Difficult Cholecystectomy Research Articles

BN SO21 - Factors influencing subtotal cholecystectomy

Abstract Background Laparoscopic Cholecystectomy (LC) is the main treatment for symptomatic gallstone disease. Sub-total cholecystectomy (SC) has become increasingly utilised as a safe alternative to conversion to open when unable to visualise the critical view of safety. This avoids the morbidity of an open operation whilst minimising the risk of iatrogenic injury to the common bile duct. Male sex, increasing age, previous acute cholecystitis and ERCP have previously been identified as independent risk factors for SC. We aim to identify factors that increased the likelihood of SC within our cohort and the effect of SC on post-operative morbidity. Method All patients who had LC as either an elective or emergency procedure between 1st July 2020 and 30th June 2022 were identified and included in this study. Patient and operative details were retrieved from their electronic record and a Charlson co-morbidity index was calculated. Any post-operative complication was noted and graded according to the Clavien-Dindo classification. Statistical analysis was performed using SPSS with ANOVA analysis being performed for continuous data. Odds ratios were calculated with a 95% confidence interval. Statistical significance was taken as a p value < 0.05. Results 974 patients underwent LC with 4.8% having SC. Factors associated with increased risk of SC included: previous acute cholecystitis (OR 9.37 (4.69-18.70), increased age (mean = 58.7 vs 50.9), higher Charlson co-morbidity index (mean = 2.60 vs 1.43) male sex (OR 2.49 (1.38-4.48), emergency operation (OR 2.30 (1.23-4.30), Diabetes Mellitus (OR 2.58 (1.23-5.36); and previous ERCP (OR 2.62 (1.13-6.11). 30-day morbidity was higher for SC (25.5% vs 8.1%) with major complication (Clavien-Dindo > 2) being significantly more frequent (OR 6.64(2.53-17.4). Median post-operative length of stay was 2 days for SC and 0 days for LC. Conclusion Although regarded as a safe option in difficult cholecystectomy, our study shows that there is significant morbidity associated with subtotal cholecystectomy. However, the majority of patients only require a short hospital stay post-operatively. Multiple risk factors were identified for SC with previous acute cholecystitis being the most strongly associated with SC. Diabetes was identified as an independent risk factor alongside higher Charlson co-morbidity index as a generic marker of co-morbidity. Interestingly, CBD diameter > 8mm on pre-operative imaging was not shown to increase risk of SC.

Bailout for the Difficult Gallbladder: Subtotal vs. Open Cholecystectomy-A Retrospective Tertiary Care Center Experience.

Background and Objectives: A difficult gallbladder anatomy augments the risk of bile duct injuries (BDIs) and other complications during a laparoscopic cholecystectomy. This study compares the outcomes of a laparoscopic subtotal cholecystectomy (LSTC) and open total cholecystectomy (OTC) for difficult cholecystectomies. Materials and Methods: This retrospective analysis of gallbladder procedures (LSTC or OTC) from 2016 to 2023 examined patient demographics, surgical details, and postoperative results. The primary outcome was the incidence of a BDI. Secondary outcomes included operative duration, blood loss, and postoperative complications. Results: Seventy-one patients were included in the study. Of them, 59.2% (n = 42) underwent an LSTC and 44.6% (n = 29) underwent an OTC. The LSTC cohort was more likely to have a day-surgery case with a same-day discharge (33.3% vs. 0%, p = 0.009), less blood loss (71.4 ± 82.26 vs. 184.8 ± 234.86, p = 0.009), and a shorter operative duration (187.86 ± 68.74 vs. 258.62 ± 134.52 min, p = 0.008). Furthermore, BDI was significantly lower in the LSTC group (2.4% vs. 17.2%, p = 0.045). However, there were no significant differences between the two groups concerning intraoperative drain placement, peri-cholecystic fluid collection, bile leak, and other complications (p > 0.05). Conclusions: LSTC is a safe and effective alternative to OTC for challenging gallbladder cases. Further studies with larger sample sizes and longer follow-up periods as well as different study designs are warranted.

Indocyanine Green and Hepatobiliary Surgery: An Overview of the Current Literature.

