BACKGROUND Eisenmenger syndrome presents a unique challenge for the acute care surgeon. Even routine operations such as laparoscopic appendectomy or cholecystectomy become challenging due to the cardiopulmonary physiologic changes and anatomic anomalies associated with Eisenmenger syndrome. The care of these patients can be further complicated by the severity of disease, surgical complexity, and the abnormal anatomy associated with the syndrome. CASE REPORT A 35-year-old patient with Eisenmenger syndrome and abdominal heterotaxy presented with acute cholecystitis. She underwent percutaneous cholecystostomy tube placement during her index hospitalization, which was complicated by atrial fibrillation and a cerebrovascular accident due to air embolism. Three months after presentation, she underwent an uncomplicated open cholecystectomy. She was discharged on post-operative day 5, and her course was notable only for a superficial surgical site infection requiring incision and drainage and antibiotics. CONCLUSIONS Our experience managing acute cholecystitis in a patient with Eisenmenger syndrome, abdominal heterotaxy with interrupted inferior vena cava, and bilateral superior vena cava, highlights critical aspects of care of such patients in the context of routine acute surgical care. Pre-operative planning should include optimization of cardiopulmonary function, an individualized anesthetic plan to maintain systemic vascular resistance, and bailout maneuvers in the event of cardiovascular collapse, such as planning for extracorporeal membrane oxygenation with axillary cannulation in the case of our patient.

Laparoscopic cholecystectomy is the gold standard for gallbladder disease, but the decision to switch to open surgery is still a critical one. The purpose of the study was to determine the conversion rate, to identify predictive risk factors and to analyze the results of the institution-wide conversion rate. A retrospective cohort study was conducted in the Department of Surgery, Community Based Medical College, Bangladesh (CBMC,B), Mymensingh, Bangladesh, between January 2020 and December of 2022, to assess factors leading to the change from laparoscopic to open cholecystectomy and analyze the impact of early change on patient safety and post-operative outcomes. Medical records of 320 patients, who had a laparoscopic cholecystectomy course for symptomatic gallbladder disease. Demographics, pre-operative findings, operative details and post-operative results were collected. Conversion from laparoscopic cholecystectomy to open cholecystectomy rate was 4.7% (n=15). Bivariate analysis revealed age at surgery (p=0.001), particularly age 50-59 years (20.8% change), gender (19.1% vs. 2.2%, p=0.002), and history of upper abdominal surgery (26.7% vs. 3.6%, p=0.008). A slight positive correlation between age (r=0.42) and gender (r=0.36) was confirmed by Pearson correlation. The main causes of change were thickened adhesions (40%) and acute inflammations (33.3%). The converted group had significantly more time to return to activity (92.5±18.3 vs. 54.2±12.5 minutes, p=0.001) and more hospital stays (5.8±1.6 vs 2.3±0.8 days, p=0.001). The patient profile for transfer from laparoscopic cholecystectomy to open cholecystectomy was clear for high-risk patients. We observed that time-oriented transformation guided by pre-operative risk factors and intra-operative challenges are key surgical judgement that reduces the risk of major complications and prioritises patient safety in favour of procedural rigour. CBMJ 2026 January: vol. 15 no. 01 P:127-133

Postoperative wounds are at high risk for complications such as infection, wound dehiscence, and sepsis, particularly in patients with hypoalbuminemia that impairs tissue regeneration. This case report aims to evaluate the effectiveness of nursing care management based on education about wound care and nutrition in improving the knowledge of patients and families. Method: A descriptive case report approach was conducted on Mrs. S (32 years old) diagnosed with burst abdomen and hypoalbuminemia after open cholecystectomy in the Medical-Surgical Inpatient Unit of Hospital X. The intervention consisted of educational sessions using leaflet and video media based on Evidence-Based Practice (EBP), covering aseptic principles, wound care steps, signs of infection, and the importance of high-calorie high-protein (HCHP) nutrition. Evaluation was performed using pre-test and post-test assessments. Results: The patient’s knowledge score increased from 40 (pre-test) to 100 (post-test), while the family’s knowledge improved from 40 to 80. Analysis using the 3M approach (Man, Method, Material) indicated that educational effectiveness was supported by active involvement of nurses and family, interactive learning methods, and accessible educational media. Conclusion: Implementation of 3M-based nursing management through combined leaflet and video education proved effective in enhancing the knowledge, skills, and preparedness of patients and families in performing independent wound care at home

