Elective Cholecystectomy Research Articles

A Woman With Recurrent Periumbilical Cramping

A 65-year–old woman presented to the emergency department with intolerable periumbilical cramping pain that lasted for hours, nausea, and cold sweats. Her pain episodes, which previously resolved with intravenous analgesia, began after her elective cholecystectomy 2 years prior. On physical examination, she was conscious, afebrile, and slightly tachycardic at 102 beats/min. Her blood pressure was 133/83 mm Hg. Abdominal palpation revealed tenderness over the periumbilical region. Results of laboratory tests were normal, including WBC count, liver function, and C-reactive protein level.

TH2.3 Elective versus emergency management of gallstone disease at a tertiary referral centre amidst the COVID-19 pandemic - should the protocol be altered?

BackgroundGallstones are a common pathology affecting approximately 15% of the population in UK, 20% of which are symptomatic. It is suggested symptomatic patients undergo cholecystectomies. Guidelines recommend this is performed within one week of initial emergency presentation or 52 weeks for elective case. Surgical capacity to manage emergency cholecystectomies was limited due to the COVID pandemic. We assessed wait time discrepancy between elective and emergency cholecystectomies.MethodsA retrospective review of all patients undergoing cholecystectomies between January and November 2021 in a major tertiary referral centre in London was undertaken. Initial pathology at the time of presentation, elective vs emergency presentation, pre-surgical biliary complications along and wait times were reviewed.Results219 (74 elective, 145 emergency) patients underwent surgery, mean age 48 years (23% Male and 77% Female). Average wait times for elective cholecystectomies were 69.7 days (min 0, max 246) in comparison to 68.9 days (min 1, max 253) for emergency surgery. 22 (15%) of the patients of initial emergency presentation re-attended hospital and 6 (4%) had adverse events such as gallbladder perforation or pancreatitis due to delayed treatment. Comparatively, 9 (12%) elective patients attended A&E due to pain, with no adverse outcomes.ConclusionsOverall wait time of emergency vs elective cholecystectomies were similar. This review indicates emergency cases require prioritisation over elective cholecystectomies due to the higher number of re-attendance and adverse events. Emergency cases need to be prioritised to meet guidelines, which could also reduce complication rates whilst awaiting surgery and lead to fewer adverse outcomes.

Moynihan Prize 2 Cholecystectomy in patients with cirrhosis: a population-based cohort study from England

Abstract Introduction There is an increased risk of cholelithiasis in patients with liver cirrhosis irrespective of the underling aetiology. Cholecystectomy is the recommended definitive treatment for symptomatic gallstones. However, in patients with cirrhosis the postoperative outcomes after cholecystectomy are not fully defined. This population-based cohort study aimed to determine postoperative outcomes after emergency and elective cholecystectomy in patients with cirrhosis. Methods Linked electronic healthcare data from England were used to identify all patients undergoing cholecystectomy between January 2000 and December 2017. Length of stay (LOS), 30-day re-admission, case fatality and the odds ratio (OR) of 90-day mortality were calculated for patients with and without cirrhosis, adjusting for age, sex and co-morbidity using logistic regression. Results Of the total 69141 eligible patients who underwent a cholecystectomy, 511 (0.74%) had cirrhosis. In patients without cirrhosis 86.55% underwent a laparoscopic procedure compared with 57.53% in patients with cirrhosis (p<0.0001). LOS was longer in those with cirrhosis (3 IQR 1–8days vs 1 IQR 1–3days, p<0.0001). The 30-day re-admission rate was greater in patients with cirrhosis, 36.79% compared with 14.95% in those without cirrhosis. The 90-day case fatality after elective cholecystectomy in patients with and without cirrhosis was 2.79% and 0.43%; and 12.82% and 2.39% following emergency cholecystectomy. This equated to a 3-fold (OR 3.22 (95%-CI 1.72–6.02)) and a 4-fold (OR 4.52 (95%-CI 2.46–8.33)) increased odds of death at 90-days following elective and emergency cholecystectomy after adjusting for confounders. Conclusion Patients with cirrhosis undergoing cholecystectomy have an increased 90-day risk of postoperative mortality, which is significantly worse after emergency procedures.

