Difficult Cholecystectomy Research Articles

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 >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 >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.

Delayed cholecystectomy following endoscopic retrograde cholangio-pancreatography is not associated with worse surgical outcomes.

BackgroundThere is no universal consensus on the optimal timing of cholecystectomy following endoscopic retrograde cholangio-pancreatography (ERCP). This study aims to evaluate the effect of time delay and post-ERCP complications on cholecystectomy outcomes.Materials and methodsAll patients who underwent pre-op ERCP for concurrent cholelithiasis and choledocholithiasis between January 2009 and August 2019 at University Hospitals Plymouth, UK, were included. Patients who underwent single-stage cholecystectomy and common bile duct exploration were excluded from the study. Based on the delay to cholecystectomy, the patients were divided into early (within 2 weeks), intermediate (2–6 weeks) and late (> 6 weeks) groups. The operative outcomes between the three groups were compared.ResultsWe included 444 patients in the study, with 62 (14%), 90 (20%) and 292 (66%) patients in the early, intermediate and late groups, respectively. The median duration from ERCP to cholecystectomy was 75 days. There was no statistically significant difference in the conversion-to-open rate, bile leak rate or retained stones between the three groups. The median post-operative hospital stay (PHS) was 2, 2 and 1 day (P = 0.005) in the early, intermediate and late groups, respectively. The readmission rate was significantly more in the delayed group (3.2%, 11.1% and 13.7%; P = 0.05). Patients who suffered post-ERCP complications had a significantly longer PHS (4 vs 1 day, P = 0.001) and had higher conversion-to-open rate (16 vs 4.5%, P = 0.04).ConclusionDelayed cholecystectomy following ERCP is not associated with worse peri-operative outcomes and can facilitate more day-case surgery. However, early cholecystectomy can significantly reduce readmissions with gallstone-related symptoms and its associated hospital stay. Post-ERCP complications lead to a difficult cholecystectomy.

Predictors of Difficult Cholecystectomy

Predictors of Difficult Cholecystectomy

Nassar operative grade and ultrasonography prediction for difficult laparoscopic cholecystectomy

Background: ‘Gold standard’ for symptomatic cholelithiasis is laparoscopic cholecystectomy (LC) with advantagesof minimal access surgery, early return to activity with cosmetic scar. However, this may not always holdtrue in all cases. Conversion to open procedure in challenging circumstances would be in better interest of the patient even after the learning curve of the surgeon has surpassed several years. Methods: Forty patients undergoing symptomatic gall stone disease without any acute episode in past six weeks were investigated. All cases were evaluated with clinical examinations, biochemical parameters and preoperative ultrasonography done a day prior for prediction of difficult LC. All cases correlated with preoperative USG parameters and Nassar per operative grade (1-4 and 5) and analyzed for prediction to open method in difficult challenging situations. Complications associated with in 30 day of surgical interventions were also recorded. Results: Difficult cholecystectomy was anticipated with USG parameters in 20 cases, and Nassar operative grading of difficulty (Grade-3, 4 and 5) predicted in 13 cases; the latter was correlated with conversion to open methods. p<0.05 in USG parameters and Nassar grading of operative difficulty was considered significant. There were no complications nor any surgical interventions required during 30 days interval.Conclusions: Per operative Nassar grading and prior USG parameters for prediction of likelihood of difficult cholecystectomy helps in guiding surgeon in challenging situation to safely proceed to complete cholecystectomy procedure either by laparoscope or open method in the better interest of the patient.

