Completion Cholecystectomy Research Articles

A diagnosis reconsidered: the symptomatic gallbladder remnant.

Patients can present with symptomatic gallbladder disease after cholecystectomy due to a remnant gallbladder. This is a rare problem and challenging diagnosis with limited prior characterization; thus, we present a large series of patients with a gallbladder remnant. A retrospective review was performed of all patients presenting with symptomatic gallbladder remnant at a tertiary care center from 2002 to 2016. Data on presenting symptoms, diagnostic tests, treatments, and follow-up were collected. Thirty-one patients diagnosed and treated for a symptomatic gallbladder remnant were identified. The most common presenting symptoms included right upper quadrant pain (87%) and nausea (55%). The median time from symptom presentation to definitive diagnosis was 60days. Diagnostic modalities utilized in the evaluation of these patients demonstrated that endoscopic retrograde cholangiopancreatography and magnetic resonance cholangiopancreatographywere effective with sensitivities of 85% and 90%,respectively. Twenty-three (76.2%) patients underwentcompletion cholecystectomy, which proved to be definitive treatment. Additionally, eight (25.8%) patients were non-operative candidates and underwent endoscopic retrograde cholangiopancreatography and sphincterotomy, three of whom developed recurrent symptoms. A symptomatic gallbladder remnant after cholecystectomy is infrequently seen; however, the diagnosis should be considered in patients with recurrent biliary symptoms after cholecystectomy. Completion cholecystectomy can be challenging but is highly effective for definitive treatment.

Laparoscopic management of symptomatic gallbladder stump calculi

Aim: The aim of the present study was to evaluate the safety of laparoscopic completion cholecystectomy in patients with symptomatic gallbladder stump calculi. Materials and Methods: Ours was a prospective study conducted in three peripheral hospitals over a period of 6 years. All the patients undergoing elective laparoscopic cholecystectomy during this period were enrolled in the study. The outcomes of laparoscopic completion cholecystectomy in patients with gallbladder stump calculi were compared to those undergoing primary laparoscopic cholecystectomy with regards to perioperative morbidity and mortality. Results: A total of 3127 laparoscopic cholecystectomies were performed. Out of them, laparoscopic completion cholecystectomy was done in 36 (1.15%) patients. There were 21 males and 15 females in these 36 patients. The operative time and hospital stay were significantly increased in the completion group. None of our patients in the completion group required conversion. Perioperative complications were seen more often in the patients posted for completion cholecystectomy (6 [6.67%] vs. 207 [6.69%]; P = 0.0026). Bleeding was the most frequent intraoperative complication seen in the patients undergoing completion cholecystectomy. Conclusion: Laparoscopic completion cholecystectomy, though technically demanding, can be safely done even in a peripheral health setup with acceptable morbidity rate.

Our first laparoscopic right hepatectomy. A challenge for a surgical team

Background: In our group we decided to face this difficult procedure after having performed resection in all hepatic segments, including the demanding segment VII. Methods: We present the case of a young woman, 22 years old, who presented a liver mass, 70 mm in diameter, atypical characteristics in diagnostic procedures (CT, MR)and that showed hipermetabolic activity in CT-PET suggesting malignancy. The patients was placed in a supine position with legs open and partial elevation of the right chest and abdomen. Five trocars were used and a extracorporeal tourniquet was prepared using a 20 Fr thoracic drain. Surgical steps were: 1) right liver mobilization; 2)place of a textil tape around the hepatic hilum for Pringle manoeuver if necessary; 3) dissection and section of cystic artery and duct; 4) hilar dissection with control and section of right hepatic artery and right portal vein; 5)completion of cholecystectomy; 6) parenquimal transection, section of right hepatic duct with stapler and final section of the right hepatic vein with a vascular stapler. A midline incision was performed for the extraction of the specimen an a drain was left in place. Results: No Pringle manoeuver was used. Intraoperative bleeding was 500 ml. No transfusion was necessary. The postoperative course was uneventful, with a postoperative stay of 5 days. Conclusion: Right laparoscopic hepatectomy is a demanding procedure. Strict criteria of selection of patients should be applied in the early experience of the surgical teams in order to face this procedure.

Residual gall bladder: An emerging disease after safe cholecystectomy.