TU1.11 Patients’ views on laparoscopic cholecystectomy consent process: Consent in clinic improves quality of informed consent and patient satisfaction

Abstract Aims Informed consent for elective laparoscopic cholecystectomy should begin at first clinic consultation. Due to clinic time pressures, informed consent is often obtained on the morning of surgery for the first time. This study aims to assess whether consent quality and patients’ consent satisfaction are better in clinic compared to day of surgery. Methods Retrospective review of all elective laparoscopic surgeries between April and June 2021. Self-administered questionnaire was also completed by the same cohort to ascertain consent satisfaction. Results 38 patients in total during study period. 16(42.1%) were consented in clinic, and 22 were first consented on day of surgery. 25/38(65.8%) patients prefer to be consented in clinic, 13(34.2%) prefer consent on day of surgery. Significantly higher proportion of consent forms from clinic had full documentation of risks and benefits of cholecystectomy (P<0.001) compared to consents from day of surgery. Significantly higher proportion of patients consented in clinic felt adequately informed of procedure, had alternative options explained to them, were informed regarding recovery process, and felt there was adequate time for consent (P<0.05). Insignificantly higher proportion of patients consented in clinic received information leaflet about procedure. Overall consent satisfaction was significantly higher in patients consented in clinic (77% versus 55%, P=0.048%) Conclusions Consent quality and patient satisfaction levels for elective cholecystectomy were statistically significantly higher when consent was carried out in clinic prior to surgery compared to on the day of surgery. We recommend that all elective cholecystectomy consent is performed formally in clinic prior to surgery.

TU7.6 Comparing Cholecystectomy Day Case Rates during the pre-COVID and COVID Era at a Rural District General Hospital

Abstract Aims 67 000 cholecystectomies performed every year in the UK and 92% are laparoscopic. 75% of operations should be done as day cases. National rates vary between 6–50% with the most successful centres at 70%. Our aim was to audit the day case rate at our Trust pre-COVID and compare it to during COVID. Methods A retrospective audit of patients identified via clinical coding who had an elective cholecystectomy at one hospital in the Trust between 1 December 2018 to 31 November 2019. During COVID we did a prospective audit of patients identified via Theatreman who had an elective cholecystectomy at the Trust's designated “Green Hospital” between 21 September 2020 to 21 December 2020. Data for all patients was collected from electronic discharge summaries, clinic letters and patient notes. Results Pre-COVID our day case cholecystectomy rate was 73% compared to 54.7% during COVID. Pre-COVID conversion rate from planned day case to inpatient stay was 16.3% and during COVID the conversion rate increased to 44%. The waiting time for a cholecystectomy doubled during COVID to 26.3 weeks from 13.6 weeks pre-COVID. Average re-admission rate with symptomatic gallstones was 0.79 pre-COVID and 0.95 during COVID, with 64% of patients having at least one admission prior to surgery. The average length of stay pre-COVID was 0.75 days compared to 0.57 days during COVID. Summary COVID adversely affected our day case cholecystectomy rates with resultant increased waiting times for surgery and re-admissions with symptomatic gallstones however the average length of hospital stay was reduced.

Moynihan Prize 3 Financial implications of gallstone-related complications whilst awaiting elective cholecystectomy: a single institution experience of 900 patients.

AimsOver 65,000 cholecystectomies are performed each year in the United Kingdom with increasing waiting-list times due to the COVID-19 pandemic. This study set out to understand the cost to the NHS of complications experienced whilst awaiting cholecystectomy.MethodsA retrospective cohort study was carried out for all patients who had been awaiting elective cholecystectomy for more than 20 weeks on the 17th September 2021 at a large NHS Foundation Trust. Demographic data was collected at the time of listing. Re-admission data was collected from patient notes. It included clinical history, blood results and imaging investigations. Associated costs were calculated.Results900 patients included in the study (median age 56 years, 71.7% female). 138 patients (15.3%) re-presented to hospital whilst on the waiting list with complications of gallstone disease. Of these, 51 had more than one presentation to hospital with 18 patients having more than three presentations. This was equivalent to 625 days in hospital, with only 79 same day discharges, and multiple investigations were performed (ultrasound scan = 79; CT scan = 31, MRCP = 47, ERCP = 21). This was estimated to have cost a minimum of £364,917. Assuming an average time for an elective cholecystectomy of 90 mins at a cost of £1,200 per hour, 202 additional cholecystectomies could have been performed.ConclusionThis study highlights the enormous potential to reduce patient suffering by increasing the number of elective cholecystectomy lists, and at no overall additional cost to the trust.

