Incidence Of Bile Duct Injury Research Articles

Robotic assisted cholecystectomy – A retrospective cohort study of experience of 106 first robotic cholecystectomies in versius robotic platform

IntroductionLaparoscopic cholecystectomy is currently the standard of care for symptomatic cholelithiasis as well as for chronic and acute cholecystitis. The incidence of bile duct injury in laparoscopic cholecystectomy is still higher than that in open surgery. Surgical robots aim to bridge this gap. With the greater availability of surgical robots and cheaper alternatives to the Da Vinci system, surgeons can take advantage of the better manoeuvrability and better vision that a surgical robot offers. This is likely to make robotic assisted cholecystectomy a very safe option. Here, we present our early data on the robotic procedures performed by the Versius robotic system by CMR (Cambridge Medical Robotics). MethodsIt is a retrospective study, with data collected from our prospectively maintained database at Swagat Super Speciality Surgical Institute and NH, maintained collectively by CMR and our surgical residents. The first consecutive 106 planned robotic cholecystectomies that were performed by a single surgeon were included in the study. ResultsOut of 106 serial planned robotic assisted cholecystectomies (101 robotic assisted cholecystectomies + 5 combined with other procedures), no bile duct injury was reported, with a mean console time of 54.16 min and a mean setup time of 9.29 min. One procedure had to be converted to open for malignancy, and another patient had to be converted to laparoscopy due to dense adhesions with the duodenum. Three chronic liver disease (CLD) patients underwent partial cholecystectomy. A total of 70.75% of patients had no pain – visual analogy scale (VAS) pain score of 0 at POD 1 with minimal blood loss in most of the procedures. No learning curve for robotic assisted cholecystectomy was seen. ConclusionAlthough robotic assisted cholecystectomy was mostly chosen for patients in whom difficult cholecystectomy was clinically anticipated, it fared quite well. The learning curve was essentially non-existent. Robotic assisted cholecystectomy is a safe and feasible option in both simple and difficult cases of gallbladder disease.

Nasobiliary guided laparoscopic cholecystectomy following endoscopic retrograde cholangiopancreatography, randomized controlled trial

BackgroundEndoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC) is the most common management of gallstones combined with common bile duct (CBD) stones. This study aims to evaluate the impact of routine insertion of nasobiliary catheter during ERCP in cases of difficult LC. Patients & methodsFrom total 110 patients who underwent ERCP followed by LC in the period from April 2019 to April 2020, nasobiliary (NB) catheter was inserted during ERCP in 55 patients after CBD clearance (NB group). In the other 55 patients, only CBD clearance was done (Control group). In the NB group, dynamic trans-nasobiliary intraoperative cholangiography (TN-IOC) was done during dissection of Calot's triangle. At the end of the procedure, trans-nasobiliay methylene blue (MB) test was done to detect any missed biliary injury. The primary outcome to be analyzed was the incidence and severity of bile duct injury (BDI), secondary outcomes were the operative time, conversion to open surgery, and hospital stay. ResultsOf the 110 patients, 57 patients (51.8%) were males and 53 (48.2%) were females. Median age was 55 years. One case of biliary leak was reported in the NB group (1.8%), while 2 cases (3.6%) were reported in the Control group. The average operative time in the NB group was 115 min versus 128 min in the Control group (P value < 0.001). No cases were converted to open cholecystectomy in the NB group (0%) with 5 cases (9.1%) converted to open in the Control group. The average postoperative hospital stay was 2 ± 0.1 days in the NB group versus 3.6 ± 5.3 days in the Control group (P value = 0.037). ConclusionRoutine insertion of nasobiliary tube during ERCP, in patients with combined gallbladder and CBD stones, is a simple, safe and dynamic method for IOC. This maneuver does not statistically decrease the incidence of BDI but can diagnose, minimize and treat BDI with shorter operative time and hospital stay.