Indocyanine green (ICG) is an inert polypeptide that almost totally binds to high molecular weight plasma proteins; it is cleared by the hepatocytes and directly excreted into the bile with a half-life of about 3-5 minutes. Specific systems are required to see fluorescent images. The use of this dye has been reported in different surgical specialties, and the applications in hepatobiliary surgery are widening. Being firstly used to evaluate the preoperative liver function, intra- and postoperative dynamic checking of hepatic activity has been reported and integrated within perioperative protocols allowing a tailored treatment allocation. Intravenous injection (IV) or injection into the gallbladder can ease difficult cholecystectomy. Biliary leakage detection could be enhanced by IV ICG injection. Although with some contrasting results, the use of ICG for both delineating the limits of the resection and tumor-enhanced visualization was demonstrated to improve short- and long-term outcomes. Although the lack of strong evidence still precludes the introduction of this tool in clinical practice, it harbors great potential in liver surgery.

Indocyanine green in laparoscopic cholecystectomy: utility and correlation with a preoperative risk score

BackgroundThis study aims to compare the visualization of the cystic duct-common bile duct junction with indocyanine green (ICG) among 3 groups of patients divided according to the difficulty of elective laparoscopic cholecystectomy. MethodsConducted at a single center, this non-randomized, prospective, observational study encompassed 168 patients who underwent elective laparoscopic cholecystectomy and were assessed with a preoperative risk score to predict difficult cholecystectomies, including clinical factors and radiological findings. Three groups were identified: low, moderate, and high risk. A dose of 0.25 mg of IV ICG was administered during anesthesia induction and the different objectives were evaluated. ResultsThe visualization of the cystic duct-common bile duct junction was achieved in 28 (100%), 113 (91.1%), and 10 (63%) patients in the low, moderate, and high-risk groups, respectively. The high-risk group had longer total operative time, higher conversion, more complications and longer hospital stay. In the surgeon’s subjective assessment, ICG was considered useful in 36% of the low-risk group, 58% in the moderate-risk group, and 69% in the high-risk group. Additionally, there were no cases where ICG modified the surgeon’s surgical approach in the low-risk group, compared to 11% in the moderate-risk group and 25% in the high-risk group (p < 0.01). ConclusionsThe results of this study confirm that in the case of difficult cholecystectomies, the visualization of the cystic duct-common bile duct junction is achieved in 63% of cases and prompts a modification of the surgical procedure in one out of four patients.

Fitz-Hugh-Curtis Syndrome—Pelvic Inflammatory Disease: A Predictor of Difficult Cholecystectomy

Fitz-Hugh-Curtis Syndrome—Pelvic Inflammatory Disease: A Predictor of Difficult Cholecystectomy

Incidence of Endoscopic Retrograde Cholangiography after Subtotal Fenestrating and Reconstituting Cholecystectomy.

Laparoscopic subtotal cholecystectomy (SC) is used for the difficult cholecystectomy, but published experience with resource use for SC is limited. We hypothesized that the need for advanced resources are common after SC. This was a retrospective review of laparoscopic cholecystectomies between 2017 and 2021 at a large center. SC cases were identified using a medical record tool. Baseline characteristics were assessed with Student's t -test and chi-square test. Primary outcome was endoscopic retrograde cholangiography (ERC) within 60 days. Secondary outcomes were reconstituted SC on postoperative ERC and length of stay (LOS). Uni- and multivariable logistic regression were used for binary outcomes. Multiple linear regression was used for LOS. Covariates included were age, sex, BMI, and American Society of Anesthesiology class. A total of 1,222 laparoscopic cholecystectomies were performed between 2017 and 2021. Of these, 87 (7%) were SC. Male (p < 0.001) and older (p < 0.001) patients were more likely to undergo SC. Odds of postoperative ERC were higher in the SC group (odds ratio 9.79, 95% CI 5.90 to16.23, p < 0.001). There was no difference in preoperative ERC (17% vs 21%, p = 0.38). Reconstituting SC had lower odds of postoperative ERC (odds ratio 0.12, 95% CI 0.023 to 0.58, p = 0.009). LOS was 1.81 times higher in the SC group (p ≤ 0.001). Postoperative ERC was not associated with LOS (p = 0.24). We present one of the largest single-center series of SC. Patients who underwent SC are more likely to be male, older, have higher American Society of Anesthesiology class, and have increased LOS. SC should be performed when access to ERC and interventional radiology is available. In the absence of these adjuncts, reconstituting SC decreases the need for early ERC, but long-term outcomes are unknown.