Backgrounds/AimsResidual gallbladder mucosa left after subtotal/partial cholecystectomy is prone to develop recurrent lithiasis and become symptomatic, which mandates surgical removal.MethodsWe retrospectively evaluated the patients with residual gallbladder referred to us from January 2011 to December 2017. Based on MRCP we classified calot's anatomy to – type I where cystic duct was seen and type II where sessile GB stump was seen.Results21 patients with median age 38 years and M:F::1:9.5, had undergone cholecystectomy (3 months-20 years) prior, presented with recurrent biliary pain. 3 had jaundice (CBD stone, Mirizzi and biliary stricture), 1 had pancreatitis and one had malignancy of the GB. Imaging revealed type I anatomy in 14 (67%) and type II in 7 (33%). All underwent completion cholecystectomy – open in 18 and laparoscopic in 3 (one converted to open). Additional procedure was required in 5 patients – CBD exploration in 2 (10%) and one each Hepatico-jejunostomy, extended cholecystectomy and splenectomy. Median hospital stay was 1 day. There was no mortality and 10% morbidity. One patient with malignancy died at 2 years, two died of unrelated cause, one developed incisional hernia and the remaining were well at a median follow up of 29 months.ConclusionsResidual GB lithiasis should be suspected if there are recurrent symptoms after cholecystectomy. MRCP based proposed classification can guide the management strategy. Completion cholecystectomy is curative.

Laparoscopic completion cholecystectomy for late postcholecystectomy Mirizzi syndrome Csendes type 1 due to a sessile gallbladder remnant calculus

Laparoscopic completion cholecystectomy for late postcholecystectomy Mirizzi syndrome Csendes type 1 due to a sessile gallbladder remnant calculus

Remnant gall bladder and cystic duct stump stone after cholecystectomy: tertiary multicenter experience

Background: There is no doubt that cholecystectomy relieves pre-surgical symptoms of gallbladder (GB) disease. The persistence of symptoms mainly biliary pain was recorded in 10 - 20% of cases, with variety of causes. Residual GB/cystic duct stump stone is one of the most important un-expected cause. The present study was conducted to study and evaluate those patients, with their surgical treatment.Methods: This retrospective study was conducted on 27 cases with residual GB/cystic duct stump stone. The diagnosis was guided by ultrasound and magnetic resonance cholangio-pancreatography. All cases were managed by using completion cholecystectomy - either open or laparoscopic. All preoperative, operative, and postoperative data were collected.Results: Preoperative endoscopic retrograde cholangio-pancreatography and papillotomy were required in 13 patients whom were presented with obstructive jaundice. Open completion cholecystectomy techniques were done in the majority of cases (21 patients) while laparoscopic approach was feasible in only 6 cases with one conversion (1/6). The mean operative time was (89.57 ± 12.05 and 118.16 ± 12.6 min), and the mean blood loss was (195.5 ± 19.22 and 187.5 ± 23.61 ml) respectively. Intra-operative minor biliary injury occurred in two cases and repaired instantaneously. The mean hospital stay was (4.76 ± 2.81 and 2.33 ± 1.32 days) respectively. All patients were reported to be symptom-free at the follow-up after surgical treatment.Conclusions: Residual GB/cystic duct stump stone is a preventable and correctable cause of post-cholecystectomy complaint. Completion cholecystectomy is a proven treatment of choice to relieve symptoms and avoid complications; furthermore, it can be carried out laparoscopically with experienced team and facilities in spite of difficulties.

A comparative study of single incision laparoscopic cholecystectomy with conventional laparoscopic instruments versus multiple port laparoscopic cholecystectomy

