Difficult Cholecystectomy Research Articles

Laparoscopic Lumen-guided cholecystectomy in face of the difficult gallbladder

BackgroundWhere the critical view of safety cannot be established during cholecystectomy, certain salvage techniques are indicated to reduce the likelihood of bile duct injury. The present study describes a salvage technique termed the “laparoscopic lumen-guided cholecystectomy” (LLC) and reports its peri-operative outcomes.MethodA summary of the technique is as follows: (1) Hartmann’s pouch is incised and stones are evacuated; (2) the cystic anatomy is inspected from the inside of the gallbladder; (3) the lumen is used to guide retrograde dissection towards the cystic pedicle; (4) cystic duct control is achieved if deemed safe. LLC cases performed between June 2020 and January 2022 in a single health board were included. The operative details and peri-operative outcomes of the technique are reported and compared to cases of similar difficulty where the LLC was not attempted.ResultsLLC was performed in 4.6% (27/587) of cases. In all 27 cases, LLC was performed for a “frozen” cholecystohepatic triangle. Hartmann’s pouch was completely excised in all cases (27/27) and cystic duct control was achieved in 85.2% of cases (23/27). No cases of bile leak or ductal injury were reported. Rates of bile leak, post-operative complications and ERCP were lower following LLC compared to the group where LLC was not attempted (p < 0.01).ConclusionLLC is a safe salvage technique and should be considered in cases where the critical view of safety cannot be established. The technique achieves cystic duct control in the majority of cases and favourable outcomes in the face of a difficult cholecystectomy.

Operative difficulty grading scale for laparoscopic cholecystectomy at a tertiary care hospital in Eastern Nepal

Background: Predictions of difficult cholecystectomy preoperative make the surgeon prepared, thereby making a more careful dissection, back up from senior surgeons, and a low threshold for early conversion. Objectives: To utilise an operative grading scale to predict open conversion, duration of surgery, total length of stay, complications and to validate Nassar score. Methods: This was a prospective cross-sectional study done from 2020 July 9 to 2021 January 30 after ethical clearance among all patients of BPKIHS planned for laparoscopic cholecystectomy for symptomatic gallstone disease. Nassar scale was used for risk evaluation of difficult cholecystectomy. The intraoperative outcome parameters were bleeding, bile spillage, stone spillage, presence of bowel or biliary injury, operative time and conversion to open surgery. Postoperative outcomes noted were total length of stay, 30-day complications, reintervention, and mortality. The data were entered in Microsoft Excel sheet 2010 and analysis was done in SPSS v.26. Results: Seventy-four patients were analysed. Comparison of Nassar scoring system with outcomes revealed a significant association of rising Nassar grade with bile spillage, stone spillage, bleeding, post-surgical drain placement, conversion to open, duration of surgery, and total length of stay. Operative time was significantly more in male, cholecystitis, and interval cholecystectomy. Conversion to open was significantly associated with Nassar grade 4, acute cholecystitis, and interval cholecystectomy. There was no mortality, 30-day reintervention, and complication. Conclusion: Nassar operating scale is simple scale that can be used by all level of surgeons to predict difficult laparoscopic cholecystectomy. Rising grades have significant correlation with difficulty and complications.

Bile leakage and the number of metal clips on the cystic duct during laparoscopic cholecystectomy.

