Cases Of Cholecystectomy Research Articles

A prospective and retrospective observational study on residual gallbladder stones after cholecystectomy

Background: A small number of post-cholecystectomy syndrome cases result from residual stones in a lengthy cystic duct or recurrence of lithiasis in a remaining gallbladder (GB) tissue. In laparoscopic procedures, up to 13.3% may involve incomplete GB removal due to surgical complexities and anatomical variations such as adhesions or challenging morphology. Aims and Objectives: (1) To assess the incidence of retained stones in patients undergoing cholecystectomy, (2) to compare incidences among open and laparoscopic cholecystectomies, (3) to study various presenting ways and different investigational methods helping in early diagnosis and proper management, and (4) to study different operative interventions for different cases. Materials and Methods: This was a prospective and retrospective observational study. After getting ethical committee approval and informed consent, 35 patients were included in the study. The study was carried out in the Department of General Surgery at I.P.G.M.E.R./S.S.K.M. Hospital, Kolkata. Results: Most patients were post-open cholecystectomy cases. The incidence of retained GB stones was 4.48%, with females affected 2.8 times more than males. Common symptoms were pain abdomen (80%) and fever (25%). Ultrasonography diagnosed stump calculi in 85.71% of cases; magnetic resonance cholangiopancreatography (MRCP) was preferred when ultrasound was inconclusive. Conclusion: Cases underwent subtotal cholecystectomy or had long cystic duct stumps in rural hospitals, referred to tertiary hospital for further management. Symptoms included pain abdomen, fever, and sometimes jaundice. MRCP confirmed diagnoses before open re-exploration; completion cholecystectomy addressed residual stones for symptom relief and cure.

Transient Elevation of Liver Function Tests and Bilirubin Levels After Laparoscopic Cholecystectomy.

Background and Objectives: Laparoscopic cholecystectomy constitutes the current "gold standard" treatment of symptomatic gallstone disease. In order to avoid intraoperative vasculobiliary injuries, it is mandatory to establish the "critical view of safety". In cases of poor identification of the cystic duct and artery leading to a missed intraoperative injury, patients present with elevated liver function tests (LFTs) or increased bilirubin postoperatively. The aim of this study is to present a series of patients of our institute with elevated liver enzymes and bilirubin after laparoscopic cholecystectomy in the absence of intraoperative injury or any other obvious etiology and to provide a possible explanation of this finding. Materials and Methods: From 2019 to 2023, 200 patients underwent elective laparoscopic cholecystectomy at the Papageorgiou General Hospital and at the European Interbalkan Medical Center of Thessaloniki utilizing the "critical view of safety" method. We retrospectively collected the intraoperative reports, and the pre- and postoperative imaging and laboratory studies of the patients included in this series. Postoperative LFTs and bilirubin levels were extracted and the reason for their transient elevation was examined. Results: From 200 cases of laparoscopic cholecystectomy, elevated LFTs and bilirubin were found in six patients on the first postoperative day, which is suggestive of a missed intraoperative injury. All patients were asymptomatic. During the investigatory workup, a triple-phase CT of the liver and/or an MRCP were ordered, but no pathological findings, such as biliary injury, hepatic artery injury or choledocholithiasis, were found. On postoperative day 3, LFTs and bilirubin levels decreased or normalized without any intervention. No postoperative complications were reported. Conclusions: In select cases, a transient increase in LFTs and/or bilirubin may be observed in the early postoperative period after elective laparoscopic cholecystectomy in the absence of an obvious etiology. A possible interpretation of these findings could involve the pneumoperitoneum or the anesthesia regimens used intra- or perioperatively. The specific cause, however, remains undetermined and yet to be examined by future studies.

Xanthogranulomatous Cholecystitis: A Retrospective Review of Clinical Diagnosis and Treatment from a Single Center.