Background: Treatment of gall stones have evolved markedly since open cholecystectomy was first described by Lange Buch in 1881. Management has progressed through eras of nonsurgical management, laparotomy, minilaparotomy and now laparoscopic cholecystectomy which is the gold standard for the treatment of gall stone disease today. Laparoscopic surgery is the procedure of choice for most benign gall bladder diseases unless obvious contraindication exists. There has been a trend toward minimizing the required number and size of ports to reduce postoperative pain with better cosmetic results.Methods: Comparative randomized study was conducted in Department of Surgery, SDM College of Medical Sciences and Hospital between February 2017 to July 2018. 60 patients who fit into the inclusion criteria were included in the study. 30 patients were included in the multiport cholecystectomy and 30 in the SILC. Random allocation of patients presenting with symptoms suggestive of gall bladder disease with confirmatory USG study. Group1: single incision laparoscopic cholecystectomy, Group2: multiple port laparoscopic cholecystectomy.Results: Majority of presenting patients were in age group 41-50 years. No significant difference in the mean age of patients, surgical complication, conversion rates and SSI operated by the two techniques. Median time required to complete cholecystectomy by SILC technique was not significantly higher than that required for multiport cholecystectomy. Statistically significant lower postoperative pain score was seen in patients with SILC compared to Multiport laparoscopic cholecystectomy. Patients operated by SILC technique had a postoperative hospital stay of mean 4.04 days, almost same as for patients operated by multiport technique.Conclusions: Difference of Conversion rates and time required for SILC is not significantly higher than that required for multiport cholecystectomy. No rise in intra and post-operative complications occurred in the single port surgery. Postoperative pain is significantly lower in patients undergoing SILC Length of postoperative hospital stay and incidence of SSI for single port cholecystectomy is almost as same as for multiport cholecystectomy.

Robotic-assisted completion Cholecystectomy: a safe and effective minimally invasive approach to a challenging surgical scenario

Background: Subtotal cholecystectomy remains a viable and safe option when intraoperative conditions preclude visualization of the Critical View of Safety. 1.8% of these patients eventually require a reoperation. Traditionally, completion cholecystectomy following subtotal cholecystectomy required an open approach. In this study, we present our institutional experience with 16 robotic-assisted completion cholecystectomies following previous subtotal cholecystectomy. Methods: Operating room logs were reviewed from 2010-2017 to identify all robotic cholecystectomies performed at our institution. Review of all operative reports identified 16 completion cholecystectomies following a previous subtotal cholecystectomy. All additional variables including demographics, operative variables, and postoperative outcomes were collected from EMR records. Results: Median time from previous subtotal cholecystectomy to robotic completion cholecystectomy was 84 months (7 years). 58.3% of patients previously underwent an open subtotal cholecystectomy. The remaining patients underwent a laparoscopic subtotal cholecystectomy. Additional demographics and outcomes can be seen in Table 1. One patient required oral antibiotics for incisional site erythema. No patients required a conversion to an open procedure and average length of stay was 1.1 days. Conclusions: Although traditionally performed with an open approach, we have had success in recent years at our institution with a robotic-assisted approach to completion cholecystectomy. The robotic platform offers certain advantages in a hostile, reoperative field which allows these procedures to be performed in a minimally invasive fashion with a low rate of conversion. Previously limited to case reports, this series of 16 procedures represents the largest case series of robot-assisted completion cholecystectomies to date.TP20-02 Table 1Demographics and outcomes for 16 robotic-assisted completion cholecystectomy following subtotal cholecystectomyDemographicsAverage Age49.5 yearsAverage BMI32.8 kg/m2Average ASA2.6OutcomesAverage OR Time118.1 minutesAverage EBL46.9ccAverage LOS1.1 days Open table in a new tab

Laparoscopic completion cholecystectomy is generally feasable, safe and allays the symptoms in post cholecystectomy patients with gallbladder and cystic duct remnants

Laparoscopic completion cholecystectomy is generally feasable, safe and allays the symptoms in post cholecystectomy patients with gallbladder and cystic duct remnants

Transferability of laparoscopic skills using the virtual reality simulator.

Skill transfer represents an important issue in surgical education, and is not well understood. The aim of this randomized study is to assess the transferability of surgical skills between two laparoscopic abdominal procedures using the virtual reality simulator in surgical novices. From September 2016 to July 2017, 44 surgical novices were randomized into two groups and underwent a proficiency-based basic training consisting of five selected simulated laparoscopic tasks. In group 1, participants performed an appendectomy training on the virtual reality simulator until they reached a defined proficiency. They moved on to the tutorial procedural tasks of laparoscopic cholecystectomy. Participants in group 2 started with the tutorial procedural tasks of laparoscopic cholecystectomy directly. Finishing the training, participants of both groups were required to perform a complete cholecystectomy on the simulator. Time, safety and economy parameters were analysed. Significant differences in the demographic characteristics and previous computer games experience between the two groups were not noted. Both groups took similar time to complete the proficiency-based basic training. Participants in group 1 needed significantly less movements (388.6 ± 98.6 vs. 446.4 ± 81.6; P < 0.05) as well as shorter path length (810.2 ± 159.5 vs. 945.5 ± 187.8cm; P < 0.05) to complete the cholecystectomy compared to group 2. Time and safety parameters did not differ significantly between both groups. The data demonstrate a positive transfer of motor skills between laparoscopic appendectomy and cholecystectomy on the virtual reality simulator; however, the transfer of cognitive skills is limited. Separate training curricula seem to be necessary for each procedure for trainees to practise task-specific cognitive skills effectively. Mentoring could help trainees to get a deeper understanding of the procedures, thereby increasing the chance for the transfer of acquired skills.

