholangiography in Laparoscopic Cholecystectomy and the Use in Pediatric Patients.

Background: Common bile duct (CBD) injury is one of the most serious complications of laparoscopic cholecystectomy and carries an incidence of 0.3%-0.7%. Recently indocyanine green (ICG) fluorescent cholangiography (FC) has been used as an adjunct to identify the biliary tract during adult laparoscopic cholecystectomy, allowing intraoperative identification of biliary anatomy. The objective of this article is to show its successful use in pediatric laparoscopic cholecystectomies. Method: From July 1, 2017, to November 30, 2018, surgeons at John R. Oishei Children's Hospital and Women and Children's Hospital of Buffalo have been utilizing ICG-FC as an adjunct in patients undergoing laparoscopic cholecystectomy. Thirty-one patients undergoing laparoscopic cholecystectomy had 1 mL of dilute ICG (2.5 mg) injected intravenously in the operating room (OR) before trocar placement. Demographics, intraoperative details, and subjective surgeon data were recorded for elective laparoscopic cholecystectomy cases involving ICG. We hypothesize that use of ICG-FC in the pediatric and adolescent patient population is a safe, reliable, and reproducible adjunct for identification of the biliary tree. Secondary outcomes were to identify rate of biliary anatomy identification, utilization ease, and operative times while using ICG technology in pediatric patients. Results: ICG-FC was used in 31 pediatric laparoscopic cholecystectomies performed by 5 surgeons at our institution. Ages ranged from 6 to 18 years. In all cases, the cystic duct-CBD junction was visualized while performing dissection of the triangle of Calot. No intraoperative complications occurred. Conclusions: ICG-FC provides a noninvasive real-time visualization of the extrahepatic biliary tree in children and adolescents. We demonstrate that ICG-FC can successfully be used as an adjunct in pediatric patients and has the potential to facilitate with the dissection and minimize risk of bile duct injuries during pediatric laparoscopic cholecystectomies.

Demystifying The Triangle of Francois Calot

The Triangle of Calot is a landmark in anatomy located in the right upper quadrant of the abdomen. Calot in his 1891 dissertation used the cystic artery as the upper boundary. This original monograph was in medieval French, which is no longer spoken, and no official English translation is currently available.It is not clear who first used the term Triangle of Calot, but one wonders if that was when the under surface of the liver was introduced as the upper boundary, consequently introducing a new triangle, the Hepatocystic Triangle. This term is often used interchangeably with the Triangle of Calot, although their true borders differ.Mystery #1: Who was Calot?Jean‐Francois Calot [1861–1944] was born in a small farming community in the Hautes‐Pyrennes in France. He received his medical degree at the University of Paris and on graduation worked with Terrier, a surgeon, who Calot described in his publication as his mentor. Terrier had embraced the cholecystectomy as a surgical procedure after Langenbuch successfully performed the first cholecystectomy in 1882. Calot was intimately involved in caring for these patients and stated in his monograph that it was Terrier who encouraged him to study the hepatobiliary anatomy.As a physician and prosector, Calot worked on cadavers at the Ecole Pratique in Paris and came up with the following description of his famed triangle: “The triangle is not equilateral exactly, but rather both upper and lower sides represented by the artery and the cystic duct being alone equal and a little longer than the portion of the liver bile duct entering the constitution of the triangle.” It is clear from this translation that Calot meant that the upper boundary of this near‐isosceles triangle should be the cystic artery, the lower boundary, the cystic duct and the medial boundary, the common hepatic duct.Mystery #2: Who named the triangle?It is unclear who first used the term, “Triangle of Calot,” as Calot himself did not use such a name in his dissertation. It is possible that someone at a later time, in not having access to a translation of Calot’s publication, incorrectly introduced the triangle with the undersurface of the liver as the upper boundary. While this difference may seem of little consequence, such a description does matter for the surgical approach during a cholecystectomy. The undersurface of the liver houses the soul of the liver, with the confluence of major biliary and vascular structures, and is an area most surgeons would be advised to avoid during routine cholecystectomies.ConclusionWhile we may never know who named Calot’s Triangle and who introduced the similar but distinct Hepatocystic Triangle, it is clear from our investigation that these two entities are not synonymous. Such knowledge is of great importance during difficult cholecystectomies, when the normal anatomy is distorted by inflammation and vital structures are at increased risk of injury. For the practicing surgeon, using the cystic artery as the upper boundary of Calot’s Triangle is much safer than the undersurface of the liver during a cholecystectomy.