The objective of this study was to evaluate and compare the histopathological, clinical, and treatment characteristics of xanthogranulomatous cholecystitis (XGC) in patients undergoing cholecystectomy at a single center. Aim: We aim to enhance the understanding of its presentation and improve its differential diagnosis from other gallbladder pathologies. Methods: We retrospectively reviewed 6783 cholecystectomy cases performed between January 2015 and January 2023 at the General Surgery Clinic of Haydarpaşa Numune Training and Research Hospital, and a diagnosis of xanthogranulomatous cholecystitis was histopathologically established in 131 patients. In this retrospective study, we examined the clinicopathological characteristics, preoperative imaging methods and findings, histopathological images, surgical procedure methods, and postoperative complications of 131 patients. Results: The study included 131 patients, with ages ranging from 18 to 88 years, of which 74 (56.5%) were female and 57 (43.5%) were male. Ultrasound imaging was performed on 128 patients. Ultrasound imaging revealed wall thickening in 72.7% of cases, hypoechoic nodules in 13.3%, biliary tract pathologies in 10.9%, and adenomyomatosis in 3.1%. A total of 59 cases had MRI. On MRI, wall thickening was observed in 50.8% of cases, biliary tract pathologies in 33.9%, adenomyomatosis in 10.2%, hypoechoic nodules in 3.4%, and hypoechoic nodules + wall thickening (HN + WT) in 1.7%. Histopathological diagnosis was diffuse in 79.4% of cases and focal in 20.6%. In addition to cholecystectomy, non-surgical interventions were not required in 77.1% of the cases, while 11.5% underwent ERCP, 9.2% underwent percutaneous procedures, 1.5% underwent both ERCP and percutaneous procedures, and 0.8% underwent other non-surgical interventions. Of the surgeries, 93.1% were elective and 6.9% were emergency. Postoperative complications were not observed in 84% of the patients; 5.3% experienced surgical complications, 5.3% had surgical site infection, and 5.3% had other complications (pneumonia and urinary infection). The length of hospital stay ranged from 0 to 26 days, with a mean of 5.27 ± 4.59 days and a median of 4 days. Conclusions: Xanthogranulomatous cholecystitis is a rare disease of the gallbladder with no characteristic radiological or clinical findings and can often be confused with gallbladder cancer. Further studies involving larger populations are needed to improve the preoperative diagnosis.

Short-Term Efficacy of Transumbilical Single-Incision Versus Conventional Laparoscopic Cholecystectomy: A Retrospective Cohort Study.

Background: With the rising demand for minimally invasive and cosmetically appealing surgeries, transumbilical single-incision laparoscopic cholecystectomy (SILC) has been increasingly adopted, albeit in a limited number of medical centers. Our team has successfully executed transumbilical SILC for benign gallbladder diseases. This study retrospectively analyzed and compared the efficacy of transumbilical SILC with that of conventional laparoscopic cholecystectomy (CLC). Methods: We analyzed data from 358 cases of laparoscopic cholecystectomy performed at Shanghai East Hospital of Tongji University between January 2021 and October 2023. Of these, 186 cases underwent SILC (observation group), while 172 cases underwent CLC (control group). We compared patient demographics, perioperative outcomes, and satisfaction with incision scars. Primary outcomes included surgical efficacy and safety, whereas secondary outcomes encompassed postoperative hospitalization duration, pain levels, hospital costs, and scar satisfaction. Results: No significant differences were observed in patient demographics between the two groups. Both the SILC and CLC groups exhibited similar operative times (39.56 ± 14.55 minutes versus 41.82 ± 16.13 minutes, P = .164) and intraoperative blood loss (11.34 ± 3.90 mL versus 11.28 ± 3.87 mL, P = .885). The single-incision approach led to earlier postoperative bowel function recovery (22.03 ± 3.60 hours versus 24.17 ± 3.22 hours, P < .01), lower 24-hour postoperative pain scores (2.06 ± 0.84 versus 2.35 ± 0.72, P < .01), shorter postoperative hospital stays (2.88 ± 0.86 days versus 3.33 ± 0.96 days, P < .01), comparable hospitalization costs (3411.67 ± 790.86$ versus 3494.50 ± 558.76$, P = .257), and better Scar Cosmesis Assessment and Rating scores (1.78 ± 0.70 versus 2.17 ± 0.89, P < .01). Patient satisfaction was higher with the single-incision technique (8.52 ± 0.79 versus 7.80 ± 0.75, P < .01). Both groups experienced one case of incision infection (SILC 0.54%, CLC 0.58%), and there was one case of postoperative bile leakage in the CLC group (0.58%). However, the difference in complications was not statistically significant (P > .05). Conclusion: Transumbilical SILC demonstrates safe and effective near-term efficacy, offering benefits such as reduced postoperative pain and improved cosmetic outcomes, which support its clinical adoption.