Robotic-assisted completion cholecystectomy following previous subtotal cholecystectomy - a case series

Background: Subtotal cholecystectomy remains a viable and safe option when intraoperative conditions preclude visualization of the Critical View of Safety. 1.8% of these patients eventually require a reoperation. Traditionally, completion cholecystectomy following subtotal cholecystectomy required an open approach. In this study, we present our single institution experience with 16 robotic-assisted completion cholecystectomies following previous subtotal cholecystectomy. Methods: Operating room logs were reviewed from 2010–2017 to identify all robotic cholecystectomies performed at our institution. Review of all operative reports identified 16 completion cholecystectomies following a previous subtotal cholecystectomy. All additional variables including demographics, operative variables, and postoperative outcomes were collected from EMR records. Results: Median time from previous subtotal cholecystectomy to robotic completion cholecystectomy was 84 months (7 years). 58.3% of patients previously underwent an open subtotal cholecystectomy. The remaining patients underwent a laparoscopic subtotal cholecystectomy. Additional demographics and outcomes can be seen in Table 1. One patient required oral antibiotics for incisional site erythema. No patients required a conversion to an open procedure and average length of stay was 1.1 days. Conclusion: Although traditionally performed with an open approach, we have had success in recent years at our institution with a robotic-assisted approach to completion cholecystectomy. The robotic platform offers certain advantages in a hostile, reoperative field which allows these procedures to be performed in a minimally invasive fashion with a low rate of conversion. Previously limited to case reports, this series of 16 procedures represents the largest case series of robot-assisted completion cholecystectomies to date.

Laparoscopic completion cholecystectomy: an audit from the caribbean chapter of the ahpba

Laparoscopic completion cholecystectomy: an audit from the caribbean chapter of the ahpba

Management of residual gall bladder: A 15-year experience from a north Indian tertiary care centre

Backgrounds/AimsA residual gallbladder (RGB) following a partial/subtotal cholecystectomy may cause symptoms that require its removal. We present our large study regarding the problem of a RGB over a 15 year period.MethodsThis study involved a retrospective analysis of patients managed for symptomatic RGB from January 2000 to December 2015.ResultsA RGB was observed in 93 patients, who had a median age of 45 (25–70) years, and were comprised of 69 (74.2%) females. The most common presentation was recurrence pain (n=64, 68.8%). Associated choledocholithiasis was present in 23 patients (24.7%). An ultrasonography (USG) failed to diagnose RGB calculi in 10 (11%) patients; whereas, magnetic resonance cholangio-pancreatography (MRCP) accurately diagnosed RGB calculi in all the cases except for 2 (4%) and, additionally, detected common bile duct (CBD) stones in 12 patients. Completion cholecystectomy was performed in all patients (open 45 [48.4%]; laparoscopic 48 [51.6%] and 19 [20.4%] patients required a conversion to open). The RGB pathology included stones in 90 (96.8%), Mirizzi's syndrome in 10 (10.8%) and an internal fistula in 9 (9.7%) patients. Additional procedures included CBD exploration (n=6); Choledocho-duodenostomy (n=4) and Roux-en-Y hepatico-jejunostomy (n=3). The mortality and morbidity were nil and 11% (all wound infection), respectively. Two patients developed incisional hernia during follow up. The mean follow up duration was 23.1 months (3–108) in 65 patients and the outcome was excellent and good in 97% of the patients.ConclusionsPost-cholecystectomy recurrent biliary colic should raise suspicion of RGB. MRCP is a useful investigation for the diagnosis and assessment of any associated problems and provides a roadmap for surgery. Laparoscopic completion cholecystectomy is feasible, but is technically difficult and has a high conversion rate.