The Result of the Critical View of Safety Timeout Technique in Prevention of Bile Duct Injury in Laparoscopic Cholecystectomy: A Retrospective Study at a Large Community Teaching Hospital

Background: Laparoscopic cholecystectomy (LC) is the standard treatment for cholelithiasis. However, despite improvements in technology and implementation of a safer approach, such as the critical view of safety (CVS) technique, the risk of bile duct injury (BDI) remains an issue. Objective: To review LC cases at a large community hospital for BDIs and compare BDI rates between conventional technique and CVS timeout approaches. The authors hypothesized that there would be lower BDI rates in the CVS timeout group. Materials and Methods: The authors conducted a retrospective study of 1,033 consecutive patients that underwent LC at the authors’ institution between November 2015 and November 2018. Based on the timeout document and operative reports, the authors classified patients into CVS timeout and no CVS (noCVS) timeout groups and compared the BDI rates and other relevant clinical outcomes. Results: Among the 1,033 patients, 635 and 398 patients were in the noCVS timeout and CVS timeout groups, respectively. There was no significant difference in the incidence of BDI between the two groups at 1.1% versus 1.8%, respectively (p=0.375). The CVS group exhibited less preemptive conversion to open cholecystectomy, lower incidence of uncontrolled intraoperative bleeding, shorter operative time, and shorter length of hospital stay than the noCVS group. In multivariate regression analysis, operative time of more than 90 minutes was the significant independent risk factor associated with BDI, while previous biliary inflammation was marginally associated with BDI. Conclusion: The present study failed to demonstrate the beneficial effect of CVS timeout in preventing the development of BDI. The reasons could be attributed to surgeons’ competency with their varying skills and experience, the occurrence of injury before timeout, the case selection biases, or the wrong CVS identification. Further review of the actual surgical videos may offer more clarity into the unexpected outcome. Keywords: Bile duct injuries; Critical view of safety; Infundibular techniques; Laparoscopic cholecystectomy

Pattern of Presentation of Iatrogenic Biliary Injury Following Laparoscopic Cholecystectomy

Background: Cholecystectomy is one of the most now common abdominal surgeries performed every day. The incidence of bile duct injury (BDI) following open cholecystectomy is only 0.1% - 0.2%. After the introduction of laparoscopic cholecystectomy, the incidence has gone up to 0.4% - 0.7%. The present study is a prospective analysis of all patients with bile duct injury who were admitted to Dhaka Medical College Hospital during or at a variable period following cholecystectomy. Methods: To determine the pattern of presentation of iatrogenic biliary injury following cholecystectomy in the department of surgery of Dhaka Medical College Hospital, a total of 30 patients were purposively selected from May 2018 to November 2018. Patient particulars, records of physical and clinical evaluation, and operative details were collected by individual researchers. Data analysis was done by SPSS for windows version 21. Results: BDI was found very common among the age group 21 - 30 yrs (36%) and female dominant (60%). Majority of the patients presented with abdominal pain (96%), intra-abdominal collection (88%), biliary peritonitis (68%), cholangitis (60%), and obstructive jaundice (40%), and biliary fistula (40%). Laparoscopic cholecystectomy (84%) was the principal cause of biliary injury in our study. 48% of patients experienced clinical features within 7 days post-cholecystectomy. Per-operative diagnosis was done in only 12% of cases. 44% of patients in this study were recognized as Bismuth grade-3, followed by 36%, grade-2 patients. Management outcomes included wound infection (41.66%), minor bile leak (25%), peritonitis (8.33%), and renal impairment (8.33%). Conclusion: The effect of BDI is an extremely distressful clinical condition for the patients and their family members, hence proper care and management protocol should be followed.