WE2.3 Comparative study of early versus delayed laparoscopic cholecystectomy following endoscopic sphincterotomy for mild to moderate acute biliary pancreatitis

Abstract Background Acute pancreatitis is an inflammatory disease of the pancreas with acute biliary pancreatitis (ABP) accounting for 75% of cases. Current recommendations favour early laparoscopic cholecystectomy (LC) for mild acute gall stone pancreatitis during the same index admission to prevent recurrent attacks reported to be as high as 18–61% in various studies. Endoscopic sphincterotomy in cases who are unfit for cholecystectomy during the index admission or there is delay in cholecystectomy due to logistics may benefit from ES while waiting for elective cholecystectomy, in terms of reducing the number of recurrent attacks and decreasing morbidity. Methods A total of fifty-seven (57) patients of mild to moderate ABP were included in this study and were divided into three groups undergoing LC within 5 days of admission, ES within 7 days of onset of pain abdomen and LC within 4 weeks of initial illness and LC after 8 weeks of attack in the three respective groups and evaluated for level of difficulty of cholecystectomy, recurrent attacks and associated morbidity. Results Difficult LC in terms of adhesions, calots anatomy was seen in 17(n=57) patients. 13(n=38) patients had recurrent attack of pancreatitis during the waiting period for cholecystectomy, 2(n=19) in the ER group and 11(n=19) in the conservative management group, with all patients in the conservative group having more than 2 recurrent attacks. Conclusion LC in early period is a safe, effective, in patients of gallstone induced pancreatitis. ES is well tolerated and viable alternative to cholecystectomy to prevent recurrent pancreatitis until definitive treatment.

Suprapubic Cholecystectomy Improves Cosmetic Outcome Compared to Classic Cholecystectomy.

Currently, cholecystectomy is performed laparoscopically. While the conventional approach (CA) with four access ports persists, other methods seek to reduce trauma or to optimize cosmetic results. In this study, the safety and cosmetic outcome of a suprapubic approach (SA) were evaluated. Between 2015 and 2016, patients undergoing elective cholecystectomy either by CA or by a suprapubic approach (SA) at our institution were included. The cosmetic outcome, postoperative morbidity, operative time and length of stay were evaluated. Pictures of the site of intervention were taken 6–12 months postoperatively and rated on a scale from 1 (unsatisfying aesthetic result) to 5 (excellent aesthetic result). Five “non-medical” and five “medical” raters as well as one board-certified plastic surgeon performed the ratings. A total of 70 patients were included (n = 28 SA, n = 42 CA). The two groups did not differ in baseline characteristics (age, gender, BMI). The SA group showed a significantly better aesthetic outcome compared to the CA group 4.8 (4.8–4.9) vs. 4.2 (3.8–4.4), (p > 0.001). Medical raters: 4.0 (3.8–4.2) vs. 4.8 (4.6–5.0), (p < 0.001); non-medical raters: 4.2 (3.8–4.6) vs. 5.0 (4.8–5.0), (p < 0.001); plastic surgeon: 4.0 (4.0–4.0) vs. 5.0 (5.0–5.0), (p < 0.001). Fair interrater consistency was demonstrated with an ICC of 0.47 (95% CI = 0.38–0.57). No significant difference in the complication rate (1 (3.5%) in SA vs. 6 (14%) in CA, (p = 0.3)), or the operating time 66 (50–86) vs. 70 (65–82) min, (p = 0.3), were observed. Patients stayed for a median of three (3–3) days in the SA group and 3 (3–4) days in the CA group (p = 0.08). This study demonstrated that the suprapubic approach is an appropriate alternative to conventional laparoscopic cholecystectomy, presenting a better cosmetic outcome with a similar complication rate.