The most common way of closing the cystic duct in laparoscopic cholecystectomy is by using metal clips (>80%). Nevertheless, bile leakage occurs in 0.4%-2.0% of cases, and thus causes significant morbidity. However, the optimal number of clips needed to avoid bile leakage has not been determined. The primary aim of this study was to evaluate bile leakage and post-procedural adverse events after laparoscopic cholecystectomy concerning whether two or three clips were used to seal the cystic duct. Using a retrospective observational design, we gathered data from the Swedish Registry for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (ERCP) (GallRiks). From 2006 until 2019, 124,818 patients were eligible for inclusion. These were nested to cohorts of 75,322 (60.3%) for uncomplicated gallstone disease and 49,496 (39.7%) with complicated gallstone disease. The cohorts were grouped by the number (i.e. two or three) of metal clips applied to the proximal cystic duct. The main outcome was 30-day bile leakage and post-procedural adverse events. No significant differences surfaced in the rate of bile leakage (0.8% vs 0.8%; P = .87) or post-procedural adverse events (three clips, 5.7% vs two clips, 5.4%; P = .16) for uncomplicated gallstone disease. However, for complicated disease, bile leakage (1.4% vs 1.0%; P < .001) and post-procedural adverse events (10.2% vs 8.6%; P < .001) significantly increased when the cystic duct was sealed with three clips compared with two. Because no differences in the rates of bile leakage or adverse events emerged in uncomplicated gallstone disease when a third clip was applied, a third clip for additional safety is not recommended in such cases. On the contrary, bile leakage and adverse events increased when a third clip was used in patients with complicated gallstone disease. This finding probably indicates a more difficult cholecystectomy rather than being caused by the third clip itself.

Preoperative scoring system in predicting difficulty in laparoscopic cholecystectomy.

Objective: To evaluate a scoring system in predicting difficulty in laparoscopic cholecystectomy. Study Design: Non-Randomized Prospective study. Setting: Surgical Unit-1 of Holy Family Hospital, Rawalpindi. Period: January 2018 to September 2018. Material &amp; Methods: Patients with symptomatic gallstone disease that were admitted in SU-1 of Holy family hospital during the above period were included in the study. For collection of data, a pre-tested questionnaire was used after taking informed oral consent. On admission, one day before the surgery, preoperative points were allotted on basis of patient’s history, examination, hematological (CBC), biochemical (LFTs) and ultrasound results. Preoperative scores up to 5 was summed up as easy, scores 6 – 10 as difficult, 11 – 16 as very difficult. Calculated sample size was 229. SPSS version 22 and WHO Anthro calculator version 3.2.2 were used for data entry and analysis. Results: Among 230 patients that were included in the study, 188 were female and 42 were male. Various risk factors were found to have significant positive correlation with intraoperative difficulty during cholecystectomy. These are: Previous episodes of cholecystitis and pancreatitis (p=0.00), ERCP (p=0.00), tenderness in right hypochondrium (p=0.002), hepatitis serology (p=0.02), and Total Leukocyte Count (p=0.006). Whereas the following factors had insignificant relation with intraoperative difficult cholecystectomy: ALT and ALP (p&gt;0.05, p=0.06 and 0.26 respectively) and hepatits serology (p=0.406). A significant correlation was found between preoperative and intraoperative scores of the patients (p=0.003) indicating that preoperative assessment of various risk factors can predict the level of difficulty of cholecystectomy and its conversion to open cholecystectomy. Conclusion: We may conclude that the scoring system evaluated in our study is a sturdy, reliable and useful benchmark to predict difficult cases. Preoperative prediction of the risk factors of conversion or difficulty of operation is an important point for operative planning and the high-risk patients may be informed accordingly.

Video Caso Clínico: Síndrome del muñón del cístico, resección laparoscópica del remanente

