Robotic surgery may mitigate technical challenges associated with patient obesity. However, prevalence of robotic cholecystectomy and impact on outcomes in patients with obesity are unclear. We evaluated trends in robotic cholecystectomy, factors contributing to robot use, and outcomes based on BMI. We analyzed data from a statewide, 69-hospital member clinical registry and identified patients who underwent elective robotic or laparoscopic cholecystectomy from 2020 to 2024. Patients were stratified by BMI (lower than 35 kg/m2, 35 to 49.9 kg/m2, greater than or equal to 50 kg/m2) and outcomes were compared. Multivariable logistic regression was used to evaluate the association between patient characteristics, surgical approach, and outcomes. An interaction term was used to evaluate the impact of BMI category on the risk associated with the surgical approach. A total of 27,006 patients underwent laparoscopic (18,610; 68.9%) or robotic (8,396; 31.1%) cholecystectomy. Robotic approach increased over time, with the greatest increase in patients with BMI greater than or equal to 50 kg/m2 (23.1% in 2020 vs 55.8% in 2024, p < 0.001). Compared with patients who underwent laparoscopic surgery, those who underwent robotic surgery were more likely to have a higher BMI (BMI 35 to 49.9 kg/m2: odds ratio [OR] 1.15, 95% CI 1.08 to 1.23, p < 0.001; BMI greater than equal to 50 kg/m2: OR 1.34, 95% CI 1.14 to 1.57, p < 0.001). BMI did not modify the effect of surgical approach on postoperative complication risk (BMI 35 to 49.9 kg/m2 with robotic approach: OR 0.97, 95% CI 0.60 to 1.56, p = 0.887; BMI greater than or equal to 50 kg/m2 with robotic approach OR 1.55, 95% CI 0.50 to 4.86, p = 0.451). Robotic approach is increasingly used in elective minimally invasive cholecystectomy, especially for patients with the highest BMI. Postoperative outcomes did not differ across BMI groups between robotic and laparoscopic cholecystectomy, indicating that BMI did not alter the relationship between surgical approach and outcomes.

Metabolic dysfunction-Associated fatty liver disease impairs intraoperative indocyanine green fluorescence cholangiography quality: Development and validation of a predictive model.

Perioperative ketamine or esketamine for acute postoperative pain after laparoscopic cholecystectomy: A systematic review and meta-analysis with meta-regression.

Introduction: Laparoscopic cholecystectomy is commonly performed procedure in daily surgical practice worldwide in symptomatic gallbladder stone patients. During laparoscopic cholecystectomy, operating surgeons may encounter great difficulty during Calot’s triangle dissection and not able to achieved critical view of safety to proceed safe dissection with preventing common bile duct injury. In that case, we need to identified preoperative risk factors in the form of patient’s factor including comorbidity, no. of pain episode experience before current hospital admission, total number of hospital admission required for same complaints and radiological investigation including ultrasound abdomen-pelvis, CECT-A-P-T, MRCP which collectively indicate difficult cholecystectomy in preoperative periods. Intraoperative surgical findings may necessitate conversion into retrograde gallbladder dissection before doing unsafe calot’s triangle dissection to avoid major catastrophe and performing subtotal cholecystectomy in the form of either fenestrating or reconstituting subtotal cholecystectomy depending upon the condition of cystic duct opening and observing postoperative short term and long-term morbidity.[1] Methods: We retrospectively reviewed 25 patients who underwent subtotal cholecystectomy in a single unit at our institute during specific time period. Gathered all relevant preoperative, intra operative and post-operative information that predict difficult cholecystectomy during Preoperative as well as intra operative time and observed post operative short term and long term sequences(morbidity and mortality) in patients who underwent subtotal cholecystectomy Results: We analysed 25 patients who underwent subtotal cholecystectomy using either fenestrating (n-9) or reconstituting (n-16) approaches with regards to post operative bile leak. Patient who underwent Fenestrating subtotal cholecystectomy was associated with higher rate of post operative bile leak as compared to reconstituting subtotal cholecystectomy.Post operative bile leak effectively managed either by conservative management with delayed drain removal or need of postoperative ERCP, USG guided pigtail insertion as well as re-laparoscopic peritoneal lavage with drain placement in a patient who developed signs of bile peritonitis. Conclusions: Fenestrating subtotal cholecystectomy is associated with higher rate of postoperative bile leak as compared to reconstituting subtotal cholecystectomy but bile leak effectively managed non-operative or operative method. So, both approaches are safe in view of difficult cholecystectomy. We encourage the subtotal cholecystectomy approach in difficult cholecystectomy considering trends in improved short- and long-term outcomes.