Assessing Patient Preoperatively and Role in Decreasing Risks on Patients and Preventing Post-Operative Complications for Cholecystectomy

Background: Laparoscopic cholecystectomy has many difficulties which include port Insertion, Dissectionof the Calot’s Triangle , Grasping of the Gallbladder , Wall thickness, Adhesion and extraction of theGallbladder. Aim of the Study: To predict how difficult cholecystectomy will be from assessing the patientpreoperatively which, in turn, help in decreasing the risks on the patients and preventing post-operativecomplications. Patients and Methods: A prospective study conducted in the department of General Surgeryat Al-Ramadi Teaching Hospital for the period of nine months from 15th of May 2018 till the 15th of February2019. It included 60 patients, all of them were undergone laparoscopic cholecystectomy for Gallstone. Patientswith common bile duct calculus, dilated common bile duct, current attack of acute cholecystitis, those withabsolute contraindications to laparoscopic cholecystectomy, The data were collected prospectively to predictthe significance of association with patients’ characteristics. The time of operation was calculated from thefirst port site incision until the last port closure. All the intra operative events were recorded. Conversionsto open cholecystectomy were done by median or subcostal laparotomy according to the surgeon’s decisionand each patient’s condition. Results: In this study, the highest proportion of operations was categorizedas easy (58.3%), 28.3% of operations were considered difficult and 13.3% of them were very difficult. Asignificant association (P < 0.05) between operation difficulty and all of the following characteristics: Aging,obesity, history of previous biliary hospitalization, thickened bladder wall, pericholecystic collection, andlarge stones. Conclusions: The difficult laparoscopic cholecystectomy can be predicted preoperativelybased on number of factors, like: obesity, previous biliary admission, gall bladder wall thickness, ultrasoundfindings (stone size and pericholecystic fluid) and aging process, evaluating of such factors minimize thecomplications of laparoscopic cholecystectomy and conversion to the open procedure.

Open conversion in laparoscopic cholecystectomy and bile duct exploration: subspecialisation safely reduces the conversion rates

BackgroundOpen conversion rates during laparoscopic cholecystectomy vary depending on many factors. Surgeon experience and operative difficulty influence the decision to convert on the grounds of patient safety but occasionally due to technical factors. We aim to evaluate the difficulties leading to conversion, the strategies used to minimise this event and how subspecialisation influenced conversion rates over time.MethodsProspectively collected data from 5738 laparoscopic cholecystectomies performed by a single surgeon over 28 years was analysed. Routine intraoperative cholangiography and common bile duct exploration when indicated are utilised. Patients undergoing conversion, fundus first dissection or subtotal cholecystectomy were identified and the causes and outcomes compared to those in the literature.Results28 patients underwent conversion to open cholecystectomy (0.49%). Morbidity was relatively high (33%). 16 of the 28 patients (57%) had undergone bile duct exploration. The most common causes of conversion in our series were dense adhesions (9/28, 32%) and impacted bile duct stones (7/28, 25%). 173 patients underwent fundus first cholecystectomy (FFC) (3%) and 6 subtotal cholecystectomy (0.1%). Morbidity was 17.3% for the FFC and no complications were encountered in the subtotal cholecystectomy patients. These salvage techniques have reduced our conversion rate from a potential 3.5% to 0.49%.ConclusionAlthough open conversion should not be seen as a failure, it carries a high morbidity and should only be performed when other strategies have failed. Subspecialisation and a high emergency case volume together with FFC and subtotal cholecystectomy as salvage strategies can reduce conversion and its morbidity in difficult cholecystectomies.

Subtotal Cholecystectomy After Failed Critical View of Safety Is an Effective and Safe Bail Out Strategy

BackgroundBile duct injury (BDI) is accompanied by significant morbidity and long-term impact in quality of life. Subtotal cholecystectomy (STC) is an alternative to prevent this outcome but is associated with other complications. The aim of this work is to demonstrate that BDI associated morbidity exceeds STC associated morbidity, underscoring STC as a reasonable bail out strategy. MethodsWe compared 115 patients who underwent STC with 293 patients who were referred to our center with BDI type E1–E3 and underwent surgical repair. The groups were comparable because in both instances the surgeon had the opportunity to decide not to perform a total cholecystectomy once critical view of safety (CVS) was not achieved. ResultsBile leakage was found in 21% of the STC group with only one BDI (0.9%). More Accordion ≥ 4 were found in the STC group (10.4% vs 4.8%, p = 0.035); however, reoperations were more frequent in the BDI group (8.2% vs 0.9%, p = 0.006). No patient in the STC group required reintervention for completion cholecystectomy. After 3.8 years follow-up, 2.4% of patients had secondary biliary cirrhosis in the BDI group; none in the STC group. ConclusionsDespite complications of STC, morbidity associated with BDI is much higher due to high long-term reoperation rate, in addition to secondary biliary cirrhosis. STC is a safe alternative that can prevent BDI if properly and timely performed in the context of difficult cholecystectomy.