BACKGROUND: Laparoscopic cholecystectomy is one of the most frequently performed surgical procedures, which has gradually evolved to become one of the safest surgeries. However, no procedure is without risk; in this context, biliary duct injury (BDI) is the most important intraoperative complication during cholecystectomy. Common bile duct injury reaches a variable incidence between 0.4 to 1.4%, which is associated with significant long-term morbidity, including stenosis and recurrent cholangitis, significant limitations in the life quality of the patient [1]. In order to reduce the incidence of BDI, several alternative procedures can be performed during a difficult cholecystectomy, among which we can list: cholecystostomy, subtotal cholecystectomy and/or conversion to open cholecystectomy. Subtotal cholecystectomy, according to several meta-analyses, minimizes the possibility of bile duct injury, however, it is associated with the persistence or development of symptomatic gallstones in the remnant of the gallbladder or cystic duct; when this occurs, it is necessary to reoperate on symptomatic patients [1,2]. It is estimated that between 5-40% of patients who have previously undergone cholecystectomy, may present episodes of abdominal pain like those that initially motivated the surgical indication, grouped under the term "post-cholecystectomy syndrome" (PCS) [3]. PCS is mainly caused by residual lithiasis, which represents approximately 21.3% of readmissions [4]; other causes of PCS include: stenosis or bile leak, neuroma in the scar tissue, biliary dyskinesia, Oddi sphincter dysfunction. It is also worth highlighting, within the causes, the cystic duct remnant syndrome defined as "presence of a residual cystic duct greater than 1 cm that produces symptoms as a consequence of the lithiasis inside it", with a prevalence of less than 2.5% among patients that underwent cholecystectomy; however, a high index of suspicion will allow us to recognize it in the immediate postoperative period or even several years later [3,4]. The age range of onset of cystic duct remnant syndrome is from 21 to 90 years. The female preponderance of gallstones is the probable reason for greater frequency of the syndrome in this gender. Clinically, the main reason for consultation is abdominal pain in the right hypochondrium and epigastrium, which occurs in 77% of the patients; accompanied by nausea, in 44% of patients; vomiting in 31% and fever in 19% of patients [5]. Magnetic resonance cholangiopancreatography is the non-invasive technique of choice for evaluating the biliary tree, relegating endoscopic retrograde cholangiopancreatography (ERCP) as a strictly therapeutic technique. In addition, ERCP with sphincterotomy and possible placement of a stent to aid drainage of the main bile duct can be performed, along with definitive surgical treatment, by gallbladder and/or cystic remnant resection [3]. This case report details an experience of surgical reintervention in a patient with a remnant gallbladder and cystic duct with lithiasis.

Pre-operative predictors of difficult laparoscopic cholecystectomy: a comparative study between two scoring systems

Background: Laparoscopic cholecystectomy is considered as the gold standard in treating symptomatic gall bladder disease. It has now become the most common operation performed by general surgeons. At times laparoscopy becomes difficult and may need conversion to open cholecystectomy. Many scoring systems are developed to predict the difficulty of laparoscopic cholecystectomy pre operatively. Our study aims to determine factors predicting difficult cholecystectomy and validate 2 scoring systems i.e., risk score for conversion from laparoscopic to open cholecystectomy (RSCLO) vs. new scoring system (NSS).Methods: Patients presenting to Kempegowda institute of medical sciences from January 2014 to August 2015 with symptoms of gall stone disease were screened for cholelithiasis.100 patients undergoing laparoscopic cholecystectomy were randomly selected. Every patient was given pre-operative score, after applying their symptoms to the scoring system and these scores were compared with the intraoperative findings and post-operative outcome. Thereby, calculating the sensitivity and specificity of the scoring systems.Results: On univariate and multivariate logistic regression-BMI&gt;27.5 kg/m2 (p=0.010), Palpable gallbladder (p=0.022), previous hospitalization for acute cholecystitis (p=0.15), Sonology: wall thickness&gt;4 mm (p=0.0015), presence of pericholecystic edema, were found statistically significant. RSCLO system was better in predicting easy cholecystectomy i.e., low risk for conversion, while NSS was better in predicting difficult, very difficult cholecystectomies {converted cases}, its sensitivity being 100%.Conclusions: New scoring system can predict difficult cases reliably. Scoring patients preoperatively can decrease intra-op difficulties. Patients can pre-op be informed about possible risk of conversion to open cholecystectomy.

On-table hepatopancreatobiliary surgical consults for difficult cholecystectomies: A 7-year audit