To evaluate the feasibility of a commercial simulator to reproduce key steps of canine laparoscopic cholecystectomy, and to compare surgical performance when using 3-D versus 2-D visualization. 16 gallbladder inserts mounted in a laparoscopic cholecystectomy model were used. Inserts were randomly assigned to 2-D or 3-D visualization groups and placed in a laparoscopic training box. All procedures were performed on a single day in 2022 by 1 American College of Veterinary Surgeons resident who completed prestudy training on the simulator to minimize learning-curve effects. A board-certified surgeon supervised all procedures. Surgical steps included cystic duct dissection, endoclip application, cystic duct transection, and gallbladder removal. Measured outcomes included surgical times for defined intervals, total procedure time, intraoperative complications, and residual simulated liver tissue attached to the gallbladder. Time from instrument insertion to first endoclip placement and total surgical time were significantly shorter with 3-D visualization compared to 2-D, and the differences in medians suggested clinically meaningful improvements in performance. There were no significant group differences in bile leakage, incomplete clipping, or the amount of residual foam attachment. This physical simulator allowed reproduction of most key procedural steps in canine laparoscopic cholecystectomy. Three-dimensional visualization improved surgical efficiency for a trainee operator. The simulator provided a safe, accessible platform for early skills acquisition before progressing to cadaveric or clinical training.

Background: Laparoscopic cholecystectomy (LC) is one of the most common surgical procedures performed globally. While it is generally considered safe, there remains a risk of serious biliary injuries occurring during the procedure. Indocyanine green (ICG) is a water-soluble, non-toxic dye that allows real-time intraoperative visualization of the extrahepatic biliary tree. Aim: This study aims to compare the bile duct injury rate, duration of surgery, conversion rate, length of hospitalization, and overall outcomes between laparoscopic cholecystectomy with and without indocyanine green (ICG). Methods: Ninety-two patients who underwent LC from October 2023 to October 2024 were included in the study; 42 of them underwent LC with ICG (group 1), and 50 did not receive it (group 2). Both groups were compared regarding intraoperative complications, duration of surgery, conversion rates, length of hospitalization, and overall outcomes. Results: The mean total operative time in minutes for group 1 was 44.6 minutes, compared to 51.1 minutes for group 2 (p-value = 0.001). No CBD or cystic duct injuries occurred in any patient in either group. Two patients were converted to open cholecystectomy in group 2, while none were converted in group 1; however, there was no statistically significant difference between the two groups (p-value = 0.174). There was no significant statistical difference in the length of hospital stay between both groups (p-value = 0.08). Conclusions: Indocyanine green (ICG) in LC allows for better visualization of the extrahepatic biliary system, leading to a significant reduction in operative time, gallbladder perforation, and bile spillage; however, there is no significant difference in bile duct injury rates, conversion rates to open surgery, or length of hospitalization in the ICG group.

Laparoscopic cholecystectomy (LC) is the gold standard for the treatment of symptomatic gallbladder diseases such as cholecystitis and cholelithiasis and it is the most performed procedure in general surgery with more than 1.5 million cholecystectomies performed annually in the United States. The reasons behind the increasing number of laparoscopic surgeries are improved postoperative pain and improved healing time as compared to open cholecystectomy resulting in earlier recovery and discharge from the hospitals. However, even if it is considered a minimally invasive technique, the intensity of pain on the first postoperative day is significant. Appropriate pain control is essential for optimizing the clinical outcomes and to ensure the patient can walk as early as possible after surgery