648 Predictive Factors for Subtotal Cholecystectomy

Abstract Introduction Subtotal-cholecystectomy (STC) is a rescue procedure in dealing with difficult gallbladders undertaken when a critical view of safety is not possible to allow complete cholecystectomy, thereby avoiding complications. Aim Determine what patient factors increase risk of STC in patients undergoing elective laparoscopic cholecystectomy (LC) and therefore aid prediction in patients reduced suitability for day surgery. Method Data was collected between 01/01/2022 and 31/07/2023 from three hospitals throughout the Aneurin-Bevan University Health-Board, Wales, UK. All patients receiving elective LC had data collected on age, BMI, gender, ERCP preceding operation, surgical duration, length of stay and 30-day complications, amongst others. Results Of a total of 1060 patients were included in this study(77.36%female, 22.64%male), 81 where STC (7.64% of total LC; 56.8%female, 43.2%male). There were three 30-day mortalities, one of whom underwent STC(p= 0.09). The overall complication rate was 6.41%, significantly raised in the STC group(13.58%vs5.82%;p=0.007). As expected, there was a significant increase in bile-leak following subtotal(12.35%vs1.12%; p=0.0001) , however, there was no increase significance for bleed (0%vs0.41%;p=0.5644), wound infection(0%vs3.68%;p=0.079), collection(0.09%vs0.51%;p=0.404) or bile duct injury(0%vs1.02%; p=0.0001). Predictors for STC were higher age(70-79years;p=0.0016), male gender(p=0.0001), and ERCP preceding surgery(p=0.0001). Both length of stay(median 1vs 0days;p=0.0001) and length of procedure (median 122vs 76minutes;p=0.0001) were increased following STC. High BMI, diabetes(p=0.1991) and smoking(p=0.7921) had no association. Conclusions Subtotal cholecystectomy is a safe alternative when facing difficult cholecystectomy where critical view of safety is not achievable. Factors predicting STC were male gender, advanced age and prior ERCP.

The textbook outcome for cholecystectomy: Is it a good quality tool for a low-morbidity procedure?

IntroductionCholelithiasis is the most common hospital diagnosis of the digestive system, and its treatment, if symptomatic, is laparoscopic cholecystectomy. There is a growing need for comprehensive determination of postoperative outcomes and the efficiency of healthcare facilities. The “textbook outcome”(TO) indicates the quality of care commonly used in oncological procedures, obtained by adding several postoperative parameters, which informs whether a perfect result has been obtained. The main objective of this study is to determine the TO for cholecystectomy and to see the factors that influence its achievement. MethodsRetrospective observational unicentric cohort study on patients who underwent cholecystectomy between 2018–2020. We defined TO as those patients who met the following premises: Clavien-Dindo complications < III, postsurgical stay less than the 75th percentile (<3 days), and no readmissions or mortality in the first ninety days. Perioperative characteristics were analyzed, and the patients were divided into two groups according to whether or not they achieved TO. We defined criteria for difficult cholecystectomy according to the operative report. ResultsThe percentage of TO was 72% (342/475) (82.6% in elective surgery and 60.5% in urgent surgery). The univariate analysis showed that the following factors are associated with achieving TO: female sex, age <63 years, ASA risk < III, elective surgery, laparoscopic approach, and not difficult cholecystectomy. After multivariate analysis ASA < III (OR 2.39 CI95% 1.37–4.16), elective surgery (OR 2.77 CI95% 1.64–4.67), laparoscopic approach (OR 5.71 CI95% 2.89–11.30) and not to be difficult cholecystectomy (OR 0.42 CI95% 0.259–0.71) remained statistically significant. ConclusionsThe TO is a healthcare quality tool that is simple to perform, easily interpretable, and helpful for evaluating quality in healthcare and comparing centers. It applies not only to oncological procedures but also to cholecystectomy.