Management of Post Cholecystectomy Bile Duct Injury: Pertinent Factors Contributing to Good Surgical Outcomes

Objective: Surgical management remains the mainstay treatment for bile duct injury (BDI) post-cholecystectomy. Achieving long-term patency and lessening anastomotic failure depends on important factors including the types of repairs, timing of repairs, and surgical expertise. The present study focused on the impact of these factors on the surgical outcomes of BDI repair. Materials and Methods: Fifty-nine patients who were treated with BDI post cholecystectomy at the surgical department between January 2003 and December 2018 were retrospectively reviewed. The patients were categorized as 11 in-house and 48 referral patients, of which 22 patients had bile duct repairs prior to referral. Surgical outcomes and factors, including types of repairs, timing of repairs, and surgical expertise, impacting on the treatment results were analyzed. Results: The mean age of the patients was 47.6 years. The BDI incidence in the authors’ hospital was 0.14%. Complications occurred in 21 patients (35.6%), of which intraabdominal collection was the most common at 10 patients (16.9%). The median length of hospital stay was 16 days for in-house patients and 17 days for the referral group (p=0.542). The mortality rate was 1.7%. The overall patency was 93% with mean follow up 106.4 months. Concerning the primary patency rate, the partial segments IV/V liver resection and hepaticojejunostomy techniques had better long-term patency compared to primary repairs at 92.3% versus 37.5% (p=0.017), and biliary bypass at 92.3% versus 80% (p=0.44). BDI repairs performed by primary surgeons increased the risk of anastomotic failure in comparison to those done by hepatobiliary surgeons with 10-year patency at 53.3% versus 95.4% (p=0.014). Delayed repairs longer than six weeks after injury offered positive long-term outcomes compared to early repairs done within six weeks after injury, with a 10-year patency at 85.4% versus 31.3% (p&lt;0.001). Conclusion: Delayed repair performed by the hepatobiliary surgeon with appropriate surgical techniques decreased anastomosis stricture and achieved good overall surgical outcomes in the management of post cholecystectomy BDI. Keywords: Bile duct injury; Cholecystectomy; Surgical management

Understanding intraoperative fluorescent cholangiography: ten steps for an effective and successful procedure.

Common bile duct injuries (BDI) during laparoscopic cholecystectomy (LC) continue to be the source of morbidity and mortality. The reason for BDI is mostly related to the misidentification of the extrahepatic bile duct structures and the anatomic variability. Near-infrared fluorescent cholangiography (NIFC) has proven to enhance visualization of extrahepatic biliary structures during LCs. The purpose of this study was to describe the most important steps in the performance of NIFC. In accordance to the most current surgical practice of LC at our institution, a consensus was achieved on the most relevant steps to be followed when utilizing NIFC. Dose of indocyanine green (ICG), time of administration, and identification of critical structures were previously determined based on prospective and randomized controlled studies performed at CCF. The ten steps identified as critical when performing NIFC during LC are preoperative administration of ICG, exposure of the hepatoduodenal ligament, initial anatomical evaluation, identification of the cystic duct and common bile duct junction, the cystic duct and its junction to the gallbladder, the CHD, the common bile duct, accessory ducts, cystic artery and, time-out and identification of Calot's triangle, and evaluation of the liver bed. Routine use of NIFC is a useful diagnostic tool to better visualize the extrahepatic biliary structures during LC. The implementation of specific standardized steps might provide the surgeon with a better algorithm to use this technology and consequently reduce the incidence of BDI.

Laparoscopic Cholecystectomy in Patients with Left Sided Gallbladder Using an Indocyanine Green (ICG) Fluorescence Cholangiography

Introduction: Left-sided gallbladder is a relatively rare anatomical variation that is frequently associated with a biliary system anomaly. In patients with LSGB, LC is associated with a higher incidence of bile duct injury (4.4%), necessitating the establishment of a safe surgical approach in these patients. Here, we describe a case of left-sided gallbladder with cirrhotic liver treated by using an ICG fluorescence cholangiography during laparoscopic cholecystectomy. Method & Results: 62-year-old man with gallbladder adenomyoma was admitted to our hospital. Computed tomography demonstrated that the gallbladder was centrally dislocated and left-sided gallbladder with right-sided ligamentum teres. A laparoscopic cholecystectomy was performed. The round ligament was attached to the right side of the gallbladder, and the left-sided gallbladder was diagnosed by intraoperative findings (figure 1.). The patient was discharged 2 days after surgery without postoperative complications. Conclusions: ICG fluorescence cholangiography should be used in cases of left-sided gallbladder during laparoscopic cholecystectomy. An assessment of the extra- and intrahepatic biliary system is essential to avoid biliary injury in cases of left-sided gallbladder.

