Complication Of Laparoscopic Cholecystectomy Research Articles

Factors Influencing Bile Duct Injuries: A Dreaded Complication of Laparoscopic Cholecystectomy.

Bile duct injuries (BDIs) are dreaded complications of one of the most common general surgical procedures. The injury impacts the quality of life and may have several long-term complications. In some cases, it can also lead to mortality. This paper aims to review works that have already been published about bile duct injuries and elaborate on the factors leading to it. This includes elaborating on both surgical and non-surgical factors. It also plans to highlight practices and methods to avoid BDIs. Medical research databases were searched using cholecystectomy and bile duct injuries as keywords. Papers including pre-operative or intraoperative factors, that may cause bile duct injuries, were further shortlisted for this study. Understanding and knowledge of anatomy plays a key role in bile duct injuries and is essential before performing the surgery. Factors related to the patients, surgeons, and logistics also play a major role in causing bile duct injuries. Bile duct injuries can be reduced using certain strategies like the B SAFE strategy, R4U line, bail-out methods, imaging techniques along with referrals to Hepatobiliaryspecialist centers to avoid bile duct injuries.

Biodegradable Stents: A Breakthrough in the Management of Complex Biliary Tract Injuries: A Case Report

Background and Clinical Significance: Biliary tract injuries are a recognized complication of laparoscopic cholecystectomy. Early diagnosis and prompt management are crucial to minimize complications such as bile leaks, strictures, and fistula formation. This case report highlights the use of a biodegradable biliary stent in managing a complex biliary injury and discusses the impact of delayed diagnosis on treatment outcomes. Case Presentation: We present the case of a 30-year-old male who sustained a Strasberg E2 biliary tract injury during a laparoscopic cholecystectomy. Initially misdiagnosed, the injury was only recognized on the fourth postoperative day. The patient underwent a Roux-en-Y hepaticojejunostomy and subsequently developed a postoperative biliary fistula, which was managed with percutaneous drainage. A biodegradable biliary stent was later placed to address a stricture and minimize the need for future interventions. One year later, the patient presented with symptoms of cholangitis, and radiological findings revealed a narrowing of the biliary lumen. The stricture was resolved and an endoscopic gastrojejunal shunt was placed to prevent further complications. The patient is currently in good condition with no signs of further complications. Conclusions: This case emphasizes the importance of early diagnosis in managing biliary tract injuries and highlights the potential of biodegradable stents to reduce the need for repeat interventions. Despite a delayed diagnosis necessitating complex surgical procedures, the use of a biodegradable stent proved effective in managing postoperative complications. Further studies are needed to evaluate the long-term efficacy of biodegradable stents in similar clinical scenarios.

Our experience of laproscopic cholecystectomy with associated complications and their treatment: a study of 200 cases

Background: The aim of this study was to evaluate the intraoperative and postoperative complications of laparoscopic cholecystectomy along with their treatment. Methods: The study was conducted in a tertiary care government teaching hospital in central Gujarat, India. And conventional laparoscopic cholecystectomy was performed after all relevant investigations. Results: In our analysis of 200 cases of planned laparoscopic cholecystectomy, we have found that the median age of patients undergoing operation was 47 years. In our study, 140 (67%) of the patients were female and 60(33%) male cases. It is noted that there were more complications in male patients (OR=2.95, CI 95%, 1.42-4.23, p<0.001). The total number of complications were 60 (30%) out of which 45 (22%) were found to be intraoperative complications and rest were post operative complications. In our study, most common complication encountered was iatrogenic perforation which caused spillage of stones or bile 35 (17.5%) followed by bleeding from gallbladder fossa 12 (6%). CBD injury which is one of the most dreaded complications of laparoscopic cholecystectomy occurred in only 1 patient (0.5%). Among the post operative complications bleeding from abdominal cavity 12 (6%), bilioma 7 (3.5%) and infection of surgical wounds 4 (1.5%) were common. There was a total rate of 5% conversions to open surgery. Conclusions: Adopting laparoscopic cholecystectomy as a new technique for treatment of cholelithiasis, introduced a new spectrum of complications. Major biliary and vascular complications are life threatening, while minor complications cause patient discomfort and prolongation of the hospital stay. It is important recognizing IOC complications during the surgery so they are taken care of in a timely manner during the surgical intervention.