Cystic Lymph Node Identification Is More Reliable Than Critical View of Safety in Difficult Cholecystectomies.

The cystic lymph node (CLN) represents an anatomic safety marker and a surrogate marker of technique during laparoscopic cholecystectomy (LC). We aim to demonstrate the value of CLN in comparison to the critical view of safety (CVS) and study the effects of increasing difficulty on the 2 approaches. A prospective study of consecutive LC was conducted. Patient demographics, type of admission, clinical presentation, operative difficulty grade, visualization of CLN, identification of CVS, operative time, and complications were recorded and analyzed. Of 393 LCs, half of the admissions were emergencies. Thirty-four percent had obstructive jaundice or acute cholecystitis. The CLN was visually identified in 81.7% with a small difference between operative difficulty grades 1 to 3 versus 4 to 5. Although CVS was unachievable in 62 patients, 43 (69.4%) still had an identifiable CLN. The median operating time was 68 minutes with 1 mortality but no conversions or intraoperative complications. Identifying the CLN during LC could compliment the CVS in avoiding major ductal injury. Dissecting lateral to the CLN to commence the process of displaying the cystic pedicle structures may be a strategy in safely achieving the CVS. During the more difficult LC where displaying the CVS is impossible, the CLN may be the key anatomic landmark.

Challenging situations in cholecystectomy and strategies to overcome them

Summary Background Cholecystectomy may be difficult and hazardous, causing major morbidity and mortality. This review aims to identify situations increasing the probability of difficult gallbladders and present today’s best practice to overcome them. Methods Review of the literature and expert comment. Results One in six gallbladders is expected to be a difficult cholecystectomy. The majority can be predicted by patient history, clinical symptoms, and pre-existing comorbidities. Acute cholecystitis, mild biliary pancreatitis, prior endoscopic sphincterotomy, and liver cirrhosis are the predominant underlying diseases. Early or delayed cholecystectomy, percutaneous cholecystostomy, and pure conservative treatment are evidence-based options. Early laparoscopic cholecystectomy is of advantage in patients fit for surgery, with subtotal cholecystectomy or conversion to open surgery as bail-out strategies. The choice of the procedure depends on the experience of the surgeon. Conclusion Clinical decisions should follow a pathway based on patients’ risk, favoring laparoscopic cholecystectomy whenever possible. The implementation of an institutional pathway to deal with difficult gallbladders is recommended.

Preoperative prediction of difficult laparoscopic cholecystectomy based on diffusion-weighted magnetic resonance imaging.

Laparoscopic cholecystectomy is a common surgery with a varying difficulty level. Difficult laparoscopic cholecystectomy may be experienced by many surgeons. If difficult procedures are predicted preoperatively, surgeons may be able to plan the surgical approach and treatment accordingly. Studies have reported using blood and clinical imaging data to predict difficult cholecystectomy. However, to our knowledge, no studies have reported using MRI. The purpose of this study was to evaluate the usefulness of MRI as a predictor of difficult laparoscopic cholecystectomy. We retrospectively evaluated 25 patients with cholecystitis or biliary colic who had undergone diffusion-weighted whole-body imaging before laparoscopic cholecystectomy. The apparent diffusion coefficient value of the cystic duct was measured and its relationship with operative time and blood loss was examined to assess the capacity of diffuse-weighted whole-body imaging to predict difficult cholecystectomy. Further, we collected blood data and compared its usefulness as a predictor. The apparent diffusion coefficient value of the cystic duct was significantly lower in patients with difficult laparoscopic cholecystectomy than in those with non-difficult procedures (P= .00007). White blood cell count and serum C-reactive protein level were significantly higher in patients with difficult cholecystectomy than in those with non-difficult procedures (P= .035, .030). In the receiver operating characteristic analysis, the apparent diffusion coefficient value was the best predictor. Our results suggest that the apparent diffusion coefficient value of the cystic duct is a predictor of difficult laparoscopic cholecystectomy. In the future, it may be useful to study changes in coefficient values over time to determine optimal surgical timing.