Laparoscopic Hepatico-jejunostomy for Benign Bile Duct Strictures - Our Experience

Introduction: The incidence of bile duct injuries (BDI) after cholecystectomy is around 0.6%. Biliary strictures following BDI is a worrisome complication. Laparoscopic hepatico-jejunostomy for benign biliary strictures has been a rarely attempted operation. The aim of this study is to describe our experience in the laparoscopic approach for biliary stricture repair- currently not attempted by many centres. Methods: A retrospective study of eleven (11) patients with benign biliary strictures secondary to cholecystectomy, operated between 2012 and 2020, was conducted. Demographics, co-morbidities, presenting symptoms, details of index surgery, type of lesion, pre-operative and post-operative workup and therapeutic interventions were recorded. The biliary strictures were staged according to the Bismuth-Strasberg classification. A side to side anastomoses with Roux-en-Y reconstruction was performed in all cases. Complications, mortality, and long-term follow-up were recorded. Results: Eleven patients with benign biliary strictures were operated. the female to male ratio was 3:2. The mean age of the population under study was 30 years. All eleven cases operated were E3 according to the Strasberg classification. The operative time recorded was ranged between 240 - 480 mins. The median value of bleeding was 200 mL (range 50-1100 mL). Oral intake was started in the first 48 hrs. No bile leak was noted in any of our patients. No patients have underwent re-intervention till date. No mortality was recorded. The maximum follow-up was 48 months (Range 2-48 months). Conclusion: The benefits of minimal access techniques may be utilized successfully in the management of benign biliary strictures with acceptable morbidity.

Retrospective Study of Common Bile Duct Injury after Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy is one of commonest laparoscopic surgeries but carries out serious complications, one of them with high morbidity and mortality which is Bile Duct Injury. Biliary leak, biliary peritonitis and obstructive jaundice presents BDI with different management planes from ERCP and stent application up to abdominal exploration and roux-en-y hepatico-jeujenostomy to restore bile system continuity, this fact drove the attention of healthcare institutes to this problem. Is to assess different types of Bile duct injuries (BDI) after laparoscopic cholecystectomy and the outcome of different surgical procedures and recent radiological interventional procedures. This is a retrospective study carried on 50 patients underwent laparoscopic cholecystectomy and complicated by bile duct injury in benha university hospitals, after approval of local ethics committee, all patients included in the study were informed about the procedure and a written consent was obtained from every patient before carrying the different surgical procedures and recent radiological interventions. The study was done from January 2004 till January 2020. BDI during laparoscopic cholecystectomy occur more frequently when compared to open surgery. They occur twice to three times, more frequently than after an open surgery. Among early presentations is bile leak which occurred in (56%) who present early within first week. Different plans of management which differs from radiological intervention with (14%) up to abdominal exploration with (70%). Increased incidence of bile duct injury with laparoscopic cholecystectomy more than open cholecystectomy. Over confidence of some surgeons can cause serious damage. Roux en y Hepatico-jeujonostomy is the preferred surgical procedure. Intervention radiology plays important role in diagnosis and management of BDI.

Bile duct injury during laparoscopic cholecystectomy: An Indian e-survey.

Backgrounds/AimsIn the absence of national registry of laparoscopic cholecystectomy (LC) or its complications, it is impossible to determine incidence of bile duct injury (BDI) in India. We conducted an e-survey among practicing surgeons to determine prevalence and management patterns of BDI in India. Our hypothesis was that majority of surgeons would have experienced a BDI during LC despite large experience and that most surgeons who have a BDI tend to manage it themselves.MethodsAn 18-question e-survey of practicing laparoscopic surgeons in India was done.Results278/727 (38%) surgeons responded. 240/278 (86%) respondents admitted to a BDI during LC and 179/230 (78%) affirmed to more than one BDI. A total of 728 BDIs were reported. 36/230 (15%) respondents experienced their first BDI even after >10 years of practice and 40% had their first BDI even after having performed >100 LCs. 161/201 (80%) of the respondents decided to manage the BDI themselves, including 56/99 (57%) non-biliary surgeons and 44/82 (54%) surgeons working in non-biliary center. 37/201 (18%) respondents admitted to having a mortality arising out of a BDI; the mortality rate of BDI was 37/728 (5%) in this survey. Only 13/201 (6%) respondents have experienced a medico-legal case related to a BDI during LC.ConclusionsPrevalence of BDI is high in India and occurs despite adequate experience and volume. Even inexperienced non-biliary surgeons working in non-biliary centers attempt to repair the BDI themselves. BDI is associated with significant mortality but litigation rates are fortunately low in India.