Intrahepatic bilioma as a complication of laparoscopic cholecystectomy: a case report

A biloma is described as an encapsulated collection of intra- or extrahepatic bile related to trauma mechanisms at the level of the biliary tree. Its etiological origin is a traumatic injury following biliary or hepatic surgery, which can cause iatrogenic conditions. In some cases, it can resolve spontaneously, but this is very uncommon. Treatment focuses on performing percutaneous drainage, endoscopy, and should be associated with antibiotics according to the patient's requirements; in some cases, the placement of a stent will be necessary. It is important to note that if the biloma is associated with an infectious condition, it must be drained immediately.

The incidence of complications in Laparoscopic Cholecystectomy in Acute Cholecystitis in tertiary Care Setup

Abstract Laparoscopic cholecystectomy is the procedure usually performed in our setups for both acute & chronic Cholecystitis and simple gall stone disease. Objective Find the outcomes of laparoscopic cholecystectomy in acute cholecystitis in our hospital setup. Methods This prospective cross sectional study was conducted in Hazrat Bari Sarkar Hospital Islamabad on 10th Nov 2022 to 30 June 2023. The patients from above 10 year age with both genders were included by convenient sampling. All Diagnosed cases of gall stone disease with acute cholecystitis, acute on chronic cholecystitis, abscess, and empyema or mucocele gall bladder were included in this study. SPSS 22 was used for data analysis that was recorded on a performa. Results This study included 77 laparoscopic cholecystectomies done for Acute Cholecystitis. 53 female & 24 male patients with female to male ratio of 2.2:1 undergoing laparoscopic cholecystectomies were included in the study. The mean age of patients was 47.6 years + 11.6 SD. The mean operative time was around 90min + 13.5 SD and the mean hospital stay was 2.23 days + 0.77 SD with a range of 1-4 days. Conversion rate to open cholecystectomy was noted in 8 cases. The operative complications were bleeding in 2 cases, minor bile duct injury in 2 cases, surgical site infection 15 cases, retained stone in 2 cases. Conclusion Laparoscopic cholecystectomy for acute cholecystitis has better results in patient outcomes as regards post-operative recovery & length of hospital stay & safety.

How to prevent complications in laparoscopic cholecystectomy: a critical view of safety

How to prevent complications in laparoscopic cholecystectomy: a critical view of safety

Preoperative MRCP is not Associated with Lower Complication Rates but Shorter Hospital Stay in Laparoscopic Cholecystectomy

Abstract Background Laparoscopic cholecystectomy is a very common procedure and while preoperative magnetic resonance cholangiopancreatography (pMRCP) is widely used for detection of choledocholithiasis and preoperative planning, the benefits in patients with normal preoperative cholestatic parameters remain unclear. Aims We aimed to investigate a large cohort of patients after laparoscopic cholecystectomy to analyse the impact of pMRCP on complication rates. Methods This retrospective cohort study consecutively includes all patients receiving elective or acute laparoscopic cholecystectomy between 2010 and 2020. Exclusion criteria were conversion to open cholecystectomy and preoperatively elevated cholestatic parameters. Complication rates were recorded and patients stratified depending on the use of pMRCP for preoperative planning. Results 3163 patients underwent laparoscopic cholecystectomy between 2010 and 2020, 2568 of which showed normal cholestatic parameters preoperatively. Of these patients, 684/2568 (27%) were male and 1884/2568 (73%) female. The most frequent indications for laparoscopic cholecystectomy were cholecystolithiasis in 72% (1845/2568) of cases, followed by cholecystitis in 18% (465/2568). The majority of patients (2267/2568, 88%) indeed received pMRCP, while the remaining 301/2568 patients did not. Postoperative complication rates did not significantly differ between the two groups (396/2267 (17%) in the pMRCP group and 58/301 (19%) without pMRCP, p=0.469). One case of pancreatitis occurred in the pMRCP group, versus two reported cases in the other group. Interestingly, the length of hospital stay after cholecystectomy was significantly shorter in the group with pMRCP versus without (4 days (range 1-61 days) versus 7 days (range 1 – 66 days), respectively, p = 0.023). Conclusion Preoperative MRCP seems to not prevent complications in laparoscopic cholecystectomy, since postoperative complication rates were comparable between the two patient groups with and without pMRCP. However, postoperative hospital stay was significantly shorter in patients undergoing pMRCP compared to patients without pMRCP.