The Association of Preoperative Risk Factors for Laparoscopic Conversion to Open Surgery in Elective Cholecystectomy.

BackgroundLaparoscopic cholecystectomy is a common operation worldwide, with low mortality (0.01%) and morbidity (2–8%). It has been reported 2.9 to 3.2% of elective laparoscopic cholecystectomies are converted to open surgery. Converted cases are associated with increased complications rates.MethodTwo thousand and seventy-five patients, 82.8% females and 17.2% males who underwent elective laparoscopic cholecystectomy in our hospital, between March 1, 2016, and February 28, 2018, were prospectively collected in a database. Pearson's Chi-squared and Fisher's exact tests were used to determine significance, with p <0.05 deemed statistically significant. We analyzed seven risk factors associated with conversion to open surgery; age, gender, body mass index (BMI), previous abdominal surgeries, the presence of contracted gallbladder, Mirizzi syndrome, or choledocholithiasis. Laparoscopic cholecystectomy was performed using a 3-port technique (73%) and a 4-port technique (27%).ResultsFinding associated “strong” factors to conversion: male patients, >60-years-old, previous upper abdominal surgery, contracted gallbladder, Mirizzi syndrome or choledocholithiasis. The presence of a higher or lower BMI did not influence the rate of conversion. The most impact association were males over 60 years, and males with an earlier upper abdominal surgery.ConclusionLaparoscopic cholecystectomy is the gold standard for gallstones and gallbladder disease; however, inflammation, adhesions, and anatomic difficulty continue to challenge the use and safety of this approach in a small number of patients. This study identifies predictors of choice for open cholecystectomy. In view of the raised morbidity and mortality associated with open cholecystectomy, distinguishing these predictors will serve to decrease the rate of conversion and address these factors preoperatively.How to cite this articleHanson-Viana E, Ayala-Moreno EA, Ortega-Leon LH, et al. The Association of Preoperative Risk Factors for Laparoscopic Conversion to Open Surgery in Elective Cholecystectomy. Euroasian J Hepato-Gastroenterol 2022;12(1):6–9.

Requirement of preoperative blood typing for cholecystectomy and appendectomy: a systematic review

PurposeBlood typing, or group and save (G&S) testing, is commonly performed prior to cholecystectomy and appendectomy in many hospitals. In order to determine whether G&S testing is required prior to these procedures, we set out to evaluate the relevant literature and associated rates of perioperative blood transfusion.MethodsStudies from January 1990 to June 2021 assessing the requirement of preoperative G&S testing for elective or emergency cholecystectomy and appendectomy were retrieved from MEDLINE, EMBASE and CINAHL databases. The search was performed on 6th July 2021 (PROSPERO registration number CRD42021267967). Number of patients, co-morbidities, operation performed, number of patients that underwent preoperative G&S testing, perioperative transfusion rates and financial costs were extracted.ResultsWe initially screened 194 studies of which 15 retrospective studies, a total of 477,437 patients, specifically met the inclusion criteria. Ten studies reported on cholecystectomy, two studies on appendectomy and three studies included both procedures. Where reported, a total of 177,539/469,342 (37.8%) patients underwent preoperative G&S testing with a perioperative transfusion rate of 2.1% (range 0.0 to 2.1%). The main preoperative risk factors associated with perioperative blood transfusion identified include cardiovascular co-morbidity, coagulopathy, anaemia and haematological malignancy. All 15 studies concluded that routine G&S is not warranted.ConclusionThe current evidence suggests that G&S is not necessarily required for all patients undergoing cholecystectomy or appendectomy. Having a targeted G&S approach would reduce delays in elective and emergency lists, reduce the burden on the blood transfusion service and have financial implications.

Emergency single-incision laparoscopic cholecystectomy for acute cholecystitis: A multi-center study.