Development of acute cholecystitis following laparoscopic partial cholecystectomy.

In cases where the dissection of Calot's triangle is difficult during laparoscopic cholecystectomy, laparoscopic partial cholecystectomy is an alternative to total cholecystectomy to prevent bile duct damage. However, recurrent symptoms and bile duct problems associated with the remaining gallbladder tissue may develop in patients over time. The case of a 45-year-old male who underwent laparoscopic partial cholecystectomy one year previously is presented here. In the postoperative period, as a result of tests for the continuing symptoms of cholecystitis, stones and surrounding abscess were detected in the remaining gallbladder tissue, so open completion cholecystectomy was applied. In acute cholecystitis, as severe inflammation of the hilar structures does not allow safe dissection, partial cholecystectomy can be applied. However, in these patients, there is a risk of recurrence of cholecystitis symptoms and the development of biliary pancreatitis and choledocolithiasis because of the remaining tissue. Therefore, it should not be forgotten that endoscopic and/or surgical intervention may be necessary at least in some patients.

Safe Completion of Laparoscopic Cholecystectomy and Its Conversion Rate in a Tertiary Care Hospital

AbstractObjectives: Laparoscopic cholecystectomy is a very good and safe procedure for the removal of gall bladder. The objective of our study was to see the conversion rate of laparoscopic cholecystectomy in our unit.Methods: This is a retrospective descriptive study. We conducted this study on 167 patients who under-went gall bladder removal in our unit at a Public sector hospital of Lahore.Results: Our study showed that 163 (97.6%) out of 167 patients had safe complete laparoscopic cholecystectomy while 4 (2.4%) had to be converted to open cholecystectomy. About 40% of the procedures completed by laparoscope were difficult. Approximately 98% were completed by consultants and 42% weresafely performed by the senior registrars.Conclusion: Gall bladder surgery can be safely completed with laparoscope with good team effort and self-awareness of team.

Short- and Long-Term Outcomes after a Reconstituting and Fenestrating Subtotal Cholecystectomy

Multiple surgical techniques are recommended to perform cholecystectomy safely in difficult cases, such as conversion to open operation or subtotal cholecystectomy (STC). Reconstituting and fenestrating STC are 2 techniques for STC. The aim of this study was to investigate the short and long-term morbidity and quality of life associated with STC and to compare the outcomes after reconstituting and fenestrating STC. Patients who underwent STC were identified. Short-term morbidity assessed included bile leakage, bile duct injury, intra-abdominal infection, reinterventions, and readmittance. Long-term morbidity included bile duct stenosis and recurrent biliary events. Differences in the outcomes of fenestrating and reconstituting STC were assessed. Quality of life was assessed by EuroQol 5 Dimensions, Short-Form 36 Questionnaire, and Gastrointestinal Quality of Life Index questionnaires. Subtotal cholecystectomy was performed in 191 patients, of which 102 (53%) underwent fenestrating STC and 73 (38%) underwent reconstituting STC. Bile leakage was significantly more common after fenestrating STC (18% vs 7%, respectively; p < 0.022). After a median of 6 years follow-up (interquartile range 5 to 10 years), recurrence rate of biliary events was lower after fenestrating than reconstituting STC (9% vs 18%, respectively; p < 0.022). Overall reintervention rate did not differ between the 2 groups: 32% in the fenestrating STC group and 26% in the reconstituting STC group (p= 0.211). Completion cholecystectomy was performed significantly more in patients after fenestrating STC (9% vs 4%; p < 0.022). Subtotal cholecystectomy is a safe and feasible technique for difficult cases for which conversion only will not solve the difficulty of an inflamed hepatocystic triangle. The choice for reconstituting or fenestrating STC depends on intraoperative conditions and both techniques are associated with specific complications.