BackgroundCholecystectomy is considered a general surgical operation. However, general surgeons are not trained to manage severe complications such as bile duct injury (BDI) and should refer to hepatopancreatobiliary (HPB) surgeons when difficulty arises. This study aimed to investigate the outcomes of patients who had on-table HPB consults during cholecystectomy. MethodsThis is an audit of 50 patients who required on-table HPB consult during cholecystectomy from 2011 to 2017. Consultations were classified as “proactive” and “reactive”, where consults were made before or after surgical incision, respectively. Patient demographics and perioperative details were collected. ResultsThe median age of the patients was 62.5 years [interquartile range (IQR) 50.8–71.3 years]. Eight (16%) patients had underlying HPB co-morbidity. Gallbladder wall was thickened in all patients (median 5 mm, IQR 4–7 mm), and common bile duct was of normal caliber in all patients (median 5 mm, IQR 4–6 mm). Median length of operation and length of stay were 165 min (IQR 124–209 min) and five days (IQR 3–7 days), respectively. Subtotal cholecystectomy was performed in 18 (36%) patients. Forty-eight patients were initially managed by laparoscopic approach, 15 (31%) required open conversion; majority (9/15, 60%) were initiated before on-table consult. Majority of referrals (98%) were reactive. Common reasons for referral included unclear anatomy or anatomical variations (30%), presence of dense adhesions and/or contracted gallbladder (18%) and impacted stones in Hartmann's pouch (16%). Three (6%) patients were referred for BDI (2 Strasberg D and 1 Strasberg E1), and two (4%) were referred for torrential bleeding from arterial injury (1 cystic artery and 1 right hepatic artery). Any morbidity and 30-day readmission were 22% and 6%, respectively. There was no 90-day mortality. ConclusionsCalling for help in BDI is obligatory, but in other instances is a personal choice. Calling for help prior to open conversion is lacking and this awareness should be raised. Whether surgical outcomes could be improved by early HPB consult needs to be determined by larger multicenter reports.

Cause and outcome of aborting a difficult laparoscopic cholecystectomy due to severe inflammation: a study of operative notes.

Upon encountering a difficult cholecystectomy in which, after a reasonable trial of dissection, anatomical identification has not been attained due to severe inflammation, and the risk of additional dissection is deemed to be hazardous, "bail-out" strategies are encouraged safety valves. One strategy is to abort the cholecystectomy and refer the patient to a HPB center for further management. A retrospective review was conducted of cholecystectomies performed by HPB surgeons at our center between 2005 and 2019. We identified 63 patients who had an aborted cholecystectomy because of acute or chronic cholecystitis and were referred for additional care. Of these, operative notes and other clinical records were available for 43 patients who were included in this study. 42 cholecystectomies (98%) were started laparoscopically. 25 patients (58%) had chronic cholecystitis, and 18 (42%) had acute cholecystitis. 40 cases (93%) fell into the highest level of difficulty on the Nassarscale (Grade 4). Procedures were aborted at the following stages of dissection: in 10 patients (23%), none of the gallbladder was identified; in another 11 (26%), only the dome of gallbladder was identified; the body of the gallbladder was exposed in 13 (30%); and dissection of the hepatocystic triangle was attempted unsuccessfully in 9 (21%). Following referral to our center, 30 patients (70%) were managed with total cholecystectomy while in 13 cases (30%), subtotal cholecystectomy was performed. Aborting cholecystectomy and referring the patient to an HPB center is rarely needed but is an effective bail-out strategy for general surgeons encountering highly difficult operative conditions due to inflammation.

Role of Critical View of Safety in Laparoscopic Cholecystectomy

Background: Biliary injury is frequently seen as a complication after laparoscopic removal of gall bladder. In order to minimize the occurrence of this dreadful complication, “critical view of safety” involving dissection in the triangle of Calot’s and subsequent recognition of cystic structures before surgery has been proposed. Objective: To determine the role of critical view of safety in laparoscopic cholecystectomy. Study Design: Descriptive cross-sectional study. Place and Duration of Study: Department of Surgery, Benazir Bhutto Shaheed Teaching Hospital Abbottabad from 1st January 2018 to 30th September 2019. Methods: Three hundred patients requiring laparoscopic cholecystectomy were enrolled. Before clipping, the cystic artery and duct were isolated by critical view of safety. Demographic data of patients in addition to occurrence of intra-operative or post-operative complications was recorded. Results: Majority of study participants were females, 264 (88%) females and 36 (12 %) males. Females were older than males (p&gt;0.05). Operative findings included non inflamed gall bladders in 83% patients of which 90% were females and rest were males. Difficult cholecystectomy like acutely inflamed gall bladder was seen in 17% patients and out of those 13% were females. Most of the patients were discharged from hospital by the third post-operative day. Only one patient developed bile leak but that was due to cystic duct slipped ligature. Conclusions: The incidence of injury to biliary ducts during laparoscopic cholecystectomy can be minimized by application of “critical view of safety”. Key words: Critical view of safety (CVS), Laparoscopic cholecystectomy (LC), Common bile duct (CBD)

Routine use of ICG to enhance operative safety in emergency laparoscopic cholecystectomy: a randomized controlled trial.