FREQUENCY OF EASY AND DIFFICULT LAPAROSCOPIC CHOLECYSTECTOMY FOR CHOLELITHIASIS

The prevalence of gallstone disease is influenced by factors such as age, gender, and marital status. Ultrasonography is important for screening. Laparoscopic cholecystectomy (LC) is the standard treatment for symptomatic cholelithiasis, but some cases may require conversion to open surgery (OC). Preoperative ultrasound assessments, particularly the common bile duct (CBD) diameter, may help predict the difficulty of LC and prepare for potential complications. Objective: The objectives of this study are to assess the frequency of easy and difficult laparoscopic cholecystectomy in patients with cholelithiasis and to compare the mean diameter of the common bile duct between cases of easy and difficult laparoscopic cholecystectomy. Methods: This sctional study was conducted from February 10, 2023, to August 10, 2023, and included 170 patients (ages 18-60 years) undergoing laparoscopic cholecystectomy for cholelithiasis. Both genders were included. Variables such as age, gender, diabetes, hypertension, and cholecystectomy status were recorded. The mean and standard deviation (SD) were calculated for age and CBD diameter. An independent t-test was used to compare CBD diameters between easy and difficult LC cases. Chi-square tests were applied to control for effect modifiers. Results: The mean age of the patients was 52.32 ± 4.89 years. Other patient characteristics included an average height of 162.90 ± 9.25 cm, weight of 75.95 ± 12.32 kg, and BMI of 27.47 ± 4.72. The common bile duct diameter was 4.55 ± 1.42 mm. Gender distribution showed 54.7% male and 45.3% female patients. Of the 170 patients, 84 (49.4%) were classified as easy LC cases, while 86 (50.6%) were classified as difficult. The mean CBD diameter was significantly different between the two groups, measuring 3.54 ± 1.03 mm in easy cases and 5.52 ± 1.02 mm in difficult cases (p = 0.001). Conclusion: This study highlights the importance of preoperative assessment of common bile duct diameter in predicting the difficulty of laparoscopic cholecystectomy. Patients with a larger CBD diameter are more likely to experience a difficult LC, emphasizing the need for personalized surgical planning. These findings underscore the value of preoperative ultrasonography in optimizing patient outcomes and reducing the risk of conversion to open surgery.

Derivation and validation of a predictive model for subtotal cholecystectomy

IntroductionRates of subtotal cholecystectomy (STC) are increasing in response to challenging cases of laparoscopic cholecystectomy (LC) to avoid bile duct injury, yet are associated with significant morbidity. The present study identifies risk factors for STC and both derives and validates a risk model for STC.MethodsLC performed for all biliary pathology across three general surgical units were included (2015–2020). Clinicopathological, intraoperative and post-operative details were reported. Backward stepwise multivariable regression was performed to derive the most parsimonious predictive model for STC. Bootstrapping was performed for internal validation and patients were categorised into risk groups.ResultsOverall, 2768 patients underwent LC (median age, 53 years; median ASA, 2; median BMI, 29.7 kg/m2), including 99 cases (3.6%) of STC. Post-operatively following STC, there were bile leaks in 29.3%, collections in 19.2% and retained stones in 10.1% of patients. Post-operative intervention was performed in 29.3%, including ERCP (22.2%), laparoscopy (5.0%) and laparotomy (3.0%). The following variables were positive predictors of STC and were included in the final model: age > 60 years, male sex, diabetes mellitus, acute cholecystitis (AC), increased severity of AC (CRP > 90 mg/L), ≥ 3 biliary admissions, pre-operative ERCP with/without stent, pre-operative cholecystostomy and emergency LC (AUC = 0.84). Low, medium and high-risk groups had a STC rate of 0.8%, 3.9% and 24.5%, respectively.DiscussionThe present study determines the morbidity of STC and identifies high-risk features associated with STC. A risk model for STC is derived and internally validated to help surgeons identify high-risk patients and both improve pre-operative decision-making and patient counselling.