On-table Hepato-pancreatico-biliary Surgical Consults for Difficult Cholecystectomies Have Inferior Outcomes

Introduction: Laparoscopic cholecystectomy is a general surgical operation. “Call for help” is an acceptable standard for intra-operative difficulties. Locally, “call for help” is attended by hepato-pancreatico-biliary (HPB) specialists. We audit referral patterns and outcomes for on-table referrals for difficult cholecystectomy.

Cause and outcome of aborting a difficult cholecystectomy: a study of operative notes

Cause and outcome of aborting a difficult cholecystectomy: a study of operative notes

Safety Profile of Subtotal Cholecystectomy, what to Tell our Patients?

Background and Aims: Subtotal cholecystectomy (STC) is an alternative to total cholecystectomy (TC) in patients with severe inflammation/adhesions around the hepato-cystic triangle. This study aims to evaluate the safety profile of STC. Materials and Methods: We retrospectively reviewed all patients who had STC between February 2009 and August 2019. Patients who had cholecystectomy for gallbladder malignancy or as part of another operation were excluded from the study. Results: A total of 5661 patients underwent cholecystectomy during the study period. Out of these, 97 (1.7%) underwent STC. The laparoscopic to open conversion rate was high at 48.8% (47 cases), as was the overall post-operative complication rate 45.4% (44 cases). No patients suffered iatrogenic bile duct injury. Nineteen patients suffered post-operative bile leak (19.6%). This was significantly higher in patients who had STC in the acute setting (41% vs 13% for elective STC cases, P=0.04). There was no statistically significant difference in the incidence of bile leak among the patients who had reconstituting STC and fenestrating STC. The 90-day readmission rate was 8.2% (8 cases). No mortalities were recorded within 90-day post STC. Conclusions: STC seems to be an effective technique to avoid bile duct injury in difficult cholecystectomy cases. However, the peri-operative morbidity associated with STC is relatively high. Surgeons should be aware of STC's risks and should take appropriate steps to minimise the risks.

Feasibility and safety in difficult laparoscopic cholecystectomies; a single surgeon experience.

Background: laparoscopic cholecystectomy is commonly used for the treatment of gallstones. Objective: To determine the feasibility and safety of difficult laparoscopic cholecystectomies. Methodology: This cross sectional study was based on retrospective collection of data from patient records, including 323 patients with difficult laparoscopic cholecystectomies was conducted in Department of Surgery, Sharif Medical City Hospital, and Rasheed Hospital, Lahore from June 2010 to December 2019. Difficult cholecystectomy was defined on intraoperative findings based on Nassar intraoperative scoring system. Feasibility was defined as successful accomplishment of procedure without complication and safety was defined as having no intraoperative or postoperative complications. Results: There were 75 (23.21%) male and mean age was 48±8 years. Class I difficulty was observed in 185 (57.3%) patients, class II difficulty in 83 (25.7%) patients, class III difficulty in 44 (13.6%) patients and class IV difficulty in 11 (3.4%) patients. Mean duration of surgery and mean hospital stay were 98.87±11.76 minutes and 1.91±1 days, respectively. Conversion to open cholecystectomy was done in 10 (3.1%). The procedure was feasible in 313 (96.9%) patients. Overall complications were seen in 19 (5.9%) patients. The complications included Common Bile Duct injury in 1 (0.31%) patient, intraoperative bleeding in 1 (0.3%) patients, bile leakage in 2 (0.62%) patients, postoperative jaundice in 3 (0.93%) patients, superficial infections in 10 (3.1%) patients and deep infections in 2 (0.62%) patients. Safety of laparoscopic surgery was seen in 304 (94.1%) patients. Conclusion: Laparoscopic cholecystectomy in difficult situations was found to be feasible and safe in majority of patients. However, it was associated with a longer operative time.