Early laparoscopic cholecystectomy in acute gallbladder perforation: Single-centre experience.

Background:Acute gallbladder perforation (GBP) is associated with significant mortality and morbidity. Percutaneous drainage followed by interval cholecystectomy has been the preferred management. The outcomes of early surgery, especially by laparoscopy, have not been well studied in GBP. We present our experience in early laparoscopic cholecystectomy in GBP.Methodology:A retrospective analysis of patients admitted with GBP between April 2014 and December 2018 was done. Clinical presentation, preoperative imaging, surgical procedure, operative findings and the outcomes in these patients were analysed. Video of the surgeries was reviewed in case of the absence of data from the case records.Results:Fifteen patients were treated for GBP during the study period. Eleven patients were male, and the mean age was 61 years. Fourteen patients (93.3%) had associated co-morbidities. Systemic inflammatory response syndrome, sepsis, severe sepsis and septic shock were present in 3, 3, 6 and 3 patients, respectively. The location of the collection was gallbladder fossa, pericholecystic, subhepatic and diffuse in 3, 5, 4 and 3 patients, respectively. Intraoperatively, 13 patients were detected to have perforation at the fundus of the gallbladder. Cystic duct stump was managed with clip, endoloop, suturing and external drainage in 7, 2, 5 and 1 patient, respectively. Laparoscopic cholecystectomy was completed in 12 (80%) patients. Retroinfundibular technique was used in 12 (80%) patients. There was one conversion. Two patients required endoscopic retrograde cholangiogram + bile duct stenting, and one was reexplored for cystic artery bleed. There were no mortalities. The median duration of post-operative hospital stay and drain removal was 3 (1–19) and 3 (1–6), respectively.Conclusion:Early laparoscopic cholecystectomy in acute GBP is feasible and can be safely performed in centres having sufficient expertise. Retroinfundibular technique of laparoscopic cholecystectomy is useful in tackling frozen Calot's triangle in GBP.

Impact of Endoscopic Retrograde Cholangiopancreatography on Laparoscopic Cholecystectomy

Background: For Common Bile Duct (CBD) stones an Endoscopic Retrograde Cholangiopancreatography (ERCP) is done prior to cholecystectomy. However, the ideal timing of cholecystectomy following ERCP is still a matter of debate. The aim of the present study was to observe the possible impact of ERCP on subsequent laparoscopic cholecystectomy.Material and Methods: This case control study was carried out in the Department of Surgery Unit 1, Holy Family hospital, Rawalpindi, from January 2018 to March 2019. A total number of 300 patients of symptomatic gallstones presenting to outpatient department were enrolled. Two groups, A (control group) and B (case group) were made on the basis of absence or presence of CBD stones, respectively. Group A underwent laparoscopic cholecystectomy within three working days of admission. In group B, ERCP was performed prior to cholecystectomy. Primary operating surgeon filled structured questionnaires for each patient immediately after surgery to compare operative differences between both groups. The baseline demographic details, clinical characteristics, laboratory investigations and peri-operative findings of both groups were recorded. Means and percentages were calculated with P value <0.05 regarded as statistically significant.Results: Majority of patients in this study were females (81%) of middle age group (42.5+15 years). Biliary colic was most common presenting complaint in both groups (33%). Dissection in triangle of Calot (P=0.00) and removal of gallbladder from liver bed (P=0.00) was significantly more difficult in group B than A. Intra-abdominal lavage was also done more often in post ERCP group (P=0.00). However procedural time did not vary between the two groups (P=0.19).Conclusions: Preoperative ERCP increases difficulty in laparoscopic cholecystectomy but does not prolong procedural time.Key words: Choledocholithiasis, Endoscopic retrograde cholangiopancreatography, Laparoscopic cholecystectomy

Double Cystic Artery Originating in a Right and a Segment IV Hepatic Artery: A Case Report