Minimally invasive subtotal cholecystectomy. What surgeons need to know.

Minimally invasive laparoscopic cholecystectomy is among the most frequently performed abdominal surgeries. Bile duct injury is a significative complication that occurs in about 0.2-0.3% of open procedures and 0.5% of laparoscopic surgeries, with concomitant vasculobiliary injuries in 12-61% of cases. Most of these lesions occurs during challenging severe cholecystitis where the intense inflammation obscures the hepatocystic anatomy. In this case a bailout strategy such as a subtotal cholecystectomy should be considered. Subtotal cholecystectomy is a surgical technique performed to remove a portion of the gallbladder while leaving part of it behind. In such complex cholecystectomies, surgeons should be aware of this technique, and subtotal cholecystectomy should be part of their surgical armamentarium. We aim to familiarize surgeons with bailout techniques like subtotal cholecystectomy and gallbladder emptying for challenging acute cholecystectomy cases to reduce the risk of vasculobiliary injury. This multimedia article provides, a comprehensive step-by-step overview of the different possible minimally invasive subtotal cholecystectomy procedures, we outline five distinct techniques for conducting subtotal cholecystectomy, including some tips and tricks and demonstrates the usefulness of a minimally invasive approach. Finally, we emphasize the importance of carefully choosing between laparoscopic and robotic approaches and suggests using adjunctive tools, such as preoperative indocyanine green, to better identify common bile duct anatomy.

Can Hemogram Parameters and Derived Ratios Predict Conversion From Laparoscopic to Open Cholecystectomy?

Backgrounds Laparoscopic cholecystectomy (LC) is the gold standard for surgical removal of gallbladder today. In challenging cholecystectomy cases, conversion to an open technique may be necessary. Therefore, the preoperative prediction of conversion to open technique holds significant importance for patient safety and surgical strategy. In the literature, conversion to open cholecystectomy has been associated with many contradictory predictive factors. The aim of this study is to identify and comprehensively evaluate the predictive laboratory parameters and ratios associated with the conversion from laparoscopic to open cholecystectomy. Methods In this historical cohort study, the data of patients who were scheduled for and underwent LC between January 1, 2018, and September 1, 2023, were retrospectively evaluated. The preoperative laboratory findings and surgical notes of the patients were reviewed retrospectively from the archives. The correlation between patient data and the cholecystectomy groups was analyzed, and comparisons were made between the groups. Results All 160 patients initially underwent a laparoscopic approach. In emergency cases, a statistically significant association was found between lymphocyte count (p = 0.017) and lymphocyte-to-monocyte ratio (LMR) (p = 0.041) with operations completed laparoscopicallyand between neutrophil-to-lymphocyte ratio (NLR) (p = 0.007) and Systemic Inflammatory Response Index (SIRI) (p = 0.031) with operations converted to open surgery. In elective cases, gamma-glutamyl transferase (GGT) (p = 0.024) and total bilirubin (TBIL) (p = 0.003) were found to have a statistically significant association with operations converted to open surgery. In the logistic regression analysis, hematological parameters and ratios were not found to have a statistically significant relationship in predicting the conversion to open surgery. Conclusion Although significant differences were observed in laboratory parameters and derived ratios such as the NLR and LMR, logistic regression analysis did not identify any of these measures as significant predictors of conversion from laparoscopic to open surgery. Further prospective studies with larger sample sizes are needed in this area.

Intraoperative imaging and management of common duct stones during subtotal cholecystectomy.