Single-incision laparoscopy is accepted as a safe alternative to multiple port laparoscopy for elective cholecystectomy; however, there are limited data on its use in patients with acute cholecystitis. The present multi-center study evaluated the outcomes of emergency single-incision surgeries for acute cholecystitis in hospitals in Belgium, Jamaica, and Trinidad and Tobago over a 5-year period. Standardized definitions of uncomplicated and complicated acute cholecystitis were used and the data were compared using SPSS software. The results revealed that over the 5-year period, 108 patients with a mean age of 48±15 years and a mean body mass index of 27±4.2 kg/m2 underwent emergency single-incision cholecystectomies. The surgeries were successful in 92.1% of cases without supplemental trocars being used. The overall morbidity rates (9.3%) were also comparable to the historic controls with multiple port cholecystectomy. As was expected, the complicated cholecystitis group required a significantly longer operating time (86.11±30.16 vs. 66.79±16.8; P<0.00194), as well as supplemental trocars (7.9%) vs. 0; P=0.0413). On the whole, the present study demonstrates that emergency single-incision cholecystectomy is a technically feasible and safe procedure for patients with acute cholecystitis. These findings advocate a low threshold to place additional ports to assist with dissection and exposure.

Complications lithiasiques chez les patients drépanocytaires

Chronic haemolysis exposes patients with sickle cell disease (SCD) to the development of black pigment gallstones, which can trigger biliary complications. In order to avoid these complications, elective cholecystectomy is recommended in France for all SCD patients with detected gallstones. However, all surgeries, and especially abdominal surgeries, entail an increased risk of vaso-occlusive complications in the peri- and post-operative periods, the most dreadful one being the acute chest syndrome. Preoperative transfusion has been shown in several studies to reduce acute postoperative complications, but exposes the patient to definitive alloimmunization, or even delayed post- transfusion haemolysis, justifying a recent trend towards transfusion sparing. The conditions for avoiding transfusion for a simple and frequent surgery such as cholecystectomy are based on a benefit- risk balance, and must be discussed on a case-by-case basis by the SCD specialist. In particular, it seems fully justified to perform prophylactic preoperative transfusion in patients with a history of recent vaso-occlusive crisis or acute chest syndrome (within 6 months preoperatively), and those operated on in an emergency setting, who are particularly at risk of postoperative events.

Evaluation of carbohydrate loading on clinical results and metabolic responses in patients undergoing laparoscopic cholecystectomy

ObjectiveInsulin resistance is associated with a number of postoperative complication and delays recovery. Carbohydrate rich drinks given preoperatively may decrease these deleterious effects. This study evaluated the clinical effects of a preoperative carbohydrate loading in patients undergoing laparoscopic cholecystectomy. MethodsIn this a randomized clinical trial conducted at (XXX) Medical Center located, patients undergoing elective cholecystectomy were included. Patients were randomly divided into fasting and dextrose-receiving groups. The outcomes of this study are the pain, pre- and postoperative blood sugar, fasting blood sugar, insulin, cortisol, albumin, CRP (c-reactive protein), and wound conditions such as wound infection and the amount of fluid discharge from the drain. The data was statistically analyzed using SPSS v22. ResultsPatients who received carbohydrates before surgery experienced less pain on the day after surgery (P-value <0.05). Insulin resistance, CRP, CRP to albumin ratio and cortisol levels were significantly reduced in dextrose group (P-value <0.05) However, difference in glucose levels and albumin was not significant in the two groups. ConclusionThe present results show that although carbohydrate loading is associated with reduced postoperative pain and reduction in inflammatory factors along with insulin resistance.

Toward Zero Prescribed Opioids for Outpatient General Surgery Procedures: A Prospective Cohort Trial