Post Cholecystectomy Stump Calculus Cholecystitis with Completion Cholecystectomy –A Rare Case Report

Post Cholecystectomy Stump Calculus Cholecystitis with Completion Cholecystectomy –A Rare Case Report

Subtotal cholecystectomy for the hostile gallbladder: failure to control the cystic duct results in significant morbidity

BackgroundOutcomes following the inability to control the cystic duct due to a hostile triangle of Calot during cholecystectomy remain unknown. The purpose of this study was to analyze the safety and efficacy of subtotal cholecystectomy, with attention to the necessity for secondary interventions. MethodsSixteen thousand five hundred ninety six cholecystectomies from January 2002 to August 2014 were reviewed, identifying patients managed with subtotal cholecystectomy, defined as the inability to isolate/transect the cystic duct. After propensity matching, we investigated surgical indications, perioperative outcomes, and the necessity for secondary ERCP, percutaneous drainage, and completion cholecystectomy. Results65 (0.39%) patients underwent subtotal cholecystectomy; 54 (83.1%) began laparoscopically, of which 30 (55.6%) required conversion to laparotomy. Subtotal cholecystectomy, performed more frequently for acute cholecystitis (70.8% vs 34.6%), was associated with extended hospitalizations (4 d vs 2 d) and frequent surgical site infections (20% vs 4.6%). 25 (38.5%) subtotal cholecystectomy patients required ≥1 secondary intervention, and compared to standard cholecystectomy, underwent higher rates postoperative ERCP (30.8% vs 5.4%), percutaneous drainage (9.2% vs 1.5%), and completion cholecystectomy (6.2% vs 0%) [all P < 0.05]. DiscussionSubtotal cholecystectomy fails to control the cystic duct, resulting in significant morbidity. Most do not require completion cholecystectomy; however, patients demand close observation and, frequently, secondary interventions.

Does a second resection provide a survival benefit in patients diagnosed with incidental T1b/T2 gallbladder cancer following cholecystectomy?

BackgroundIncidental T1b/T2 gallbladder cancers are often managed with a second resection. However it is unclear whether the additional surgical risk is associated with any survival advantage. The aim of this study was to examine the outcomes of patients who underwent a second resection following a diagnosis of incidental T1b/T2 gallbladder cancer. MethodsA retrospective analysis of patients undergoing surgical management following a diagnosis of incidental T1b/T2 gallbladder cancer between 1994 and 2014. Survival outcomes were analysed using the Kaplan–Meier method. ResultsTwenty two patients underwent completion surgery following diagnosis of T1b/T2 gallbladder cancer at initial cholecystectomy, 11 of which were found to have residual disease. The presence of residual disease at second surgery in T1b/T2 disease was associated with worse overall survival (residual disease: median survival 12 months, absence of residual disease: median survival not reached, p = 0.025). ConclusionA significant percentage of patients with T1b/T2 disease have identifiable residual disease following second surgery. Residual disease is associated with poor survival. It is therefore important to inform patients that completion cholecystectomy is primarily performed to inform staging rather than to improve prognosis.

Choledochal cyst: their clinical presentation, diagnosis and treatment in central Nepal: a retrospective study

Background: Choledochal cyst is a rare congenital malformation involving the cystic dilatation of intrahepatic or extra-hepatic or both bile duct .The estimated incidence is one in 1000 live birth in Asian population with female to male ratio 3:1.Objectives: To study the clinical presentations, diagnostic modalities, treatment and outcome of choledochal cyst in College of Medical Sciences, Bharatpur, NepalMethods: A retrospective review of the records of all the patients who were diagnosed as choledochal cyst and underwent medical or operative intervention in our hospital in the period of January 2013- January 2015.Results: We have analyzed ten cases of choledochal cyst. We found most common age group of presentation of choledochal cyst was 6-10 yr with female preponderance (70%). Most common presenting symptom was pain abdomen (100%) followed by jaundice (50%). However classical triad of abdominal pain, jaundice, and an abdominal mass was not seen in any of the cases. Ultrasonography was found to be 100 % accurate in diagnosis of choledochal cyst. Todani type I cyst was the most common type. Nine out of ten cases underwent complete cyst excision with cholecystectomy and Roux-en-Y hepaticojejunostomy without any major complication. Malignancy was not seen in any patients.Conclusion: Choledochal cyst is a rare disease. Most common age group of presentation is 6-10 yrs. Pain abdomen is the most common clinical presentation. Ultrasonography is usually the first examination and is very sensitive for diagnosis of choledochal cyst. Complete cyst excision, cholecystectomy and internal drainage is the treatment of choice.