Subtotal cholecystectomy is advocated in patients with severe inflammation and distorted anatomy preventing safe removal of the entire gallbladder. Not well documented in this surgically complex population is the feasibility of intraoperative imaging and management of common bile duct (CBD) stones. We evaluated these operative maneuvers in our subtotal cholecystectomy patients. We retrospectively reviewed all cholecystectomy cases from 2014 to 2023 at a single Veterans Affairs (VA) Medical Center using VASQIP (VA Surgical Quality Improvement Program), selecting subtotal cholecystectomy cases for detailed analysis. We reviewed operative reports, imaging and laboratory studies, and clinical notes to understand biliary imaging, stone management, complications, and late outcomes including retained stones (within 6months), and recurrent stones (beyond 6months). 419 laparoscopic (n = 406) and open (n = 13) cholecystectomies were performed, including 40 subtotal cholecystectomies (36 laparoscopic, 4 laparoscopic converted to open). Among these 40 patients IOC was attempted in 35 and completed in 26, with successful stone management in 11 (9 common bile duct exploration [CBDE], 2 intraoperative endoscopic retrograde cholangiopancreatography [ERCP]). In follow-up, 3 additional patients had CBD stones managed by ERCP, including 1 with a negative IOC and 2 without IOC. Thus, 14 (35%) of 40 patients had CBD stones. Of note, IOC permitted identification and oversewing or closure of the cystic duct in 32 patients. There were no major bile duct injuries and one cystic duct stump leak (2.5%) that resolved spontaneously. Subtotal cholecystectomy patients had a high incidence of bile duct stones, with most detected and managed intraoperatively with CBDE, making a strong argument for routine IOC and single-stage care. When intraoperative imaging is not possible, postoperative imaging should be considered. Routine imaging, biliary clearance, and cystic duct closure during subtotal cholecystectomy is feasible in most patients with low rates of retained stones and bile leaks.

The use of propofol to induce anesthesia can mitigate the oxidative stress created by laparoscopic cholecystectomy, but not thiopental

Aim: Laparoscopic cholecystectomy is one of the treatment methods in symptomatic cholelithiasis cases, and pneumoperitoneum has been shown to increase oxidative stress. Our aim is to compare propofol and thiopental in terms of their effects on oxidative stress parameters in laparoscopic cholecystectomy cases. Materials and Methods: After obtaining Ethics Committee permission, patients who underwent laparoscopic cholecystectomy were divided into thiopental and propofol groups according to the agent used for anesthesia induction in the randomized and prospective study. Serum serum oxidative stress parameters levels were measured in all patients two times, before induction of general anesthesia and at the 30th minute postoperatively. Results: When comparing the preoperative period with the postoperative period, TAS levels increased statistically significantly in the propofol group (preoperatively 1.21±0.21 mmolH2O2/L, postoperatively 1.31±0.18 mmolH2O2/L, p

Resident level is associated with operative time in laparoscopic cholecystectomy

BackgroundWhile previous literature has shown that resident involvement increases operative time, the influence of resident involvement on operative time is generally not considered in current methods of case time predictions or operating room planning. Furthermore, evidence of prolonged case times based on the level of the assisting resident is yet scarce. We hypothesized that operative time would increase with the post-graduate year of assisting residents as they gain more autonomy in the operating room. Study designThis was an observational cohort study in which we retrospectively analyzed 802 laparoscopic cholecystectomy cases performed in a single academic institution between May 2014 and December 2020. Only cases in which a Post Graduate Year 1 to 5 (PGY) resident was assisting were included. ResultsPGY1–4 residents had statistically significant positive time coefficient results in all linear regression models, except PGY2s in urgent cases. PGY-2 residents had the longest overall average case time of 98 min. Emergent cases were more likely to have prolonged case times. ConclusionsThe increased average case time associated with PGY-2 residents is likely due to a new level of increased autonomy in the operating room (OR) during this year of training. The linear regression results indicated PGY1–4 residents were more likely to have longer laparoscopic cholecystectomy operative times than the PGY5 residents, except PGY2s in urgent cases. This may reflect the accumulation of surgical skills at the PGY5 level. Resident involvement should be considered in the prediction of operative time in an academic setting.

Factors contributing to prolonged operative time for laparoscopic cholecystectomy performed by trainee surgeons: a retrospective single-center study.