The difficult cholecystectomy: What you need to know.

This review discusses the grading of cholecystitis, the optimal timing of cholecystectomy, adopting a culture of safe cholecystectomy, understanding the common error traps that can lead to intraoperative complications, and how to avoid them. 1-28 The Tokyo Guidelines, American Association for the Surgery of Trauma, Nassar, and Parkland scoring systems are discussed. The patient factors, physiologic status, and operative findings that predict a difficult cholecystectomy or conversion from laparoscopic to open cholecystectomy are reviewed. With laparoscopic expertise and patient conditions that are not prohibitive, early laparoscopic cholecystectomy is recommended. This is ideally within 72 hours of admission but supported up to the seventh hospital day. The majority of bile duct injuries are due to misidentification of normal anatomy. Strasberg's four error traps and the zones of danger to avoid during a cholecystectomy are described. The review emphasizes the importance of a true critical view of safety for identification of the anatomy. In up to 15% of operations for acute cholecystitis, a critical view of safety cannot be achieved safely. Recognizing these conditions and changing your operative strategy are mandatory to avoid harm. The principles to follow for a safe cholecystectomy are discussed in detail. The cardinal message of this review is, "under challenging conditions, bile duct injuries can be minimized via either a subtotal cholecystectomy or top-down cholecystectomy if dissection in the hepatocystic triangle is avoided". 21 The most severe biliary/vascular injuries usually occur after conversion from laparoscopic cholecystectomy. Indications and techniques for bailout procedures including the fenestrating and reconstituting subtotal cholecystectomy are presented. Seven percent to 10% of cholecystectomies for acute cholecystitis currently result in subtotal cholecystectomy. Level of evidence: III.

Laparoscopic subtotal cholecystectomy outcomes across a low-and middle-income country metropolitan health service.

Laparoscopic subtotal cholecystectomy (LSC) is a safe alternative for difficult cholecystectomies to prevent bile duct injury and open conversion. The primary aim was to detail the use and outcomes on LSCs. Retrospective analysis of a prospectively maintained database of laparoscopic cholecystectomy (LC). Relative clinical factors, outcomes, and 30-day follow-up between LSC and LC were compared using univariate and multivariate analyses. Six hundred and twenty four cholecystectomies were performed and 53 (8.5%) required LSC. 81.8% were fenestrating LSC. Male sex was significantly overrepresented in the LSC group (p<0.01) and patients requiring LSC were significantly older (p<0.01). Same admission cholecystectomy was associated with a higher risk of LSC (p<0.01). Patients with a history of previous surgery, preoperative ERCP, or percutaneous cholecystostomy had an increased risk of undergoing LSC (p<0.01). A necrotic gallbladder was the most significant predictor of the need for a LSC (p<0.001). A contracted gallbladder, extensive adhesions, gallbladder empyema, and severe inflammation were significant predictors of difficulty (all p<0.01). Postoperative complications occurred in 26.4% of LSC patients. There were ten (18.9%) Clavien-Dindo Grade III complications, 5.7% required ERCPs, and 9.4% required relook laparotomies. Significantly, more patients in the LSC group developed bile leaks (n=8, 15%) (p<0.001). There were two readmissions within 30days, one mortality, and no BDIs occurred in the LSC cohort. LSC provides a feasible surgical option that should be utilized in complex cholecystitis.

What Happens After Discharge? A 2+ Year Follow-Up After Laparoscopic Subtotal Fenestrating and Reconstituting Cholecystectomy.

Laparoscopic subtotal cholecystectomy (LSC) is utilized to prevent complications in the difficult cholecystectomy. Medium-term outcomes are poorly studied for fenestrating and reconstituting operative techniques. A single-institution retrospective review was undertaken of all LSCs. A telephone survey was used to identify complications addressed at other institutions. We performed subgroup analyses by operative approach and of patients requiring postoperative endoscopic intervention (ERC). 28 patients met inclusion criteria. The median follow-up was 32.7 months. There were no bile duct injuries or reoperations. 21% of patients required a postoperative ERC and 50% were discharged home with a drain. Bile leaks were found to be more prevalent in the fenestrating LSC group (38% vs 0%, P = .003). The case series suggested more severe recurrent biliary disease in patients undergoing reconstituting LSC. Laparoscopic subtotal cholecystectomy appears to have satisfactory medium-term outcomes. The reconstituting LSC group trends toward more severe recurrent disease which warrants further investigation.