Background: Gallstone disease is a common gastrointestinal disorder, and cholecystectomy remains its definitive treatment. With the advancement of minimally invasive surgery, laparoscopic cholecystectomy has become the preferred technique; however, its superiority over open cholecystectomy in terms of post-operative quality of life (QoL) continues to be evaluated. Aims and Objectives: The aim of the study was to assess and compare the post-operative QoL in patients undergoing laparoscopic versus open cholecystectomy using the RAND-36 health survey. Materials and Methods: This prospective comparative observational study was conducted in the Department of General Surgery, Government Medical College, Datia, between September 2024 and August 2025. A total of 200 patients with symptomatic cholelithiasis were enrolled, of whom 100 underwent laparoscopic cholecystectomy and 100 underwent open cholecystectomy. QoL was assessed using the RAND-36 questionnaire preoperatively and at 4 weeks postoperatively. Statistical analysis was performed using the Statistical Package for the Social Sciences v21, with a P<0.05 considered significant. Results: Baseline demographic variables, including mean age (42.58±12.35 vs. 43.11±11.98 years, P=0.68) and gender distribution (male 36% vs. 39%, female 64% vs. 61%), were comparable between groups. At 4 weeks, laparoscopic cholecystectomy demonstrated significantly superior QoL scores across seven of eight domains: physical functioning (88.68±22.40 vs. 60.00±30.00; P=0.01), role limitations due to physical health (98.75±10.55 vs. 70.00±20.00; P=0.001), emotional role (98.67±11.49 vs. 75.00±25.00; P=0.001), vitality (83.11±12.46 vs. 60.00±15.00; P=0.01), social functioning (98.88±5.20 vs. 80.00±15.00; P=0.001), pain (97.30±15.49 vs. 70.00±20.00; P=0.01), and general health (67.00±35.51 vs. 50.00±30.00; P=0.04). Emotional well-being showed no significant difference (P=0.88). Conclusion: Laparoscopic cholecystectomy provided faster recovery, less pain, and better short-term QoL outcomes compared with open cholecystectomy. It should be preferred as the standard surgical approach for symptomatic gallstone disease.

Abstract Introduction Intraoperative cholangiography (IOC), once the gold standard during open cholecystectomy, has become a controversial and inconsistently applied step in laparoscopic cholecystectomy (LC). Factors such as inadequate training, variable difficulty, and divergent surgical techniques might contribute to its declining use. Method We propose a novel IOC difficulty classification based on Mr. Nassar's standard IOC technique where 5 Fr (or 4 Fr for narrow ducts) ureteric catheter introduced from the medial right upper quadrant port, employing a trans-cystic basket-in-catheter (BIC) technique. Prospectively collected data and vidoes for LC operations performed by a single surgeon adopting index admission, single-session management of cholelithiasis from January 2023 to June 15, 2025. Classification Grade I: From the initial CD cut Grade II: Only possible by engaging the tip of the catheter and using the cholangiogram-clamp CD manipulation or proximal CD dissection is required Grade III: Proximal dissection of CD up to the junction between CD-common hepatic duct (CHD) junction Impacted proximal CD stone (Ghost stone) Grade IV: IOC only possible from the Gallbladder when CD access is not feasible. Grade V: only possible through Direct bile duct (BD) puncture. Subgrade “A”: when Guidewire assistance required. Results Grade I in 70%, Grade II in 18% (IIA 2%), Grade III in 6% (IIIA 2%), Grade IV in 2% (IVA 1%), whereases cholangiography was abandoned in 1% where BD puncture was not indicated. Conclusions This classification provides a structured approach to standardizing and assessing IOC difficulty in LC, potentially improving training and procedural consistency.

Abstract Aim The internet is a primary resource for patients seeking information on medical conditions and treatments. High-quality information is associated with better clinical outcomes. This pilot study evaluates the quality of online information on laparoscopic cholecystectomy using the validated modified Ensuring Quality Information for Patients (EQIP) tool. Method We conducted a Google search using eight terms, including “laparoscopic cholecystectomy” and “gallbladder removal.” The first 100 results for each term were reviewed, yielding 800 websites. After removing duplicates, non-English sites, and websites targeting medical professionals or children, 171 websites met inclusion criteria. For this pilot study, 100 websites were sequentially selected for analysis. Website quality was assessed using the modified EQIP tool, with scores categorised into content, structure, and identification domains. Results The median modified EQIP score was 60.3%. Median scores for the content, identification, and structure domains were 50%, 50%, and 90%, respectively. Only 3 (3%) websites stated how patients were involved in their creation, and 53 (53%) failed to include alert signs for complications post-procedure. Conclusions The information we evaluated can reasonably be considered representative of what is most readily accessible to patients. There is an urgent need to improve the quality of online patient information regarding laparoscopic cholecystectomy. The current resources lack critical information on risks and post-operative warning signs, limiting patients’ ability to make informed healthcare decisions. Efforts should focus on enhancing the accessibility and comprehensiveness of online materials.