Efficacy of different indocyanine green doses in fluorescent laparoscopic cholecystectomy: A prospective, randomized, double-blind trial.

Intraoperative bile duct injury is a significant complication in laparoscopic cholecystectomy (LC). Near-infrared fluorescence cholangiography (NIFC) can reduce this complication. Therefore, determining the optimal indocyanine green (ICG) dosage for effective NIFC is crucial. This study aimed to determine the optimal ICG dosage for NIFC. This was a prospective, randomized, double-blind clinical trial at a single tertiary referral center, including 195 patients randomly assigned to three groups: lower dose (0.01 mg/BMI) ICG (n = 63), medium dose (0.02 mg/BMI) ICG (n = 68), and higher dose (0.04 mg/BMI) ICG (n = 64). Surgeon satisfaction and detection rates for seven biliary structures were compared among the three dose groups. Demographic parameters did not significantly differ among the groups. The medium dose (72.1%) and higher dose ICG groups (70.3%) exhibited superior visualization of the common hepatic duct compared to the lower dose group (41.3%) (p < 0.001). No differences existed between the medium and higher dose groups. Similar trends were observed for the common bile duct and cystic common bile duct junction. In patients undergoing fluorescent laparoscopic cholecystectomy, the 0.02 mg/BMI dose of indocyanine green demonstrated better biliary structure detection rates than the 0.01 mg/BMI dose and was non-inferior to the 0.04 mg/BMI dose.

A Randomised Controlled Study to Reduce the Incidence of Umbilical Port Site Complications in Laparoscopic Cholecystectomy Using Uniform Methods of Umbilical Hygiene

A Randomised Controlled Study to Reduce the Incidence of Umbilical Port Site Complications in Laparoscopic Cholecystectomy Using Uniform Methods of Umbilical Hygiene

The Use of Neutrophil-to-Lymphocyte Ratio, Monocyte-to-Lymphocyte Ratio and Platelets-to-Lymphocyte Ratio in the Assessment of the Risk of Conversion and Complications After Cholecystectomy Performed Due to Symptomatic Cholelithiasis.

Laparoscopic cholecystectomy is quite a safe procedure, as only about 2% of cases result in clinically significant postoperative complications. The occurrence of conversion and postoperative complications is associated with prolonged hospitalization and higher perioperative mortality. Some parameters assessed in preoperative laboratory tests are used to predict the risk of conversion and clinically significant postoperative complications. The aim of this study was to evaluate the usefulness of preoperative neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR) and platelets-to-lymphocyte ratio (PLR) values in predicting the risk of conversion and complications in laparoscopic cholecystectomy performed due to symptomatic cholelithiasis. A retrospective analysis of patients operated on for symptomatic cholelithiasis was performed. The Results of preoperative laboratory tests were assessed - NLR, MLR and PLR. Their impact on early outcomes of surgical treatment was analyzed in the study population. The analysis concerned 227 patients operated on for symptomatic cholelithiasis. The study group included 61 (26.9%) men and 166 (73.1%) women. As the NLR, MLR and PLR values increase, the length of hospitalization increases (rS 0.226, 0.247 and 0.181, respectively), as well as the risk of converting the procedure to an open method (p<0.05). Moreover, with increasing NLR and MLR values, the grade of postoperative complications according to the Clavien-Dindo scale increases (p 0.0001 and 0.008, respectively). The grade of postoperative complications does not depend on the PLR value. The risk of conversion can be assessed based on preoperative NLR, MLR and PLR values in patients undergoing surgery for symptomatic cholelithiasis. Elevated preoperative NLR and MLR values are associated with a higher grade of postoperative complications in the Clavien-Dindo scale.

Laparoscopic cholecystectomy for symptomatic cholelithiasis in children and adolescents: analysis of 50 cases from a single institution.