To test the hypothesis that ICG fluorescence cholangiography (ICG-FC) helps to identify critical structures during laparoscopic cholecystectomy (LC) and hence reduce biliary injuries and conversions. In LC, biliary injury and conversion often happen if the biliary anatomy is misidentified. This was a single-center randomized controlled trial from 2017 to 2019. Patients with acute cholecystitis requiring LC were assessed for eligibility for the trial. Patients in the trial were randomized to undergo either conventional LC (conventional arm) or LC with ICG-FC (ICG arm). Conversion rate and biliary injury incidence were outcome measures. Totally 92 patients participated (46 patients in each arm). The median age was 61years in both arms (p = 0.472). The conventional arm had 22 men and 24 women; the ICG arm had 24 men and 22 women (p = 0.677). The two arms were comparable in all perioperative parameters. The time from ICG injection to surgery was 67 (16-1150) min. Both arms had an 8.7% conversion rate (p = 1.000). The median operative time was 140.5min in the conventional arm and 149.5min in the ICG arm (p = 0.086). The complication rate was 15.2% in the former and 10.9% in the latter (p = 0.536), and both had a 2.2% bile leakage rate. The median hospital stay was 3.5d in the former and 4.0d in the latter (p = 0.380). ICG-FC did not make any difference in conversion or complication rate. Its routine use in LC is questionable. However, it may be helpful in difficult cholecystectomies and may be used as an adjunct. The trial was registered with the Institutional Review Board of University of Hong Kong/Hospital Authority Hong Kong West Cluster ( http://www.med.hku.hk/en/research/ethics-and-integrity/human-ethics ). UW17-492.

Comparison of Fenestrating and Reconstituting Subtotal Cholecystectomy Techniques in Difficult Cholecystectomy.

PurposeCholecystectomy is one of the most frequently performed surgeries. Although laparoscopy is considered the gold standard approach, it cannot prevent biliary injuries. Subtotal cholecystectomy has been performed mainly to prevent biliary injuries during difficult cholecystectomies. This study aimed to analyse our subtotal cholecystectomy results for difficult cholecystectomy cases and to evaluate the fenestrating and reconstituting techniques.MethodsRetrospective data were collected and analysed statistically for cases that underwent subtotal cholecystectomy in a single referral centre between 2015 and 2020. Comparisons were made of the patients’ age, gender, preoperative American Society of Anaesthesiologists (ASA) score, comorbidities, surgical timing, surgical procedure choice, postoperative complications, and mortality.ResultsThe number of patients who underwent subtotal cholecystectomy was 46; 30.4% underwent emergent surgery and 69.6% underwent elective surgery. Twelve patients had subtotal fenestrating cholecystectomy and 34 had subtotal reconstituting cholecystectomy. Wound issues were noted in 17.4% of the patients, while 10.9% had temporary biliary fistulas that resolved spontaneously. Reoperation was performed in one patient due to high-output biliary drainage. Patients with postoperative complications had significantly higher co-morbid conditions (p=0.000), but surgery timing (p=0.192) and type of subtotal cholecystectomy (p=0.409) had no statistically significant effect on complications. Mortality showed a statistically significant correlation with patient comorbidities, surgery timing, and the type of procedure (p<0.05). Postoperative complications showed a statistically significant correlation with mortality (p<0.05).ConclusionSubtotal cholecystectomy prevents major biliary complications after cholecystectomy. Yet, the frequency of postoperative complications after subtotal cholecystectomy is incontrovertible. Intraoperative characteristics and the surgeon’s expertise decide the optimal choice of the subtotal cholecystectomy technique.

Performance of ultrasound in the diagnosis of cholecystitis: not so (ultra)sound?