Acute calculus cholecystitis is a common surgical emergency that has traditionally been treated with conservative treatment followed by delayed laparoscopic cholecystectomy. The Tokyo Guidelines of 2013/2018 and the World Society of Emergency Surgeons (WSES) 2020 guidelines on acute calculus cholecystitis have recommended early laparoscopic cholecystectomy. Early laparoscopic cholecystectomy is performed within 7 days from the onset of symptoms and is associated with better outcomes, shorter stay in the hospital, and reduced cost. In this review, we will investigate the role of early laparoscopic cholecystectomy and the risk of conversion to open cholecystectomy in the management of acute calculus cholecystitis.

Abstract Aim High-quality operation notes are vital for safe post-operative care, effective communication, and medico-legal protection. The RCSEng and GIRFT guidelines recommend clear, comprehensive, and preferably typed documentation for all procedures (total score 32). This audit assessed the quality of cholecystectomy operation notes against these standards, comparing biliary versus non-biliary surgeons. Method This multicentre retrospective cohort study included consecutive adult patients who underwent elective or emergency cholecystectomy across three hospitals between August 2023 and July 2024. Cases were grouped based on whether the operating surgeon was classified as biliary or non-biliary specialist. Operation notes were audited against GIRFT guideline criteria, and results were compared between the two groups. Results Of 564 patients, 405 (71.8%) were female, with a median age of 53 years. Biliary surgeons performed 125 (22.2%) procedures, while non-biliary surgeons performed 439 (77.8%). Emergency cholecystectomies were more frequently performed by biliary surgeons (44.8% vs 35.1%, p=0.047), who also had a higher rate of typed operation notes (94.4% vs 59.0%, p<0.001). The median GIRFT score was significantly higher among biliary surgeons (29 [IQR 27–31]) compared to non-biliary surgeons (19 [IQR 16–21]), p<0.001. Notably, none of the non-biliary surgeons achieved a perfect score (32/32). Conclusions This audit highlights a clear and concerning gap in compliance with GIRFT standards among non-biliary surgeons. The marked disparity in operative note quality carries important implications for patient safety, medico-legal accountability, and clinical continuity. To address this, the implementation of typed, standardised operation notes should be mandated, with targeted interventions to ensure adherence to national documentation standards.

Risk Factors for Conversion in Laparoscopic Cholecystectomy and Development of a Predictive Nomogram.

Purpose: Laparoscopic cholecystectomy (LC) is a minimally invasive surgical procedure offering reduced postoperative pain, shorter hospital stays, and faster recovery. Despite these benefits, pain from tissue trauma, pneumoperitoneum, and gallbladder removal remains significant. This study compares the analgesic efficacy of the Modified Thoracoabdominal Nerve Block via Perichondrial Approach (M-TAPA) and intraperitoneal bupivacaine with or without dexmedetomidine in patients undergoing LC. Materials and Methods: This prospective, randomized, single-blind trial included 60 ASA I/II patients undergoing elective LC under general anesthesia. Patients were divided into three groups: M-TAPA block (Group M), intraperitoneal bupivacaine (Group B), and intraperitoneal bupivacaine plus dexmedetomidine (Group BD). Postoperative pain was assessed using the Numeric Rating Scale (NRS) at six-hour intervals for 24 hours. Secondary outcomes included rescue analgesic requirements and side effects. Data were analyzed using ANOVA, Kruskal-Wallis, and Bonferroni post hoc tests. Results: Group BD and Group M showed significantly lower NRS scores compared to Group B (p