To investigate the clinical characteristics of symptomatic cholecystolithiasis and laparoscopic cholecystectomy complications in pediatric patients. The medical records of 50 children and adolescents who underwent laparoscopic cholecystectomy were analyzed. We evaluated gender, age, body mass index, preoperative clinical aspects, perioperative complications, and gallstone composition. Among the patients, 33 (66%) were female, and 17 (34%) were male. The mean age was 11.4 ± 3.6. All patients were diagnosed with cholecystolithiasis by abdominal ultrasonography. Twelve patients (24%) had hematological disease: eight (16%) with sickle cell anemia and four (8%) with hereditary spherocytosis. Thirteen patients (26%) were obese. Twelve patients (24%) had complicated biliary disease. During the intraoperative period, three patients (6%) had excessive bleeding in the hepatic hilum, and one had an accidental injury to the common bile duct. Three (6%) postoperative complications (acute pancreatitis, common bile duct stenosis, and intestinal obstruction) were observed. Among 28 patients (56%), 25 (50%) had cholesterol gallstones, and three (6%) had bile pigment gallstones. The evolution of cholecystolithiasis in the pediatric population can present serious complications, emphasizing the need to avoid temporizing cholecystolithiasis in children and adolescents because laparoscopic cholecystectomy in this group is safe, with low complication rates.

Factors causing conversion in laparoscopic cholecystectomy

Introduction and purpose: Laparoscopic cholecystectomy (LC) is the gold standard surgical procedure in the treatment symptomatic gall bladder disease. Conversion is not a failure or complication. It is only a step taken to ensure patient safety and to avoid complications. The objective of our study was to investigate the rate and the causative preoperative and intraoperative factors of conversion and to help surgeons have an idea about potential intraoperative challenges. Materials and methods: Laparoscopic cholecystectomy procedures performed on 4433 patients with signs and symptoms of cholelithiasis-cholecystitis who were diagnosed with abdominal ultrasonography were retrospectively reviewed. The patients were grouped on the basis of age, gender, length of hospitalization, history of preoperative endoscopic retrograde cholangiopancreaticography (ERCP), diabetes mellitus (DM), chronic fibrotic cholecystitis, gall bladder polyps, and urgent-elective surgery. The rate and causative factors of conversion were investigated. Statistical analyses were carried out using IBM SPSS for Windows, version 17.0 (IBM statistics for Windows version 17, IBM Corparation, Armonk, New York, United States) software package. Result: In our study, the conversion rate was 0.85%. Male gender, advanced age, increased length of hospitalization, history of preoperative ERCP, urgent surgery (acute-hydropic cholecystitis), and chronic fibrotic cholecystitis were the significant risk factors for conversion. DM had no effect on conversion. Conclusion: Conversion should not be necessarily regarded as a complication in laparoscopic cholecystectomy. Identifying patients with significant risk factors for conversion can significantly minimize the complications of the laparoscopic procedure. This may assist in identifying high-risk patients and reviewing surgical strategy in this patient group.

Summary of Complications of Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy is a widely performed surgical procedure for the treatment of gallbladder-related conditions. While it is considered a safe and effective approach, it is not without complications. This comprehensive review explores the epidemiology, risk factors, complications, and management of complications associated with laparoscopic cholecystectomy. A thorough understanding of these aspects is crucial for healthcare providers to optimize patient outcomes and ensure the safe delivery of this common surgical procedure

Near-infrared indocyanine green fluorescent cholangiography in urgent and emergency laparoscopic cholecystectomy: a preliminary study after propensity score-matched study

IntroductionBile duct injury is a major complication of laparoscopic cholecystectomy (LC). Indocyanine green near-infrared fluorescence cholangiography (ICG-NIFC) is a well-recognized technique who provides an intraoperative mapping of the biliary system.MethodsAll patients underwent urgent LC and randomly divided into two groups: in one group, only white light imaging was used and, in the ICG group, ICG was used. Due to the heterogeneity of our groups, a PSM was performed with a 1:1 PSM cohort.ResultsThe use of ICG clearly decreases the operation time (p value 0.002). The overall rate of intra- and post- operative complications was 4.17% and 15.8% respectively. Post-operative biliary duct injury trend decreases in ICG group and after the homogenization of the 2 cohorts, the intra- and post- operative complications (including vascular and biliary duct injury) results changed with a highest rate of complication in the cohort with no-ICG administration.The use of NIFC demonstrated a protective effect against intra- and post- operative complications and biliary duct injury (HR 0.037, p value 0.337 and HR 0.039, p value 0.647; HR 0.288; p value 0.05 and HR 0.635; p value 0.687, respectively).ConclusionsThe intra-operative use of NIFC showed a trend in the reduction of the rate of intra- and post-operative complications, the duration of surgery, and the length of hospital stay. ICG is a highly safe approach to urgent and emergency LC, as for elective LC, and could lead the surgeon to conduct the procedure more efficiently.