Ultrasound has long been the radiological investigation of choice for right upper quadrant pain in the detection of gallstones and cholecystitis. However, previously reported sensitivity, specificity and other diagnostic metrics have varied widely and the underlying patient numbers have been small. We present robust and exhaustive diagnostic metrics based on a large series of 795 patients. All laparoscopic cholecystectomies at Portsmouth Hospitals University were prospectively logged between 2017 and 2020. Ultrasound findings, Nassar operative difficulty and histopathological findings were all collected in addition to patient biometrics. In our large patient series, the sensitivity of ultrasound for cholecystitis was lower than previously reported at 75.7% for acute cholecystitis, 34.6% for chronic cholecystitis and 42.7% overall. Moreover, we show that sensitivity degrades with the time between ultrasound and cholecystectomy, falling below 50% at 140 days. Finally, we show that ultrasound strongly predicts the Nassar difficulty grade of cholecystectomy and that its ability to do so is greatest when the interval between ultrasound and cholecystectomy is less than 27 days. We present robust diagnostic metrics for ultrasound in the diagnosis of cholecystitis. These should caution the clinician that ultrasound may miss a quarter of cases of acute cholecystitis and over half of all cases of cholecystitis. Conversely, the finding of a thickened gallbladder wall on ultrasound can predict a 'difficult cholecystectomy' and highlight the need for appropriate expertise and resources. Both this prediction and the diagnostic sensitivity are best if the ultrasound is done less than 27 days before cholecystectomy.

Predicting the difficult laparoscopic cholecystectomy based on a preoperative scale

It is important to establish the difficulty of a cholecystectomy preoperatively to improve the outcomes. There are multiple risk factors for a difficult cholecystectomy that may depend on the patient, the disease, or extrinsic factors. The aim of this study is to evaluate the predictive capacity of a difficult cholecystectomy with a preoperative scale. A diagnostic trial study was designed to evaluate the performance of a scale to predict the difficulty of laparoscopic cholecystectomy, considering as a reference standard the intraoperative findings evaluated according to an intraoperative difficulty scale. A ROC curve was performed and used to estimate predictive value of the preoperative score to predict the difficulty of a cholecystectomy preoperatively. The ROC curve shows an area of 0.88 under the curve. The calculated ideal cutoff was 8, with a sensitivity, specificity, positive predictive value and negative predictive value of 75.15%, 88.31%, 87.32 and 76.83%, respectively. It was demonstrated that, as the difficulty predicted by the preoperative scale increases, the rate of conversion to open procedure, the rate of subtotal cholecystectomies, the rate of complication and the rate of a critical view of safety failed increase. We suggest implementing the preoperative scale in all patients who are planning laparoscopic cholecystectomy, considering it a simple and easy tool to perform. This to inform the patient, organize the surgery schedule, select personnel, request support and have adequate pre-operative planning.Graphical abstract

Elective laparoscopic cholecystectomy: recurrent biliary admissions predispose to difficult cholecystectomy

IntroductionPatients undergoing elective laparoscopic cholecystectomy (ELLC) represent a heterogeneous group making it challenging to stratify risk. The aim of this paper is to identify pre-operative factors associated with adverse peri- and post-operative outcomes in patients undergoing ELLC. This knowledge will help stratify risk, guide surgical decision making and better inform the consent process.MethodsAll patients who underwent ELLC between January 2015 and December 2019 were included in the study. Pre-operative data and both peri- and post-operative outcomes were collected retrospectively from multiple databases using a deterministic records-linkage methodology. Patients were divided into groups based on clinical indication (i.e. biliary colic versus cholecystitis) and adverse outcomes were compared. Multivariate regression models were generated for each adverse outcome using pre-operative independent variables.ResultsTwo-thousand one hundred and sixty-six ELLC were identified. Rates of peri- and post-operative adverse outcomes were significantly higher in the cholecystitis versus biliary colic group and increased with number of admissions of cholecystitis (p < 0.05). Rates of subtotal (29.5%), intra-operative complication (9.8%), post-operative complications (19.6%), prolonged post-operative stay (45.9%) and re-admission (16.4%) were significant in the group of patients with ≥ 2 admissions with cholecystitis.ConclusionOur data demonstrate that patients with repeated biliary admission (particularly cholecystitis) ultimately face an increased risk of a difficult ELLC with associated complications, prolonged post-operative stay and readmissions. These data provide robust evidence that individualised risk assessment and consent are necessary before ELLC. Strategies to minimise recurrent biliary admissions prior to LC should be implemented.