Colecistectomía subtotal: una alternativa en el manejo de la colecistectomía difícil

Introducción. Alrededor de un 10 % de las laparoscopias se convierten a cirugía abierta por dificultades en obtener una visión crítica durante la colecistectomía en colecistitis severas. La colecistectomía subtotal es una posibilidad terapéutica disponible, que disminuye la tasa de conversión en cirugía laparoscópica y mantiene bajas tasas de morbilidad y mortalidad.
 Métodos. Estudio descriptivo, retrospectivo, de pacientes sometidos a colecistectomía subtotal en la Clínica CES (Medellín, Colombia) entre enero y diciembre de 2015. Se identificaron variables demográficas, detalles de la cirugía, morbilidad y mortalidad.
 Resultados. De un total de 710 colecistectomías en dicho periodo, a 17 (2,4 %) se les realizó colecistectomía subtotal. Quince (88 %) de ellas fueron por laparoscopia y dos requirieron conversión. La distribución en cuanto a sexo fue similar (10 mujeres / 7 hombres) y la edad promedio fue de 51 años. El tiempo quirúrgico promedio fue de 119 minutos. En 14 (82 %) pacientes se dejó drenaje subhepático. Dos pacientes presentaron fístula biliar y un paciente reingresó por un hematoma; no se presentaron otras complicaciones. La estancia hospitalaria promedio fue de 5,2 días. 
 Discusión. La colecistectomía subtotal es una alternativa en pacientes con colecistectomía difícil y en nuestra experiencia presenta una alta tasa de éxito.

How to manage a dilated cystic duct during laparoscopic cholecystectomy

Back ground Closure of the cystic duct (CD) is a must during laparoscopic cholecystectomy (LC). Metal clips were the standard technique used before. Now there are different methods used to occlude the CD (endoloop, suturing with absorbable materials, and endo-GIA stapling devices). Aim To assess different methods used in closure of dilated CD during laparoscopic cholecystectomy. Patients and methods This was a retrospective study done on 169 patients with difficult cholecystectomies of 3645 patients who had laparoscopic cholecystectomy in the General Surgery Department, Zagazig University Hospitals, in the period from January 2011 till March 2020. Results A total of 169 patients were included, comprising 98 females and 71 males, with an average age of 45±17.2 years. All patients had dilated CD during laparoscopic cholecystectomy that was occluded by different methods: large metal clips in 39 patients, ligature in 43 patients, endoloop in 33 patients, suturing to close the CD orifice in 30 patients, and endo-GIA devices in 24 patients. Conclusion We should keep in mind different methods when facing dilated CD during laparoscopic cholecystectomy according to its diameter and the availability of equipment.

A clinical study to determine predictive factors for difficult laparoscopic cholecystectomy

The technique of laparoscopic cholecystectomy (LC) has been standardized and it has become a routine and safe operation. However, there are numerous conditions which make the operation difficult necessitating conversion to open surgery. Preoperative prediction of a difficult cholecystectomy and the risk of conversion is of great help both to the patient who can be counseled appropriately pre-operatively and the surgeon who can also schedule his time and team accordingly. This prospective cross-sectional study was conducted on 118 patients undergoing laparoscopic cholecystectomy in Department of General Surgery, Aditya Birla Memorial Hospital, Chinchwad, Pune, over a period of 18 months from October 2015 to March 2017, to evaluate and correlate the clinical, biochemical and ultrasonography findings with the operative findings for anticipating difficult laparoscopic cholecystectomy. The parameters which were studied are age ≥ 60 years, sex, BMI > 30, history of (h/o) previous upper abdominal surgery, history of gall stone related complications, history of prior biliary intervention, biochemical parameters like Hb, TLC and LFT levels, gall bladder wall thickness (≥ 4 mm), pericholecystic collection, gall bladder size (contracted or distended gall bladder), stone impaction at neck/cystic duct and stone size > 1 cm. The operative parameters taken to assess the difficulty of the LC were total time taken to operate from the insertion of the trocar to the extraction of the gall bladder (more than 90 minutes), change of procedure to subtotal cholecystectomy and conversion to OC. Our study results show that significant predictors for difficult LC are increasing age of patients, h/o gall stone related complications, h/o prior biliary intervention, raised TLC and deranged LFT levels, GB wall thickness ≥ 4 mm, pericholecystic fluid collection, tensely distended/contracted GB and stone size > 1cm. However factors like sex of patient, BMI, history of previous upper abdominal surgery, haemoglobin levels and stone impacted at neck of gall bladder showed no significant relation with operative difficulty.