Cystic artery pseudo aneurysm in a patient with xanthogranulomatous cholecystitis: a multi-disciplinary approach towards management

Cystic artery pseudo aneurysm is a rare clinical entity, mostly occurring as a complication of laparoscopic cholecystectomy or following calculus cholecystitis. Patient presents with acute symptoms including upper gastro intestinal bleeding symptoms, abdominal pain and jaundice, the triad of symptoms termed as Quincke's triad, when there is a ruptured cystic artery pseudoaneurysm (CAP). Unruptured cases are mostly diagnosed incidentally. Here we present a 58-year-old patient presented to the emergency department with severe abdominal pain, malena and jaundice. CECT of abdomen was done which showed CAP. The patient was immediately taken up for radiological intervention and coiling of the pseudo aneurysm, which was unsuccessful. A covered stent was placed across the pseudoaneurysm in the right hepatic artery. Patient underwent Laparoscopic cholecystectomy and had an uneventful recovery. Owing to the fact that CAPs are rare entities, a high index of suspicion is required for diagnosis of the condition and when diagnosed, the patient can be managed by radiological intervention followed by definitive surgery which can be either open or laparoscopic.

Assessing incidence and risk factors of laparoscopic cholecystectomy complications in Jeddah: a retrospective study.

We aimed to identify the risk factors for postoperative complications (POCs) of LC at a tertiary institute in Jeddah, Western Saudi Arabia. This retrospective study was conducted between June 2021 and August 2021 among patients who underwent LC at a tertiary centre in Jeddah, Saudi Arabia. Records of 596 patients were reviewed, and 510 patients were included in the final analysis after applying the exclusion criteria. Data were collected from hospital medical records. χ 2 tests and independent t tests were used to analyse categorical and continuous variables, respectively. The Mann-Whitney U test was used for nonparametric data. Multivariate regression analysis was used to adjust the P values to determine the most strongly and independently associated risk factors. Our data showed that the overall incidence of intraoperative complications (IOCs) was 10.8%. The most common complications were gallbladder perforation (n=28, 5.5%), bile leakage (n=25, 4.9%), and bleeding (n=15, 2.9%). POCs occurred in 11% of the patients; the majority complained of abdominal pain (n=36, 6.9%), had elevated liver function tests (n=14, 2.7%), and retained stones (n=11, 2.2%). Acute cholecystitis, overweight, diabetes, and male sex were significant predictors of IOC, POC, and conversion to open cholecystectomy (P<0.05). LC complications have a multifactorial aetiology. Patient awareness of all possible IOCs is fundamental. The improved skill and experience of the surgical team can mitigate serious complications.

Indications and Complication of Laparoscopic Cholecystectomy at a Tertiary Care Setting in Sindh Province: A Cross Sectional Survey

Objective: The study was aimed to-evaluate the indications and-complications-of the laparoscopic cholecystectomy at a tertiary care setting in sindh province. Background: The-hepato-biliary-system is affected by a wide range of illnesses known as gall bladder diseases, each of which has a unique clinical presentation and degree of morbidity. The majority of adult populations in Western nations are affected by cholelithiasis, which affects 5% to 25% of the adult population. Initially, people from developing nations had little access to the advantages of laparoscopic cholecystectomy. Materials and Methods: A cross sectional study was carried out at the surgical dept Chandka Medical College Hospital Larkana for a period of 6 months in 2020 which included patients who went through laparoscopic cholecystectomy were included in the study, however, the patients having a history of previous abdominal surgery, hepatobiliary carcinoma , challenges ejection fraction, patients with coagulopathies and those reactive for HbsAg or HCV antibodies were excluded from the study. Results: The mean age of the subjects was 43.8± 9.67 years. There were 93.7% of study participants were females, 18.6% were diabetic and 26.5%) were hypertensive. 41.81% patients were aged between 30 to 40 years. The indications for the cholecystectomy included Symptomatic cholelithiasis for 148 (83.62%) cases, acute cholecystitis for 24(13.56%) cases and gall bladder polyp for 5 (2.82%) cases. There were 11 (6.21%) cases which needed to be converted to open cholecystectomy. Bile leaking was reported in 8 (4.52%) cases and injury to liver/intestine were reported for 3 (1.69%) cases. Conclusion: In a setting of a developing country, -laparoscopic-cholecystectomy-looks to be a safe and-effective treatment with few complications. Keywords: Laparoscopic cholecystectomy, Indications, Complications, cholelithiasis.