The effect of surgical strategy in difficult cholecystectomy cases on postoperative complications outcome: a value-based healthcare comparative study.

In patients undergoing laparoscopic cholecystectomy (LC) for complicated biliary disease, complication rates increase up to 30%. The aim of this study is to assess the effect of differences in surgical strategy comparing outcome data of two large volume hospitals. A prospective database was created for all the patients who underwent a LC in two large volume hospitals between January 2017 and December 2018. In cases of difficult cholecystectomy in clinic A, regular LC or conversion were surgical strategies. In clinic B, laparoscopic subtotal cholecystectomy was performed as an alternative in difficult cases. The difficulty of the cholecystectomy (score 1-4) and surgical strategy (regular LC, subtotal cholecystectomy, conversion) were scored. Postoperative complications, reinterventions, and ICU admission were assessed. For predicting adverse postoperative complication outcomes, uni- and multivariable analyses were used. A total of 2104 patients underwent a LC in the study period of which 974 were from clinic A and 1130 were from clinic B. In total, 368 procedures (17%) were scored as a difficult cholecystectomy. In clinic A, more conversions were performed (4.4%) compared to clinic B (1.0%; p < 0.001). In clinic B, more subtotal laparoscopic cholecystectomies were performed (1.8%) compared to clinic A (0%; p = < 0.001). Overall complication rate was 8.2% for clinic A and 10.2% for clinic B (p = 0.121). Postoperative complication rates per group for regular LC, conversion, and subtotal cholecystectomy in difficult cholecystectomies were 45 (15%), 12 (24%), and 7 (35%; p = 0.035), respectively. The strongest predictor for Clavien-Dindo grade 3-5 complication was subtotal cholecystectomy. Surgical strategy in case of a difficult cholecystectomy seems to have an important impact on postoperative complication outcome. The effect of a subtotal cholecystectomy on complications is of great concern.

Risk prediction models for difficult cholecystectomy.

IntroductionIn some cases, laparoscopic cholecystectomy (LC) may be very difficult and easily converted to laparotomy, causing many complications to patients and prolonging the prognosis time. Thus, to evaluate the difficulty of LC before operation is extremely important.AimTo explore the risk factors of difficult cholecystectomy (DC) and to establish a risk prediction model of DC.Material and methodsThe data of 201patients who underwent cholecystectomy from 1 January 2018 to 10 November 2019 were analysed retrospectively. The highest quartile (P75) of cholecystectomy operation time was used as a cutting point of DC (≥ P75) and NLC (< P75). Logistic regression was used to analyse the influencing factors of DC, and its risk model was constructed for prediction.ResultsMultivariate logistic regression analysis showed that body mass index (BMI) > 25 kg/m2, white blood cell (WBC) > 10 × 109/l, calculus incarcerated in neck of gallbladder, frequency of acute cholecystitis in the last 2 months > 4 times, thickness of gallbladder wall > 0.5 cm, and maximum diameter of gallstone > 2 cm were independent risk factors for DC. The prediction efficiency of the logistic regression equation was 0.879 (χ2 = 1.457, p > 0.05).ConclusionsBased on analysis of risk factors, a logistic risk prediction model for difficult cholecystectomy was established. This model can be used to predict the difficulty of cholecystectomy.