The critical view of safety during laparoscopic cholecystectomy: Strasberg Yes or No? An Italian Multicentre study

BackgroundLaparoscopic cholecystectomy is considered the gold standard for the treatment of gallbladder lithiasis; nevertheless, the incidence of bile duct injuries (BDI) is still high (0.3–0.8%) compared to open cholecystectomy (0.2%). In 1995, Strasberg introduced the "Critical View of Safety" (CVS) to reduce the risk of BDI. Despite its widespread use, the scientific evidence supporting this technique to prevent BDI is controversial.MethodsBetween March 2017 and March 2019, the data of patients submitted to laparoscopic cholecystectomy in 30 Italian surgical departments were collected on a national database. A survey was submitted to all members of Italian Digestive Pathology Society to obtain data on the preoperative workup, the surgical and postoperative management of patients and to judge, at the end of the procedure, if the isolation of the elements was performed according to the CVS. In the case of a declared critical view, iconographic documentation was obtained, finally reviewed by an external auditor.ResultsData from 604 patients were analysed. The study population was divided into two groups according to the evidence (Group A; n = 11) or absence (Group B; N = 593) of BDI and perioperative bleeding.The non-use of CVS was found in 54.6% of procedures in the Group A, and 25.8% in the Group B, and evaluating the operator-related variables the execution of CVS was associated with a significantly lower incidence of BDI and intraoperative bleeding.ConclusionsThe CVS confirmed to be the safest technique to recognize the elements of the Calot triangle and, if correctly performed, it significantly impacted on preventing intraoperative complications. Additional educational programs on the correct application of CVS in clinical practice would be desirable to avoid extreme conditions that may require additional procedures.

Transillumination of Calot's Triangle on Laparoscopic Cholecystectomy: A Feasible Approach to Achieve a Critical View of Safety.

BackgroundLaparoscopic cholecystectomy is currently one of the most commonly performed procedures globally. Morbidity of laparoscopic cholecystectomy is low; however, bile duct injury is still a feared complication. Despite worldwide efforts, the global incidence of bile duct injury remains higher for laparoscopic cholecystectomy compared with open cholecystectomy. Despite the general belief that the learning curve and lack of laparoscopic skills represent the most common causes of bile duct injuries, the principal cause is the misidentification of biliary anatomy. The aim of our study is to determine if laparoscopic transillumination is a feasible approach to bile and vascular structures visualization during laparoscopic cholecystectomy because the only other method for real-time visualization is fluorescent cholangiography, which can be cost-prohibitive and requires specialized equipment and training.Materials and methodsWe performed a retrospective comparison of outcomes between the transillumination approach in 10 patients receiving laparoscopic cholecystectomy (group A) and a control group of 50 conventional laparoscopic cholecystectomy patients (group B). We compared demographic data, type of surgery, operative time, bleeding, intraoperative and postoperative complications, and hospital stay. We used a conventional four-port positioning for laparoscopic cholecystectomy, and a 5-mm/30° scope was used as a light source and placed behind the area identified as Calot’s triangle.ResultsGroup A consisted of 10 patients (9 women, 1 man), with a mean age of 50.7 (± 17.4) years. The mean body mass index (BMI) in group A was 26.8 (± 0.65) kg/m2. In group A, three of the cholecystectomies were conducted as emergency procedures. Group B consisted of 50 patients (40 women, 10 men), with a mean age of 49.7 (±15.2) years. The mean BMI in group B was 27.5 (±4.5) kg/m2, and two cholecystectomies were emergency procedures. In comparing the transillumination approach with conventional cholecystectomy, we found no statistical differences in operative time, bleeding, complications, or mean hospital stay.ConclusionsLaparoscopic transillumination is a feasible method for real-time visualization of Calot’s triangle structures. Our initial experience with transillumination did not provide better outcomes than conventional cholecystectomy.