Beyond the Expected: Evaluating Preoperative Predictors of a Difficult Cholecystectomy Aboard the USNS Comfort.

Mini abstract Typical preoperative markers of a difficult laparoscopic cholecystectomy did not apply during the US Naval ShipComfort Deployment in 2019. This prospective study reveals the importance of preparedness for short-term surgical missions, the impact of health care disparities on the severity of disease, and the need for deliberate and thoughtful engagement with host-nation partners.

Predicting Difficulty in Laparoscopic Cholecystectomies: An Evaluation of the Labbad-Vivas Score and Its Correlation With the Parkland Grading Scale.

Background Difficult laparoscopic cholecystectomy (DLC) denotes the surgical extraction of the gallbladder under circumstances where associated conditions within the same organ, adjacent structures, or patient-specific conditions impede a smooth, expeditious, and comfortable dissection. It is imperative to utilize tools that aid in anticipating this challenging surgical scenario, enabling the implementation of appropriate measures. Objective This study aimed to assess the effectiveness of the Labbad-Vivas score (LVS) in predicting DLC and its correlation with the Parkland Grading Scale (PGS). Methodology A prospective study was conducted, including patients diagnosed with gallstone disease undergoing LC (laparoscopic cholecystectomy) at the "Dr. Luis Razetti" University Hospital in Barcelona, Venezuela, between September and December 2023. Results Forty patients were studied, with 80% (n=32) being female and 95% (n=38) under the age of 65; surgeries were elective in 72.5% (n=29) of cases; 35% (n=14) had an LVS ≥16 (difficult cholecystectomy); and 62.5% (n=25) of patients presented Grades 1 and 2 on the PGS. Total cholecystectomy was performed in 95% (n=38) of the patients. The LVS showed a sensitivity of 80%, specificity of 92%, positive predictive value of 85.7%, and negative predictive value of 88.5% to predict DLC, with an area under the receiver operating characteristic curve of 0.897 (95% confidence interval (CI) = 0.792-1.003). A Pearson correlation coefficient of 0.805 (95% CI = 0.656 - 0.904) was obtained between both scores. Conclusion The use of the LVS score in the preoperative setting is feasible as a predictor of DLC, given its effectiveness and high correlation with the PGS.

Subtotal cholecystectomy; A substandard bail-out technique?

Introduction: While the open approach was previously mandated as the salvage procedure in difficult cholecystectomies, subtotal cholecystectomy has since been implemented. While this technique may prevent biliary duct injury intraoperatively, it comes with major pitfalls. Case Series: We present a series of four cases where a subtotal cholecystectomy was previously performed, in which further gallstone-related complications occurred. Conclusion: We aim to increase awareness toward recurrent symptoms that may require further evaluation and repeat procedures in patients with previous cholecystectomy; and drawbacks relating to performing subtotal cholecystectomies—opting instead for open cholecystectomy, recruitment of another senior or specialist hepatobiliary surgeon and/or transfer to a tertiary center with the appropriate facilities.

Preoperative predictive factors of difficult laparoscopic cholecystectomy

Background Laparoscopic cholecystectomy is a routine start-up procedure for any surgeon interested in the field of laparoscopy. However, one may encounter complex cases that may increase the risk of perioperative complications. It is crucial to identify these cases preoperatively for better surgical planning. Herein, we studied preoperative risk factors for difficult cholecystectomy procedures in our Egyptian tertiary care center. Methodology One hundred patients were enrolled in our study, and their cholecystectomy procedures were classified as easy, difficult, or very difficult based on two parameters; preoperative scoring system and intraoperative findings. Results There was a significant agreement between preoperative difficulty prediction score and intraoperative findings (k=0.858, P&lt;0.001). Procedure difficulty was associated with patient hospitalization (P&lt;0.001), previous supraumbilical surgeries (P=0.004), previous acute cholecystitis (P&lt;0.001), previous jaundice (P=0.049), previous endoscopic biliary clearance (P=0.022), increased gallbladder wall thickness (P=0.001), and pericholecystic fluid collection (P=0.014). Conversion to the open approach was needed in 6 cases (6%). Age, sex, BMI, and impacted stone did not significantly impact procedure difficulty (P&gt;0.05). Conclusion Multiple preoperative parameters have been significantly associated with the increased difficulty of the laparoscopic cholecystectomy procedure. Properly identifying these parameters and their inclusion into a scoring system would be greatly helpful in determining difficult cases during the preoperative period.