Indocyanine Green Navigated Early Laparoscopic Cholecystectomy in Post ERCP Patients for Choledochocystolithiasis

Background: Although use of I.V ICG has been done in past for difficult cholecystectomies,but post ercp patients does’nt show proper biliary anatomy due to free flow of bile.Dye instillation using retrograde route through NBD tube is an ideal and novel technique and provide excellent real time view of biliary anatomy. Material and Methods: This is a retrospective observational study from July 2107 to May 2021.Total 44 pts underwent ERCP and NBD placement(with or without CBD stent) followed by day 2 laparoscopic cholecystectomy were given ontable ICG dye intraoperatively through NBD tube.Real time biliary anatomy and prevention of complications taken into account. Results: 44 patients underwent surgery.Male female ratio was 19:26.Median age was 45 yr.uncomplicated cholelithiasis was found in 20 patients,19 were acute cholecystitis,3 were chronic cholecystitis and 3 were with Mirzzi’s syndrome.In 4 patients biliary tract was not visualised as nbd tube was misplaced.Of these 2 pts were having Mirrzi’s,1 with acute cholecystitis and 1 uncomplicated cholelithiasis.Tabled 1Fluorescent cholangiographyCystic ductCBDCHDCystic duct-CHD junctionBefore Calot’s Dissection15 (33%)30 (66.7%)30 (66.7%)25 (55.6%)After Calot’s Dissection (At Critical view of safety)39 (86.7%)41 (91.1%)40 (88.9%)41 (91.1%) Open table in a new tab Conclusions: ICG dye through NBD tube provides excellent alternative for Realtime fluorescent cholangiography in Post ERCP patients.

SP3.1.7 Performance of ultrasound in the diagnosis of cholecystitis and prediction of the “difficult cholecystectomy”

Abstract Aims Ultrasound has long been the radiological investigation of choice for right upper quadrant pain for the detection of gallstones and cholecystitis. However, previously reported sensitivity, specificity and other diagnostic metrics have varied widely and the underlying patient numbers have been small. We present robust and exhaustive diagnostic metrics based on a large series of 793 patients. Methods All laparoscopic cholecystectomies at our university hospital were prospectively logged between 2017 and 2020. The ultrasound findings, Nassar operative difficulty and histopathological findings were all collected in addition to patient biometrics. Results In our large patient series, sensitivity of ultrasound for cholecystitis was lower than previously reported at 75.7% for acute cholecystitis, 34.6% for chronic cholecystitis and 42.7% overall. Moreover, we show that sensitivity degrades with the time between ultrasound and cholecystectomy, falling below 50% at 140 days. Finally, we show that ultrasound strongly predicts Nassar difficulty grade of cholecystectomy and that its ability to do so is greatest where the interval between ultrasound and cholecystectomy is less than 27 days. Conclusions We present robust diagnostic metrics for ultrasound in the diagnosis of cholecystitis. These should caution the clinician that ultrasound may miss a quarter of cases of acute cholecystitis and over half of all cases of cholecystitis. Conversely, the finding of a thickened gallbladder on ultrasound can predict a “difficult cholecystectomy” and highlight the need for appropriate expertise and resources. Both this prediction and the diagnostic sensitivity are best if the ultrasound is done less than 27 days before cholecystectomy.

Preoperative and Operative Clinical, Laboratory and Radiological Predictors of Difficult Cholecystectomy and Their Management

Preoperative and Operative Clinical, Laboratory and Radiological Predictors of Difficult Cholecystectomy and Their Management

An observational study to assess male gender as an isolated risk factor in the laparoscopic cholecystectomy

Background: Laparoscopic cholecystectomy is the procedure of choice for majority of patients with gall bladder disease. The aim of the study was to investigate the role of male gender as an isolated risk factor responsible for the increased peri-operative morbidity of laparoscopic cholecystectomy by excluding associated risk factors.Methods: This was a prospective observational descriptive study 60 cases of elective laparoscopic cholecystectomy admitted to the S. M. S. Hospital from July 2019 to May 2020 were included.Results: The most common age group in male was 41-50 years and in female was 51-60 years. Impacted stones and gall bladder wall thickness &gt;4 mm was causes of difficult cholecystectomy and evenly distributed in both sexes. Operative time (p value=0.268), visual analogue score on day 1 (p value=0.307) and hospital stay (p value=0.376) was more in male group but not statistically significant.Conclusions: Impacted stone and gall bladder wall thickness &gt;4 mm were only factors associated with difficult laparoscopic cholecystectomy and excludes male gender as an isolated risk factor for difficult cholecystectomy however large-scale studies may provide different results.