Development of an artificial intelligence system using deep learning to indicate anatomical landmarks during laparoscopic cholecystectomy

BackgroundThe occurrence of bile duct injury (BDI) during laparoscopic cholecystectomy (LC) is an important medical issue. Expert surgeons prevent intraoperative BDI by identifying four landmarks. The present study aimed to develop a system that outlines these landmarks on endoscopic images in real time.MethodsAn intraoperative landmark indication system was constructed using YOLOv3, which is an algorithm for object detection based on deep learning. The training datasets comprised approximately 2000 endoscopic images of the region of Calot's triangle in the gallbladder neck obtained from 76 videos of LC. The YOLOv3 learning model with the training datasets was applied to 23 videos of LC that were not used in training, to evaluate the estimation accuracy of the system to identify four landmarks: the cystic duct, common bile duct, lower edge of the left medial liver segment, and Rouviere’s sulcus. Additionally, we constructed a prototype and used it in a verification experiment in an operation for a patient with cholelithiasis.ResultsThe YOLOv3 learning model was quantitatively and subjectively evaluated in this study. The average precision values for each landmark were as follows: common bile duct: 0.320, cystic duct: 0.074, lower edge of the left medial liver segment: 0.314, and Rouviere’s sulcus: 0.101. The two expert surgeons involved in the annotation confirmed consensus regarding valid indications for each landmark in 22 of the 23 LC videos. In the verification experiment, the use of the intraoperative landmark indication system made the surgical team more aware of the landmarks.ConclusionsIntraoperative landmark indication successfully identified four landmarks during LC, which may help to reduce the incidence of BDI, and thus, increase the safety of LC. The novel system proposed in the present study may prevent BDI during LC in clinical practice.

Biliary stricture after Roux-en-Y hepaticojejunostomy for bile duct injury–surgical challenge: a single-center expertise

Background Laparoscopic cholecystectomy has been considered the gold standard since the 1990. Yet the incidence of bile duct injury (BDI) has increased from 0.06 to 0.3% for open cholecystectomy to 0.5 to 1.4% when done laparoscopically. Roux-en-Y hepaticojejunostomy (RYHJ) is the most widely approved management for most post-cholecystectomy BDIs, yet some patients experience incapacitating biliary complications, such as jaundice or recurrent attacks of cholangitis, in addition to anastomotic stricture. Aim The aim of this study was to assess the short-term outcomes of a multidisciplinary approach regarding failed RYHJ after post-cholecystectomy BDI. Materials and methods A total of 15 patients were enrolled in the descriptive study after failure of RYHJ performed because of post-cholecystectomy BDI. Patients comprised six males and nine females. All patients after definitive treatment underwent follow-up by abdominal ultrasound and liver function tests for at least 11 months. Results One (6.7%) patient had liver transplantation because of liver cirrhosis. Four (26.7%) other cases were managed by revisionary surgery for the hepaticojejunostomy as the stricture was so tight. The reminder 10 cases underwent trial of percutaneous trans-hepatic cholangiography (PTC), but unfortunately six of them (40% of the whole group) failed to be dilated adequately, and they indeed underwent surgery, and the other four (26.7%) were dilated successful. During the follow-up, three (20%) patients had biliary leakage and two patients developed re-stricture, with one mortality because of pulmonary embolism. Conclusion Good long-term results can be achieved in patients with RYHJ stricture through a case-by-case analysis and an immediate multidisciplinary approach in expert hepatobiliary center.