Elective laparoscopic cholecystectomy is increasingly being conducted as a day-case procedure. However, some patients planned for day-case surgery stay in hospital for at least one night. The aim of this study was to identify factors associated with conversion from planned day-case to in-patient management for elective laparoscopic cholecystectomy. This was an exploratory retrospective analysis of observational data from the Hospital Episode Statistics dataset for England. All patients aged ≥ 17years undergoing a planned elective day-case laparoscopic cholecystectomy between 1st April 2017 and 31st March 2024 were identified. The exposure of interest was discharge on the day of admission (day-case) or requiring overnight stay. For reporting, providers were aggregated to an Integrated Care Board (ICB) level. A total of 286,754 elective LCs planned as day-case were identified over the seven-year study period. Of these, 74,957 (26.1%) stayed in hospital for at least one night and were classed as day-case to in-patient stay conversions. In multilevel, multivariable modelling, conversion to in-patient stay was associated with great age (odds ratio (OR) 2.54 for 17-29 vs ≥ 70years, p < 0.001), male sex (OR = 1.11, p < 0.001), deprivation (OR 1.14, first vs fifth quintile, p < 0.001), open surgery (46.93, p < 0.001), and low annual surgeon volume (OR 1.73, < 10 vs ≥ 80 LCs per year, p < 0.001). Comorbidities and post-procedural complications were also strongly associated with conversion. Across the 42 ICBs in England, model-adjusted conversion rates varied from 14.5% to 39.0%, 18 (42.9%) ICBs had conversion rates above the 99.8% control limit. Conversion from day-case to in-patient stay was associated with increasing age, male sex, deprivation, open surgery, low surgeon volume, comorbidity and post-procedural complication. Our findings will help surgical team identify patients suitable for day-case laparoscopic cholecystectomy.

Bile duct injuries following cholecystectomy surgery were followed up after undergoing ERCP procedure . Total 34 patients were taken , out of which 10 patients expired or were lost to follow up, so 24 patients were taken. 14 patients had only bile duct leaks and rest were having leaks with stricture. Success of ercp in patients with only leaks was 13/ 14(93%) .Out of stricture only 5 patients could be cannulated and 2 were successful, 2 out of 5 (40%). So ERCP is more successful if there is leak rather than leak with stricture

Chronic cholecystitis is a persistent inflammatory disorder of the gall bladder, commonly arising from recurrent mild or subclinical bouts of acute cholecystitis. It is marked by mucosal atrophy, fibrotic thickening, and distortion of the gallbladder wall. The condition is strongly associated with gall stones, whose continuous mechanical irritation and intermittent obstruction lead to progressive fibrosis, structural alteration, and chronic inflammation . Laparoscopic or open cholecystectomy operations are the common operations done in AL nassiriya city due to acute or chronic calculus cholecystitis. Chronic calculus cholecystitis may be associated with malignant changes because of chronic irritation, which is usually preceded by metaplasia due to irritation, dysplasia, carcinoma in situ, and then invasive carcinoma. 360 patients undergoing successful laparoscopic or open cholecystectomy for chronic calculus cholecystitis, all gall bladders are sent for histopathological examination to detect any malignant changes. Several cases of chronic calculus cholecystitis have developed malignant changes. Tubular adenocarcinoma, most frequently observed in women with gallstones, exhibits a downward invasive growth pattern and carries a poor prognosis. Chronic cholecystitis and epithelial metaplasia are commonly present, while undifferentiated carcinomas also prevalent among females with gallstones, demonstrate the most adverse clinical outcomes. Patients with chronic calculus cholecystitis should be treated by laparoscopic or open cholecystoctomy as soon as possible to prevent hazards of malignant changes that may be associated with chronic irritation of the stones to the gall bladder mucosa and because of histopathological types of ca. bladder that associated with gall stones are either tubular adenocarcinoma or undifferentiated carcinoma which have bad prognosis thus, after operation should send the gall bladder for histopathological examination to detect any malignant changes and deal with it as early as possible.