Laparoscopic cholecystectomy for a benign disease is often the initial endoscopic surgery performed by trainee surgeons. However, a lack of surgical experience is associated with prolonged operative times, which may increase the risk of postoperative complications and poor outcomes. This study aimed to identify the factors associated with prolonged operative times for laparoscopic cholecystectomy performed by inexperienced surgeons. This retrospective single-center study was conducted between January 2018 and December 2023. We performed a multivariate analysis to identify the factors associated with prolonged operative time by analyzing elective cases of laparoscopic cholecystectomy performed by surgeons with limited experience. The study included 323 patients, subjected to a median operative time of 89min. Multivariate analysis identified that patient characteristics such as male sex, increased body mass index, and a history of conservative treatment for cholecystitis, as well as operating surgeon's post-graduation years (< 4years), and an attending surgeon without endoscopic surgical skill certification from the Japan Society of Endoscopic Surgery, were independent risk factors for a prolonged operative time. Our findings suggest that endoscopic surgical skill-certified attending surgeons have excellent coaching skills and mitigate the operative time for elective cholecystectomy.

Acute cholecystitis, obesity, and steatohepatitis constitute the lethal triad for bile duct injury (BDI) during laparoscopic cholecystectomy.

The most feared complication during laparoscopic cholecystectomy remains a bile duct injury (BDI). Accurately risk-stratifying patients for a BDI remains difficult and imprecise. This study evaluated if the lethal triad of acute cholecystitis, obesity, and steatohepatitis is a prognostic measure for BDI. A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) registry was performed. All laparoscopic cholecystectomy cases within the main NSQIP database for 2012-2019 were queried. Two study cohorts were constructed. One with the lethal triad of acute cholecystitis, BMI ≥ 30, and steatohepatitis. The other cohort did not have the full triad present. Multivariate analysis was performed via logistic regression modeling with calculation of odds ratios (OR) to identify independent factors for BDI. An uncontrolled and controlled propensity score match analysis was performed. A total of 387,501 cases were analyzed. 36,887 cases contained the lethal triad, the remaining 350,614 cases did not have the full triad. 860 BDIs were identified resulting in an overall incidence rate 0.22%. There were 541 BDIs within the lethal triad group with 319 BDIs in the other cohort and an incidence rate of 1.49% vs 0.09% (P < 0.001). Multivariate analysis identified the lethal triad as an independent risk factor for a BDI by over 15-fold (OR 16.35, 95%CI 14.28-18.78, P < 0.0001) on the uncontrolled analysis. For the controlled propensity score match there were 29,803 equivalent pairs identified between the cohorts. The BDI incidence rate remained significantly higher with lethal triad cases at 1.65% vs 0.04% (P < 0.001). The lethal triad was an even more significant independent risk factor for BDI on the controlled analysis (OR 40.13, 95%CI 7.05-356.59, P < 0.0001). The lethal triad of acute cholecystitis, obesity, and steatohepatitis significantly increases the risk of a BDI. This prognostic measure can help better counsel patients and potentially alter management.

Reasons for laparosopic cholecystectomy conversion in a small general hospital

Background: Laparoscopic cholecystectomy is one of the most common procedures in abdominal surgery. This procedure is the gold standard for the treatment of symptomatic cholelithiasis and acute cholecystitis. However, thedifficulty and possibility of safely performing laparoscopic cholecystectomy vary considerably due to the variety of local findings and the course of the procedure. If it is not possible to complete the procedure safely by laparoscopy, due to intraoperative complications or to avoid the occurrence of complications, it is necessary to convert laparoscopic cholecystectomy to open cholecystectomy.Methods: We performed retrospective research on cases of cholecystectomy performed on all patients at the Dr. Mustafa Beganović General Hospital in Gračanica from 2014 to 2020, which were started by laparoscopy and finished using laparoscopy or converted to open cholecystectomy. Results: There were 888 cases that started as laparoscopic cholecystectomy. In 43, or 5.39% of cases laparoscopic cholecystectomy was converted to open cholecystectomy. The most common reasons for conversion from LC to OC were adhesions, the inability to identify anatomical structures, and inflammation.Conclusion: The number of conversions in our sample is in accordance with the data from the relevant research and at the same time the incidence of bile duct injuries is very low.