IntroductionAchieving satisfactory post-operative pain control for common elective general surgical procedures, while minimizing opioid utilization, remains challenging. Utilizing pre-operative educational strategies, as well as multimodal analgesia, we sought to reduce the post-operative opioid use in elective general surgery cases. MethodsBetween November 2019 and July 2021, patients undergoing elective inguinal hernia repair or cholecystectomy were enrolled in the study. Patients were divided into three cohorts: Control, opioid sparing (OS), or zero-opioid (ZO). Control patients did not have any intervention; OS patients had an opioid reduction intervention protocol applied (patient education and perioperative multimodal analgesia) and were provided an opioid prescription at discharge; the ZO had the same protocol, however, patients were not provided opioid prescriptions at discharge. Two weeks after discharge, patients were interviewed to record opioid consumption, pain scores, and level of satisfaction since discharge. ResultsA total of 129 patients were recruited for the study. Eighty-eight patients underwent inguinal hernia repair and 41 patients underwent cholecystectomy. Median post-operative morphine equivalents consumed in the Control cohort (n = 58); 46 (37.5-75) were significantly reduced when the OS protocol was enacted (n = 42); 15 (11-22.5) and further reduced to zero for every patient in the ZO cohort (n = 29) (P = 0.0001). There were no differences in patient-reported average pain scores after discharge (P = 0.08) or satisfaction levels with experience (P = 0.8302). ConclusionsOur study demonstrates that patient education and preoperative interventions can result in zero opioids prescribed after common general surgery procedures with equivalent patient satisfaction and pain scores.

Thoracic spinal anaesthesia for abdominal surgery in a humanitarian military field hospital: a prospective observational study

BackgroundProviding safe and effective anaesthesia in the context of humanitarian medicine is always a challenging situation. Spinal anaesthesia, and in particular its thoracic approach, represents a promising technique for such...

Pain after Laparoscopic Cholecystectomy: Effect of IntraperitonealInfiltration of Injection Bupivacaine

Objective: The aim of this study is to determine the effectiveness of intraperitoneal bupivacaine in patients undergoing laparoscopic cholecystectomy. Study Design: Prospective randomized study Place and Duration: Study was conducted at the department of SurgeryDow University Hospital (Ojha), Karachi for duration of six months from May 2021 to October 2021. Methods: There were 70 patients of both genders were presented in this study. Adult patients above 16 years of age, ASA class 1 &amp; 2, undergoing elective cholecystectomy were included in this study. Informed written consent was taken from all the patients for detailed demographics age, sex and body mass index. Patients were categorized into 2 groups. Group A had 36 patients and received 40 ml of intraperitoneal infiltration 0.25% Bupivacaine at Gall Bladder bed and Right Subphrenic space. Group B control group with 34 patients received no intraperitoneal Bupivacaine. Both groups received 20 ml of 0.25% Bupivacaine at ports site incisions. All patients were educated about the standard Visual Analogue Score (VAS) pain score of 0 – 10, during pre anaesthetic evaluation visit. SPSS 23.0 version was used to analyze data. Results: There were 28 (77.8%) females in group A and in group B females were 31 (91.2%). 43.55±13.93 years were the mean age in group A and in group B mean age was 39.94±11.54 years. Mean body mass index of group A was 26.14±13.41 kg/m2 and in group II mean BMI was 25.06±11.53 kg/m2. In group B close technique was used in 26 (72.2%) while in group B 24(70.6%) cases received closed technique. Post-operatively low pain score was observed in study group as compared to group B. Frequency of rescue analgesic was higher in group B as compared to group A. Conclusion: We concluded in this study that the use of intraperitoneal bupivacaine for laparoscopic cholecystectomy was significantly effective in terms of low pain and is an effective method for improving the quality of life within the early recovery period.

Observation of hemodynamic variability and level of blood cortisol while induction with propofol and etomidate: A prospective, randomized, double blind study

: To observe the effects of propofol and etomidate induction on patients undergoing laproscopic cholecystectomies regarding serum cortisol level, hemodynamic parameters, pain on injection, myoclonus, and apnea on induction.: It is a prospective, randomized, double blind study. After approval from Institute Ethics Committee, sixty patients of age between 18 and 60 years with ASA grade I and II scheduled for laproscopic cholecystectomy under general anesthesia were randomly divided into two groups: Group A (n=30) would receive injection propofol 2 mg/kg i.v., Group B (n=30) would receive injection etomidate 0.3 mg/kg i.v. as induction agent. Vital parameters at induction, laryngoscopy and thereafter recorded. Pain on injection, myoclonus, apnea on induction were carefully watched. Serum Cortisol is measured at 1 hour before induction and at 2 hours and 24 hours after induction.: Demographic variables and baseline parameters were comparable in both groups.Propofol group show significant decrease in heart rate and mean blood pressure after induction in comparison to etomidate group. Pain on injection was more in group A while myoclonus activity was higher in Group B. Serum cortisol level is significantly lower in Group B post induction compared to Group A which comes to above baseline after 24 hrs but in normal range. Etomidate is a better induction agent than propofol in view of hemodynamic stability but also led to chemical evidence of adrenocortical insufficiency in patients with ASA grade I &amp; II undergoing elective laproscopic cholecystectomy under general anaesthesia which returns to normal in 24 hrs.