Quality of life after repair of iatrogenic bile duct injury of postcholecystectomy Filipino patients

Aims: The estimated incidence of bile duct injuries (BDIs) has increased ranging from 0.4% to 0.7% since global recognition of laparoscopic cholecystectomy as a standard procedure. Bile duct injuries are associated with increased morbidity and mortality, as well as substantial health care costs, and malpractice litigation claims. This study aims to determine the quality of life (QoL) of Filipino patients after repair of BDIs incurred from their previous laparoscopic or open cholecystectomies. Methods: A total of 22 patients post-repair of BDIs and 22 age- and sex-matched patients who had unremarkable cholecystectomies from 1997 to 2017 were recruited for this study. The patients were requested to answer a survey on QoL using RAND 36-Item Health Survey 1.0, a validated survey which includes a multi-item scale that assesses eight health concepts. Results: Patients with BDIs had lower scores in all domains compared to non-BDI group. Physical functioning and role limitations due to physical health are statistically significant (p values 0.0473 and 0.0025). Conclusion: The effect of BDI is considerable and bears an impact on a patient’s health and well-being. Physical functioning and role limitations due to physical health were identified to be impaired among these patients and these factors should be assessed during long-term follow-up.

The tangible consequences and intangible implications of laparoscopic cholecystectomy-associated bile duct injuries

When laparoscopic cholecystectomy (LC) was introduced more than two decades ago, alarming rates of bile duct injuries (BDIs) occurred in up to 0.4% of operations, twice as often as with open cholecystectomy, with only a recent decrease in incidence.1 Three contemporary studies from the National Health Service database in the UK and two statewide databases in the USA (New York and California), report laparoscopic cholecystectomy bile duct injury (LC-BDI) rates between 0.08–0.22%, which are comparable to open cholecystectomy, but these estimations may not accurately represent the true incidence of BDIs elsewhere.2-4

SELSI Consensus Statement for Safe Cholecystectomy — Prevention and Management of Bile Duct Injury — Part A

Cholecystectomy is one of the commonest general surgical procedures performed all over India. The risk of bile duct injury (BDI) during laparoscopic cholecystectomy is two to three times higher than during open cholecystectomy. The worldwide incidence of bile duct injury is 0.5% or 1 in 200 cases. BDI and its consequences result in significant morbidity and may even cause mortality. BDI increases the cost of treatment and is a common reason for a medicolegal suit against the surgeons. To minimize the incidence of BDI and to manage it timely and appropriately, a set of guidelines was deemed necessary by a group of senior surgeons during a Society of Endoscopic and Laparoscopic Surgeons of India (SELSI) meeting in 2016. Guidelines for “Safe Laparoscopic Cholecystectomy” and bile duct injury management formulated by other international societies are already available. The applicability of these guidelines to Indian subjects especially in small peripheral centers was limited. Hence, a decision was taken to form a set of guidelines for general surgeons with basic laparoscopic skills with little or no advanced laparoscopic skills. Those working in a solo practice, nursing homes, and small private hospitals at talukas or districts should have “Safe Cholecystectomy” guidelines and management of BDI suitable to their situation. These guidelines were formed after three consensus meetings and have been approved by a SELSI Expert Group.

Bile duct injuries: a contemporary survey of surgeon attitudes and experiences.

The incidence of bile duct injury (BDI) during laparoscopic cholecystectomy has not changed significantly in the past 2 decades despite increased operative experience and technical refinement. We sought to evaluate surgeon-specific factors associated with BDI and to assess how surgeons manage injuries. An online survey was sent to surgeons belonging to the Society of American Gastrointestinal and Endoscopic Surgeons via e-mail. Survey items included personal experience with BDI and how injuries were addressed. Statistical analysis was performed to identify factors associated with BDI. The survey was sent to 3411 surgeons with 559 complete responses (16.5%). The mean age of respondents was 48.7years with an average time in practice of 16.1years. Most respondents (61.2%) had fellowship training. Forty-seven percent of surgeons surveyed experienced a BDI in their career with 17.1% of surgeons experiencing multiple BDIs. The majority of BDIs were identified in the operating room (64.5%); most injuries (66.9%) were repaired immediately. When repair was undertaken immediately, 77.4% of these repairs were performed in an open technique. A majority of surgeons (57.7%) felt that BDIs could theoretically be repaired laparoscopically and 25% of those surgeons had done so in practice. In multivariate logistic regression, any type of fellowship training was associated with a decreased risk of BDI (OR 0.51, 95% CI 0.34-0.76). Compared with those in non-academic practice, surgeons in academic practice were at a significantly decreased risk of having experienced a BDI (OR 0.62, 95% CI 0.42-0.92). Nearly half of those surveyed, experienced a BDI during a laparoscopic cholecystectomy. Community and private practice setting were associated with an increased risk of BDI, while fellowship training and academic practice setting conferred a protective effect. A majority of surgeons felt that BDI could be repaired laparoscopically and 25% had done so in practice.