Comparison of laparoscopic common bile duct exploration plus cholecystectomy and endoscopic retrograde cholangiopancreatography followed by laparoscopic cholecystectomy for elderly patients with common bile duct stones and gallbladder stones

BackgroundCommon bile duct (CBD) stones commonly occur in cholecystectomy cases. Management options include laparoscopic common bile duct exploration (LCBDE) or endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). While ERCP is mature, it has complications, and LCBDE is a proven alternative. This study evaluates the safety and efficacy of these treatments in elderly individuals aged 70 and older. MethodA retrospective study from January 2015 to July 2022 included 160 elderly patients (aged 70 and older) diagnosed with cholelithiasis and choledocholithiasis. Patients were divided into single-stage (LCBDE, n = 80) or two-stage (ERCP followed by LC, n = 80) treatment groups. Data collected encompassed comorbidities, symptoms, bile duct clearance, postoperative complications and long-term outcome for systematic analysis. ResultWe analyzed 160 patients treated for CBD stones, comparing single-stage and twostage groups. The one-stage group had more female patients (57.5% vs. 37.5%) and a higher mean age (80.55 ± 7 years). ASA classification, Charlson Comorbidity Index, and laboratory findings were similar. Pancreatitis and cholangitis occurred post-ERCP in the two-stage group. Stone clearance rates (92.35% vs. 95%) and biliary leakage incidence (7.5% vs. 3%) were similar, as were post-operative complications and longterm recurrence rates (13% vs. 12.5%). ConclusionIn conclusion, our research indicates that both the combination of LCBDE and LC and the sequence of ERCP followed by LC are equally efficient and secure when treating common bile duct stones in elderly patients. Consequently, the single-stage procedure may be considered the preferred treatment approach for this demographic.

Real-time fluorescence-guided adhesiolysis with indocyanine green in intra-abdominal surgery (with video)

Intra-abdominal adhesions have consistently posed a challenge for surgeons during procedures. This study aims to investigate the feasibility of utilizing indocyanine green (ICG) in conjunction with near-infrared imaging for the detection of intra-abdominal adhesions. In vitro, we analyzed factors affecting ICG fluorescence. We divided SD rats into groups to study ICG excretion in different digestive tract regions. Additionally, we reviewed surgical videos from previous cholecystectomy cases, categorizing them by ICG injection timing and assessing fluorescence imaging in various digestive tract regions. Finally, we preoperatively injected ICG into two cholecystectomized patients with abdominal adhesions, guiding intraoperative adhesiolysis with near-infrared fluorescence imaging. In vitro, we observed a significant influence of protein and ICG concentrations on ICG fluorescence intensity. Our rat experiments unveiled a strong and highly significant correlation (Kendall’s tau-b = 1, P < 0.001) between the timing of ICG injection and the farthest point of intestinal fluorescence. A retrospective case analysis further validated this finding (Kendall’s tau-b = 0.967, P < 0.001). Under the guidance of fluorescence navigation, two cholecystectomized patients with intra-abdominal adhesions successfully underwent adhesiolysis, and no postoperative complications occurred. The intraoperative combination of ICG with near-infrared fluorescence imaging effectively enhances the visibility of the liver, bile ducts, and various segments of the gastrointestinal tract while providing real-time navigation. This real-time fluorescence guidance has the potential to aid surgeons in the dissection of intra-abdominal adhesions.

A novel comparison of erector spinae plane block and paravertebral block in laparoscopic cholecystectomy.

Erector spinae plane block is an updated method than paravertebral block, possessing a lower risk of complications. This study aimed to compare erector spinae plane and paravertebral blocks to safely reach the most efficacious analgesia procedure in laparoscopic cholecystectomy cases. The study included 90 cases, aged 18-70 years, classified as American Society of Anesthesiologists I-II, who underwent an laparoscopic cholecystectomy procedure. They were randomly separated into three groups, namely, Control, erector spinae plane, and paravertebral block. No block procedure was applied to Control, and a patient-controlled analgesia device was prepared containing tramadol at a 10 mg bolus dose and a 10-min locked period. The pain scores were recorded with a visual analog scale for 24 h postoperatively. The visual analog scale values at 1, 5, 10, 20, and 60 min at rest and 60 min coughing were found to be significantly higher in Control than in paravertebral block. A significant difference was revealed between Control vs. paravertebral block and paravertebral block vs. erector spinae plane in terms of total tramadol consumption (p=0.006). Total tramadol consumption in the first postoperative 24 h was significantly reduced in the paravertebral block compared with the Control and erector spinae plane groups. Sonography-guided-paravertebral block provides sufficient postoperative analgesia in laparoscopic cholecystectomy surgery. Erector spinae plane seems to attenuate total tramadol consumption.