Learning by doing: an observational study of the learning curve for ultrasonic fundus-first dissection in elective cholecystectomy

BackgroundSurgical safety and patient-related outcomes are important considerations when introducing new surgical techniques. Studies about the learning curves for different surgical procedures are sparse. The aim of this observational study was to evaluate the learning curve for ultrasonic fundus-first (FF) dissection in elective laparoscopic cholecystectomy (LC).MethodsThe study was conducted at eight hospitals in Sweden between 2017 and 2019. The primary endpoint was dissection time, with secondary endpoints being intra- and postoperative complication rates and the surgeon’s self-assessed performance level. Participating surgeons (n = 16) were residents or specialists who performed LC individually but who had no previous experience in ultrasonic FF dissection. Each surgeon performed fifteen procedures. Video recordings from five of the procedures were analysed by two external surgeons. Patient characteristics and data on complications were retrieved from the Swedish Registry of Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks).ResultsDissection time decreased as experience increased (p = 0.001). Surgeons with limited experience showed more rapid progress. The overall complication rate was 14 (5.8%), including 3 (1.3%) potentially technique-related complications. Video assessment scores showed no correlation with the number of procedures performed. The self-assessed performance level was rated lower when the operation was more complicated (p < 0.001).ConclusionsOur results show that dissection time decreased with increasing experience. Most surgeons identified both favourable and unfavourable aspects of the ultrasonic FF technique. The ultrasonic device is considered well suited for gallbladder surgery, but most participating surgeons preferred to dissect the gallbladder the traditional way, beginning in the triangle of Calot. Nevertheless, LC with ultrasonic FF dissection can be considered easy to learn with a low complication rate during the initial learning curve, for both residents and specialists.

Clinical spectrum and management outcome in gallbladder perforation-a sinister entity: Retrospective study from Sub-Himalayan region of India.

Gallbladder perforation is an infrequent entity seen among surgical patients. Rare occurrence owes to difficulty in diagnosing gallbladder perforations. The aim of the present study was to determine the optimal management strategy that may decrease the morbidity and mortality associated with this potentially life-threatening condition. This was a retrospective study from hospital health records wherein the experience of 40 consecutive patients with gallbladder rupture, either spontaneous or secondary to both benign conditions and malignancy, was noted at a tertiary care hospital over 48 months from February 2017 till January 2021. The etiology, clinical presentation, and treatment given were analysed. Out of 40 patients included, 23 were females and the majority of patients were more than 45 years of age. Twelve patients responded to intravenous antibiotics and analgesics alone while five required an ultrasound-guided pigtail catheter drainage due to non-improving clinical condition. The failure of expectant management led to a delayed laparotomy in seven patients while four patients required emergency laparotomy because of generalized peritonitis. An elective cholecystectomy was offered to 12 patients with cholecystoenteric fistulae after diagnostic laparoscopy in the same admission. Thirty-eight patients were discharged in stable condition and doing well at 30-day follow-up. Gallbladder perforation is seen more commonly in acute calculous cholecystitis compared to other conditions. It is more evident when the treatment of acute calculous cholecystitis is delayed by more than 6-8 weeks. The spectrum of clinical presentation varies from mild pain and vomiting to generalized peritonitis. The patient often requires a step-up approach to control the ongoing sepsis for an improved outcome.

Invisible or negligent—EUS detection for the negative CT or/and MRCP CBD stone

Invisible or negligent—<scp>EUS</scp> detection for the negative <scp>CT</scp> or/and <scp>MRCP CBD</scp> stone