Anatomical variation of the cystic artery (CA) is frequently observed. However, a CA originating in a segment IV hepatic artery (HA) has been rarely reported. We report double CA originating in a right segment IV HA detected during laparoscopic cholecystectomy (LC). A 67-year-old man underwent LC for symptomatic gallstones. We ligated and divided the cystic duct initially, and performed a procedure similar to the management of CA in the hepatobiliary triangle. In contrast to the other cases, the falciform ligament was attached to gallbladder. Severe arterial bleeding was observed during the dissection. We dissected the bleeding site and found another CA for ligation. A preoperative abdominal computed tomography (CT) scan confirmed a CA originating from a segment IV HA. The patient was discharged without any events the next day. In conclusion, we report a CA originating in segment IV HA. A falciform ligament attached to gallbladder suggests the unusual CA.

Long-term outcomes after subtotal reconstituting cholecystectomy: A retrospective case series

BackgroundSubtotal cholecystectomy, where the gallbladder infundibulum is transected to avoid dissecting within the triangle of Calot, has been suggested to conclude laparoscopic cholecystectomy while avoiding common bile duct injury. However, some reports suggest the possibility of recurrent symptoms from a remnant gallbladder. MethodsA retrospective database containing 900 randomly selected cholecystectomies occurring between 2009 and 2015 was reviewed for instances of subtotal cholecystectomy. All documentation for these patients was reviewed through 01/2018. ResultsSix patients who underwent subtotal cholecystectomy were identified. All six returned for care within our institution, with a median 76 months of follow-up. No patient had signs or symptoms indicating recurrent cholelithiasis or cholecystitis. ConclusionsThis series represents six cases of subtotal reconstituting cholecystectomy with no recurrent gallbladder symptoms on long-term follow-up. This may encourage surgeons who feel that subtotal reconstituting cholecystectomy is the safest way to proceed with cholecystectomy in the setting of severe inflammation.

Fluorescent imaging with indocyanine green for intraoperative bilie ducts examination during laparoscopic cholecystectomy

Aim. Assessment of the capability of early identification of the bile ducts using near infrared light and fluorescent agent indocyanine green in laparoscopic cholecystectomy in patients with an increased risk of bile duct injury. Methods. Laparoscopic cholecystectomy using fluorescent imaging system was performed in 16 patients with different risk factors for bile duct injury. Results . The use of intraoperative imaging in a number of cases facilitated the identification of tubular structures in the Calot triangle and allowed to avoid the conversion. Conclusion . The first experience of intraoperative imaging of bile ducts using indocyanine green in laparoscopic cholecystectomy indicate that this method can become an important additional diagnostic procedure in patients with an increased risk of bile duct injury. Further research is needed to optimize methods, dosage, time and patient selection criteria.

YATROGENIC BILE DUCT INJURIES (BASED OF THE TVER REGION DATA)

Laparoscopic cholecystectomy (LC) is one of the most frequent operations. The significance of the problem with iatrogenic unwitting bile duct injuries (BDI) remains extremely actual up to the present. Our aim was to analyze the situation in the Tver region associated with this complication. From 1994 to 2017, 11280 cholecystectomies were performed in the surgical department of the regional hospital in Tver, while LC was performed in 10396 (92.9%) patients. Patients with "severe" unwitting BDI (42) from the whole region were concentrated in this clinic; we analyzed their treatment. Intraoperatively unwitting BDI were diagnosed only in 8 (19.0%) patients. The most frequent mechanism of trauma was “carving out” of bile duct fragment. In some cases, the cause of iatrogenic was the unjustifiably hasty intersection of tubular structures in the zone of the Calot triangle without their proper identification. In 15 (35.7%) patients, surgical correction of this complication was carried out in two stages. All patients eventually formed an end-to-side hepatico-, hepato- or bihepato- jejuno Roux-en-Y anastomosis, while in 36 (85.7%) patients - with replaceable transhepatic drains according to Saypol-Kurian. All patients recovered, there was no hospital mortality. In our opinion, the problem of continuous training and improvement of operational techniques (including simulation ones) for both young and “mature” surgeons remains relevant. It is necessary to use a typical tactic for the management of patients with unwitting BDI and concentrate them in a specialized hospital.