Surgical Audit of Common Bile Duct Injury During Laparoscopic Cholecystectomy in Tertiary Care Center

Objective: The current study conducted a surgical evaluation of laparoscopic cholecystectomy in a tertiary care hospital. Methods: A descriptive retrospective study was conducted at the department of surgery, JPMC between dates. All cases of patients who were above 18 years, had cholecystitis or cholelithiasis, and underwent cholecystectomy between 1st January 2013 and 31 December 2014 at Jinnah Postgraduate Medical Center were included. Only cases with complete history, examination and investigations were included. Cases with incomplete information were excluded. Sociodemographic information such as age and gender, clinical information related to biliary duct injury (BDI), causes of BDI, and risk factors for BDI were included in the study. Data was entered and analyzed using SPSS version 21. The findings were narrated in tabulated form. Result: A cumulative count of 21 bile duct injuries (BDIs) was documented, leading to an overall occurrence rate of 3.1%. Most patients (76.2% or 16 individuals) had significant injuries that affected the common bile duct (CBD), main biliary confluence, or main bile ducts. A total of 5 patients, accounting for 23.8% of the cases, had modest injuries that specifically impacted the cystic duct or smaller peripheral or Luschka ducts. The cause of the BDI was diagnosed in 71.4% of instances. Inadequate identification of anatomical features associated with the hepatic pedicle, comprising 33.3% of reported cases, was the most frequently cited cause. Subsequently, it was observed that inflammatory alterations in the gallbladder constituted 26.7% of the cases, while anatomical anomalies accounted for 13.3%. Similarly, the inappropriate application of monopolar coagulation was responsible for an additional 13.3% of the cases. Furthermore, undefined technical errors and challenges encountered during intraoperative hemorrhage management were each attributed to 6.7% of the cases. Conclusion: The present study revealed bile duct injury to be a serious and prevalent complication of laparoscopic cholecystectomy in our center. Therefore, further assessment should be taken in order to avoid occurrence of BDI in patients presenting to the public tertiary care hospitals. Keywords: Surgical audit, minimal invasive surgery, laparoscopic cholecystectomy, preoperative complications, postoperative complications, conversion to open cholecystectomy.

Complications of Laparoscopic Cholecystectomy and Knowing the Effect on Low Pressure

Complications of Laparoscopic Cholecystectomy and Knowing the Effect on Low Pressure

A Study of Extra Biliary Complications of Laparoscopic Cholecytectomy

Background: Laparoscopic cholecystectomy has rapidly become the procedure of choice for gallbladder removal and has become the most common major abdominal procedure performed throughout the world. To observe the extrabiliary complications of laparoscopic cholecystectomy this research work was done. Materials and methods: This observational study was carried out in the Department of Surgery, Chittagong Medical College Hospital, Chattogram, duration December 2015 to November 2016. A total of 100 Gall stone diseased patients were enrolled in this study and they were randomly allocated. Post operatively patients were observed, Data were collected, and Statistical analysis were obtained by using window based computer software devised with Statistical Packages for Social Sciences (SPSS-22). Results: Among 100 patients male to female ratio was 4.6:1 with maximum age group of third and fourth decade. Seventeen patients were associated with other disease e.g. diabetes mellitus and hypertension. Per-operative complication rate was 5(5.0%) among those, per-operative port site bleeding 2(2.0%), cystic artery bleeding 1(1.0%), liver bed bleeding was in 2(2.0%) cases. All these complications were managed successfully and smooth recovery within normal time.Post-operative complication rate was 1(1.0%). Among those port sites infection were in 1(1.0%) case. Conclusion: The findings of this study are expected to help taking perioperative measure to prevent extra-biliary complications. There may be some other devastating complications which may cripple the patients as well as surgeon. IAHS Medical Journal Vol 5(1), June 2022; 45-48