Comparative study of single versus multiple gallstone disease in KGH, Visakhapatnam

Objective: To evaluate the differences in the presentation, their operative implications and difficulties of single stone versus multiple gall stone disease.Methods: This is a prospective study of a minimum of 60 patients with gall stone disease (Group 1-single, Group 2-multiple) from January 2019 to December 2019 in KGH, Visakhapatnam.Results: More common in females, 40-50 years symptoms and complications, TC count difficult cholecystectomies were more in multiple gall stone pts.Conclusion: Multiple gall stones have led to more severe symptoms and complications and difficult surgery. should be motivated for early surgery even in incidental finding and should not opt for conservative management.

Assessment of difficult Laparoscopic cholecystectomy based on clinical and radiological findings

Background: Laparoscopic cholecystectomy is common procedure done in minimal invasive procedures. It is the treatment of choice for symptomatic gall stone disease all around the world. Methodology: This is case control study done in 198 patients undergoing laparoscopic cholecystectomy. Patients randomly divided as case and controls based on preoperative clinical criteria and radiological features. Results: 198 patients underwent laparoscopic cholecystectomy. Their mean age was 46.19 ± 13.03 years. There was female preponderance with 143 (72.2%) females as compared to 55 (27.8%) males. Difficult cholecystectomy was labelled in 55 (27.8%) cases based on intra-operative criteria mentioned in methodology. 13 (6.6%%) required conversion to open cholecystectomy. Easy cholecystectomies scored 0.81 as compared to 8.18 in the difficult group. The sensitivity of the preoperative score in predicting difficult cases was 98.2% with the specificity of 95.8%; positive predictive value of 90.0% and the negative predictive value of 99.3%%. The accuracy of the pre-operative scoring system was 96.56%. The area under the ROC curve (AUROC) for Preoperative Score predicting Surgery Difficulty: Difficult vs Surgery Difficulty: Easy was 0.992 (95% CI: 0.983 - 1), thus demonstrating excellent diagnostic performance. Conclusion: The preoperative score has high sensitivity, specificity, and accuracy in predicting difficult cases and can be used for identifying difficult laparoscopic cholecystectomies.

Use of indocyanine green fluorescence during hepatobiliary surgery

Background: Indocyanine green fluorescence image has been used in hepatobiliary surgery, which was mainly started by Japanese surgeons to visualize hepatobiliary structures probably because it is regarded as a reagent for estimation of hepatic function.
 Objectives: The objective of this study is to see the feasibility of use of indocyanine green in our setting during hepatobiliary surgery and its potential applications in the surgical treatment of benign and malignant liver pathology along with its selective use during difficult cholecystectomy to visualize extrahepatic biliary radical. 
 Methodology: This is a prospective cross sectional observational study performed including all consecutive patients who were posted for liver resection, both benign or malignant and selectively used in biliary surgery when biliary anatomy was uncertain. 
 
 Results: A total of thirty-nine patients had usage of indocyanine green, with a mean age of 51.6 ± 11.6 years (range, 31-75 years). In all our patients we were able to visualize the biliary system and liver parenchymal lesion.In the selective use of indocyanine green during difficult biliary anatomy during laparoscopic cholecystectomy 15/400 (3.75%), we were able to delineate biliary tree and hence five patients (1.2%) had to be converted to open cholecystectomy further preventing injury to the bile duct.
 Conclusion: Indocyanine green fluorescence imaging can be used safely and easily to identify liver tumors, hepatic segments, and extrahepatic bile ducts in real time during open and minimally invasive surgery. This allows surgeons to map the anatomical variations, status of resection margin and prevent surgical complications.