Assessment of risk factors in patients undergoing difficult cholecystectomy: a cross-sectional study at a tertiary care hospital in Central India

Background: Laparoscopic cholecystectomy (LC) is the operation of choice in the treatment of symptomatic gallstone disease. Most of the time, the levels of difficulties are hard to assume. The risk factors for difficult LC have not been adequately evaluated in Indian population, especially with respect to western Indian population. Thus, the present study was undertaken to assess the risk factors in patients undergoing difficult cholecystectomy. Method: The study involved 100 adult patients with cholelithiasis admitted in the department of surgery for cholecystectomy over a period of 2 years from Nov 2020 to Dec 2022. Preoperatively, patients were evaluated for risk factors including age, gender, BMI, history of sickle cell disease, previous abdominal surgery, presence of pericholecystic collection, gall bladder thickness, impacted calculi, adhesions in triangle of Calot‘s, and previous hospitalization for acute cholecystitis and acute pancreatitis. These factors were assessed to predict difficult LC. Results: Majority of laparoscopic procedures were easy (65%), while remaining were difficult (35%). Difficult cholecystectomy was significantly associated with age ≥50 years (p=0.016), male gender (p=0.031), BMI ≥25 kg/m2 (p&lt;0.0001), sickle cell disease (p=0.030), previous abdominal surgery (p=0.004), pericholecystic collection (p=0.017), gall bladder thickness ≥4 mm (p=0.007), adhesion in triangle of Calot‘s (p&lt;0.0001), impacted calculi (p=0.036), previous hospitalization for acute cholecystitis and acute pancreatitis (p&lt;0.0001) and diabetes mellitus (p&lt;0.0001). The conversion rate was 2%. Conclusions: An awareness about reliable predictors for difficult LC would be helpful for an appropriate treatment plan and application of the resources to anticipate difficult LC. However, further studies with larger sample size are required to confirm the findings.

Perioperative strategies for patients undergoing subtotal cholecystectomy: a single-center retrospective review of 102 procedures

BackgroundCalculous gall bladder disease is often handled by laparoscopic cholecystectomy. In cases where a safe dissection of the hepatocystic triangle cannot be carried out, a subtotal cholecystectomy (STC) may be performed. The perioperative management of patients undergoing STC is characterized by limited evidence. This large single-center series explores some of the perioperative aspects and outcomes after STC.Materials and methodsThe study population includes all patients who underwent STC at Oslo University Hospital (Ullevål and Aker Hospitals) from 01.01.2014 to 30.09.2020. A STC was defined as a cholecystectomy where there was a failure to control the cystic duct during surgery. Study variables included demographic data, comorbidities, previous biliopancreatic disease, indication for surgery, perioperative information, subsequent interventions and outcome data.ResultsDuring the study period, 2376 cholecystectomies were performed, and 102 (4.3%) were categorized as STC. Of all patients with STC, 48 (47.1%) had an intra- or postoperative ERCP during the index hospital admission. The indication for ERCP was bile leak in 37 (42.6%) of the cases. The bile leak resolution rate was 60.0 % in intraoperative ERCP vs 95.7% in postoperative ERCP. Among the STC patients, there were no injuries to the central bile ducts. Later, one patient has undergone a remnant cholecystectomy, following fenestrating STC.ConclusionSTC was a safe bailout strategy for dissection in the hepatocystic triangle in difficult cholecystectomies. Intraoperative ERCP increased procedure time and was associated with a lower rate of leak resolution, as compared to postoperative ERCP.