Gallbladder cancer is the fifth most common gastrointestinal cancer worldwide, often diagnosed incidentally after cholecystectomy for presumed benign disease. Previous studies have reported geographic variations in the incidence of incidental gallbladder cancer (IGBC), but comprehensive pooled estimates examining multiple predictors of IGBC are lacking. The study aims to synthesize the risk factors and clinical predictors associated with IGBC in patients undergoing cholecystectomy for benign gallbladder conditions. This systematic review and meta-analysis assessed studies published between January 2010 and February 2024 in databases from EMBASE, PUBMED-MEDLINE, and Scopus. Eligible studies included observational study designs evaluating risk or predictive factors for IGBC diagnosed during or after cholecystectomy for presumed benign gallbladder disease. Heterogeneity across studies was assessed using the I² statistic. Sensitivity analyses were conducted to explore the robustness of the pooled estimates. Of 2899 studies screened, 18 were included in the systematic review and 9 of these were included in the meta-analysis, covering 788,214 patients undergoing cholecystectomy. Advancing age (OR:1.09; 95% CI:1.07-1.12, I2=55.9%), female gender (OR:1.91; 95% CI:1.33-2.75, I2 = 72.1% ), elevated alkaline phosphatase (OR:1.68; 95% CI:1.41-2.00, I2 = 0%), polyp size > 10mm (OR:8.63; 95% CI:1.95-38.26, I2 = 0%), and open cholecystectomy (OR:9.20; 95% CI:5.68-14.89, I2 = 83.5%) were found to have association with IGBC. Large gallstones (> 3cm) showed no significant association. Risk of bias was low, and sensitivity analyses confirmed model robustness. This review identifies key demographic, and clinical factors associated with IGBC. These findings support the need for risk-based preoperative evaluation and careful intraoperative vigilance, particularly in patients with advanced age, female gender, elevated alkaline phosphatase, and larger gallbladder polyps. Incorporating these predictors into clinical decision-making may guide targeted histopathological examination policies, leading to earlier GBC detection and improved patient outcomes. PROSPERO Registration No: CRD42024528982.

Successful Removal of Gallbladder and Common Bile Duct Stone in a Single Session Using a Single-Operator Cholangioscopy.

Cholecystectomy, a common surgical procedure to remove the gallbladder, generally has a low complication rate. However, the emergence of MDR pathogens poses significant challenges in the post-operative management of infections. Multidrug-resistant Klebsiella pneumoniae (MDR-KP) is one of the most emerging issues in bacterial resistance. A 57 year-old woman came to the emergency unit at Dr. Soetomo General Academic Hospital with a chief complaint of pain in the upper and lower abdomen for four days. The patient had a history of cholecystectomy surgery in another hospital two weeks before admission. A cito laparotomy was performed. During surgery, turbid peritoneal fluid mixed with pus and abdominal wall fasciitis necroticans were found. From microbiology examination, MDR-KP was detected in pus. The patient was treated with Meropenem 1 g/8 hours and Amikacin 250 mg/8 hours. Unfortunately, the patient died due to sepsis and multi-organ dysfunctions. This case underscores the importance of vigilant post-operative monitoring and the need for effective infection control measures to manage and prevent MDR-KP infections in surgical patients. Enhanced surveillance and antibiotic stewardship are crucial to mitigating the risks associated with MDR organisms in healthcare settings.

Introduction: The aging surgical population presents a unique challenge characterized by "homeostenosis"—a depletion of physiologic reserve that renders patients vulnerable to perioperative stressors. This vulnerability is exacerbated by cardiometabolic multimorbidity, specifically the triad of hypertension, coronary artery disease (CAD), and type II diabetes mellitus. Managing the hemodynamic volatility associated with open cholecystectomy in such patients requires a nuanced, risk-adapted strategy. Case Presentation: We present the case of a 71-year-old male (ASA Physical Status III) with a history of hypertension, ischemic heart disease (ejection fraction 70.7% with diastolic dysfunction), and insulin-dependent type II diabetes, presenting for elective open cholecystectomy. Preoperative optimization included antiplatelet cessation and cardiac risk stratification. General anesthesia was maintained with Sevoflurane and multimodal analgesia. Intraoperatively, the patient exhibited a sympathetic surge (blood pressure 171/95 mmHg) upon surgical traction, indicative of preserved autonomic reactivity superimposed on vascular stiffness. This was successfully attenuated through rapid titration of volatile anesthesia and opioid bolusing, preventing myocardial ischemia. Postoperative analgesia utilized a continuous low-dose fentanyl infusion combined with oral paracetamol to ensure hemodynamic stability without respiratory compromise. Conclusion: Successful anesthetic management in geriatrics with cardiometabolic burden relies on anticipating the "stress gap" between demand and reserve. This case demonstrates that a vigilant, titrated approach to general anesthesia—focusing on sympathetic attenuation and opioid-sparing multimodal analgesia—can effectively mitigate perioperative risks in high-acuity patients undergoing open abdominal surgery.