Incisionless fluorescent cholangiography (IFC): a pilot survey of surgeons on procedural familiarity, practices, and perceptions.

Incisionless fluorescent cholangiography (IFC) has recently been proven feasible, safe, and efficacious as an intraoperative procedure to help identify extrahepatic bile ducts during laparoscopic cholecystectomies (LC). We conducted a pilot survey of 51 surgeons attending an international conference who perform endoscopic cholecystectomies to identify their typical LC practices, and perceptions of IFC. An international panel of ten IFC experts, all with > 500 prior IFC procedures and related research publications, convened during the 4th InternationalCongressof Fluorescence-Guided Surgery in Boca Raton, Florida in February 2017. The panel was charged with developing questions about LC practices and experience with IFC, and perceptions regarding its advantages, barriers to use, and indications. These questions then were asked to other congress attendees during one of the didactic sessions using an online polling application. Attendees, who ranged from zero to considerable experience performing IFC, accessed the survey via their portable devices. Of the 51 survey participants, 51% were from North America; 77% identified themselves as general/minimally invasive surgeons, and roughly 60% performed under 50 cholecystectomies/year. Only 12% performed routine intraoperative cholangiography (IOC), while 72.3% routinely performed critical safety reviews. Thirty-five percent estimated that their institution's laparoscopic-to-open surgery conversion rate was > 1% during LC. Roughly 95% of respondents felt that surgeons should have access to a noninvasive method for evaluating extrahepatic biliary structures; 84% felt that the most advantageous characteristic of IFC is the lack of any biliary-tree incision; and 93.3% felt that IFC would have considerable educational value in surgical training programs; and 78% felt that any surgeon who performs LC could benefit. Surgeons who participated in our survey overwhelmingly recommended the routine use of IFC during laparoscopic cholecystectomy as a complimentary imaging technique. Prospective randomized clinical trials remain necessary to determine whether IFC reduces the incidence of bile duct injuries and other LC complications.

Laparoscopic subtotal cholecystectomy: a safe approach in difficult cholecystectomy

Background: Laparoscopic cholecystectomy (LC) has been recognized as the new "gold standard" for the treatment of symptomatic gallstone disease. In order to prevent serious bile duct and vascular injuries, conversion is advocated for unclear anatomy at the Calot’s. Our aim was to assess the safety and effectiveness of laparoscopic subtotal cholecystectomy (LSC) in difficult cholecystectomy in order to reduce the incidence of bile duct injury and conversion rates.Methods: An analysis of retrospectively collected data of 452 patients who underwent LC was done at our Hospital during the period of January 2010 to December 2013. In few cases of difficult GB when Calot’s could not be dissected, laparoscopic retrograde cholecystectomy (LRC) was attempted and if that failed we adopted the technique of LSC.Results: A total of 452 patients were included. The median age was 48 years. All the 452 patients were posted for LC. Of the 452 patients, 404 patients underwent LC and the remaining 48 patients had difficult GB. Among the 48 patients having a difficult GB, 44 cases underwent LSC (3 cases underwent LSC Type-1 and 41 cases underwent LSC Type-2) and the remaining 4 cases underwent conversion to open cholecystectomy. The mean operative time was 130mins and median post op stay was 2 days.Conclusions: In our technique of LSC the conversion rates were &lt;1% with no bile duct injury and believe that it is feasible and safe for operating on difficult GB’s.