Subtotal vs total cholecystectomy for difficult gallbladders: A systematic review and meta-analysis

IntroductionWith severely inflamed gallbladders, laparoscopic cholecystectomy can be difficult and may require procedures like subtotal cholecystectomy (SC). Few studies exist comparing SC and total cholecystectomy (TC) in the setting of severe biliary inflammation. This meta-analysis aims to compare SC and TC for difficult gallbladders. MethodsMedline-OVID, Embase-OVID, and Cinahl were searched including only studies comparing SC to TC for difficult gallbladders. Primary outcome was CBD injury. Secondary outcomes included bile leak, duodenal injury, retained stone, bleeding, intraabdominal collection, wound infection, reoperation, and mortality. ResultsTen studies were included. Compared to TC, SC significantly lowered the risk for CBD injury (0 ​% vs. 1.6 ​%, RR 0.30, 95%CI 0.10–0.87) but increased risk of bile leaks (RR 3.5, 95%CI 1.79–6.84), postoperative ERCP (RR 2.86, 95%CI 1.53–5.35), intraabdominal collections (RR 2.55, 95%CI 1.32–4.93), and reoperation (RR 2.92, 95%CI 1.14–7.47). ConclusionSC is a reasonable alternative to difficult gallbladders that may decrease the risk of CBD injuries. Knowing both approaches is crucial to manage the difficult gallbladder while minimizing harm. Further studies are needed to understand the value of SC for difficult cholecystectomy.

Gallbladder Stones in Pediatric Age: An Emerging Problem: The Risk of Difficult Cholecystectomy and the Importance of a Preoperative Evaluation.

The need for cholecystectomy during pediatric age has significantly increased in the last two decades. As biliary pathology increases, the probability of complicated cholecystectomies increases too. The aim of this article is to analyze our experience with difficult laparoscopic pediatric cholecystectomy, focusing on the importance of an accurate pre-operative imaging study. We retrospectively analyzed all patients affected by cholelithiasis who underwent laparoscopic cholecystectomy at the Pediatric Surgery Department of San Camillo Forlanini hospital of Rome and Santa Maria alle Scotte University Hospital of Siena from 2017 to 2022. Demographic data, body mass index (BMI), recovery data, laboratory tests, imaging exams, surgical findings, post operative management and outcome were taken into account. Overall, 34 pediatric patients, with a mean age of 14.1 years (6-18 years) were included, with a mean BMI of 29. All patients underwent abdominal ultrasonography and a liver MRI with cholangiography (cMRI). We identified five cases as "difficult cholecystectomies". Two subtotal cholecystectomies were performed. Cholecystectomy in pediatric surgery can be difficult. The surgeon must be able to find alternative strategies to total cholecystectomy to avoid the risk of possible bile duct injury (BDI). Pre-operative imaging study trough ultrasound and especially cMRI is crucial to recognize possible difficulties and to plan the surgery.

When Critical View of Safety Fails: A Practical Perspective on Difficult Laparoscopic Cholecystectomy.

The incidence of common bile duct injuries following laparoscopic cholecystectomy (LC) remains three times higher than that following open surgery despite numerous attempts to decrease intraoperative incidents by employing better training, superior surgical instruments, imaging techniques, or strategic concepts. This paper is a narrative review which discusses from a contextual point of view the need to standardise the surgical approach in difficult laparoscopic cholecystectomies, the main strategic operative concepts and techniques, complementary visualisation aids for the delineation of anatomical landmarks, and the importance of cognitive maps and algorithms in performing safer LC. Extensive research was carried out in the PubMed, Web of Science, and Elsevier databases using the terms "difficult cholecystectomy", "bile duct injuries", "safe cholecystectomy", and "laparoscopy in acute cholecystitis". The key content and findings of this research suggest there is high intersocietal variation in approaching and performing LC, in the use of visualisation aids, and in the application of safety concepts. Limited papers offer guidelines based on robust data and a timid recognition of the human factors and ergonomic concepts in improving the outcomes associated with difficult cholecystectomies. This paper highlights the most relevant recommendations for dealing with difficult laparoscopic cholecystectomies.