Is the Safe Cholecystectomy Technique Really Safe?

Aim: This study aims to present the results of a single surgeon's experience to demonstrate the effectiveness of the 'Critical View of Safety' (CVS) technique in preventing bile duct injuries in clinical practice. &#x0D; Method: We retrospectively reviewed the records of 899 patients who underwent cholecystectomy using the CVS technique performed by a single surgeon at the Sivas Cumhuriyet University Hospital General Surgery Department between 2018 and 2023. Ethical approval for the study was obtained. Cholecystectomy cases were scanned retrospectively. The patients' age, gender, drain placement, surgery indications, and reason for switching to open cholecystectomy were recorded. &#x0D; Results: Among the 899 patients reviewed, 312 were male (34.70%), and 587 were female (65.30%). The average age was 55.10 for males and 51,65 for females. It was determined that 7(0.77%), cases converted to open cholecystectomy. The most common indication for cholecystectomy was elective gallbladder stone removal, accounting for 47.05% of cases. No major bile duct injuries were detected..&#x0D; Conclusions: The safe cholecystectomy technique can be safely applied to avoid bile duct injuries in laparoscopic cholecystectomy.

Full robotic cholecystectomy: first worldwide experiences with HUGO RAS surgical platform.

The Hugo RAS™ system (Medtronic, Minneapolis, MN, USA), approved for gynaecological and urological procedures, has been recently certified for the use in few general surgeries. Only bariatric and colorectal procedures have been described so far. Here, we report the first worldwide experience with three cases of full-robotic cholecystectomies with the Hugo RAS™ system. A description of the operative room setup, of the docking angles and details of the procedures is reported. Docking time was 12, 10, and 6 min, respectively. The total operative time was 105 min in the first case, 100 min in the second and 88 in the third case. Intra- and post-operative courses were uneventful. With this pre-defined set up, the innovative conformation of Hugo RAS™ system can safely allow performing full robotic cholecystectomy avoiding the need for additional ports.

A multifactorial evaluation of objective performance indicators and video analysis in the context of case complexity and clinical outcomes in robotic-assisted cholecystectomy.

The increased digitization in robotic surgical procedures today enables surgeons to quantify their movements through data captured directly from the robotic system. These calculations, called objective performance indicators (OPIs), offer unprecedented detail into surgical performance. In this study, we link case- and surgical step-specific OPIs to case complexity, surgical experience and console utilization, and post-operative clinical complications across 87 robotic cholecystectomy (RC) cases. Videos of RCs performed by a principal surgeon with and without fellows were segmented into eight surgical steps and linked to patients' clinical data. Data for OPI calculations were extracted from an Intuitive Data Recorder and the da Vinci ® robotic system. RC cases were each assigned a Nassar and Parkland Grading score and categorized as standard or complex. OPIs were compared across complexity groups, console attributions, and post-surgical complication severities to determine objective relationships across variables. Across cases, differences in camera control and head positioning metrics of the principal surgeon were observed when comparing standard and complex cases. Further, OPI differences across the principal surgeon and the fellow(s) were observed in standard cases and include differences in arm swapping, camera control, and clutching behaviors. Monopolar coagulation energy usage differences were also observed. Select surgical step duration differences were observed across complexities and console attributions, and additional surgical task analyses determine the adhesion removal and liver bed hemostasis steps to be the most impactful steps for case complexity and post-surgical complications, respectively. This is the first study to establish the association between OPIs, case complexities, and clinical complications in RC. We identified OPI differences in intra-operative behaviors and post-surgical complications dependent on surgeon expertise and case complexity, opening the door for more standardized assessments of teaching cases, surgical behaviors and case complexities.