BACKGROUND Situs inversus totalis (SIT) is a rare congenital anomaly characterized by complete mirror-image transposition of thoracic and abdominal organs. The presence of gallstone disease in these patients represents a diagnostic and technical challenge, particularly when laparoscopic cholecystectomy is indicated. CASE SUMMARY We report two cases of symptomatic gallstone disease in patients with SIT. The first case involved a 27-year-old female diagnosed with cholelithiasis following radiological evaluation, while the second case involved a 45-year-old male presenting with cholelithiasis and choledocholithiasis requiring preoperative endoscopic retrograde cholangiopancreatography. Cases were identified retrospectively from institutional surgical records. Data were collected from clinical charts, imaging studies, operative reports, and follow-up visits. In both patients, laparoscopic cholecystectomy was successfully performed using a mirror-image port placement strategy. No intraoperative or postoperative complications occurred, and both patients were discharged on the first postoperative day. CONCLUSION Laparoscopic cholecystectomy in patients with SIT is safe and feasible when meticulous preoperative imaging and careful adaptation of surgical technique are employed. Awareness of mirror-image anatomy and strict adherence to the critical view of safety are essential to minimize the risk of iatrogenic injury.

Background. Cholelithiasis is one of the most prevalent gastrointestinal disorders worldwide, affecting approximately 10–20% of the adult population in developed countries. Although laparoscopic cholecystectomy remains the gold standard treatment for symptomatic gallstones, a significant subset of patients is either unsuitable for surgery due to comorbidities, advanced age, anesthesia-related risks, or declines operative management. In such cases, ursodeoxycholic acid (UDCA) has been proposed as a non-invasive therapeutic alternative. Aim. This narrative review aims to critically evaluate the current evidence regarding the mechanisms, indications, efficacy, and limitations of UDCA therapy in symptomatic patients with uncomplicated gallstone disease who are not undergoing surgical intervention. Material and Methods. A narrative review was conducted by integrating data from clinical guidelines, randomized controlled trials, cohort studies, and systematic reviews. Particular emphasis was placed on outcomes such as symptom control, gallstone dissolution, recurrence rates, and patient selection criteria. Results. UDCA demonstrate beneficial effects in carefully selected patient populations, particularly in terms of gallstone dissolution and symptom relief. However, its clinical utility is limited by strict eligibility criteria, a slow therapeutic response, and high recurrence rates following treatment discontinuation. Conclusion. UDCA may represent a valuable non-surgical treatment option in selected high-risk patients when individualized appropriately. Nevertheless, its overall effectiveness remains limited, and careful patient selection is essential to optimize therapeutic outcomes.

Background: Laparoscopic cholecystectomy is the standard treatment for symptomatic gallstone disease. The routine use of drains after surgery remains controversial, with conflicting evidence regarding their role in preventing postoperative complications. Aim: To compare postoperative outcomes in patients undergoing elective laparoscopic cholecystectomy with and without drain placement. Materials and Methods: This hospital-based observational study was conducted at Meenakshi Medical College Hospital, Kanchipuram, over one year. A total of 60 patients undergoing elective laparoscopic cholecystectomy were included and divided into two groups: drain group (n = 30) and no-drain group (n = 30). Outcomes assessed included postoperative pain using Visual Analogue Scale, postoperative complications, duration of hospital stay, and recovery. Statistical analysis was performed using SPSS, and a p value &lt; 0.05 was considered statistically significant. Results: Postoperative pain was significantly higher in the drain group at 6 and 24 hours (p = 0.001). The duration of hospital stay was also significantly longer in the drain group (3.8 ± 1.2 vs 2.4 ± 0.9 days; p = 0.001). There was no significant difference in postoperative complications between the two groups (p &gt; 0.05). Conclusion: Routine drain placement after elective laparoscopic cholecystectomy does not reduce postoperative complications and is associated with increased pain and longer hospital stay. Selective use of drains may be considered based on intraoperative findings.

We aimed to investigate the impact of rationalizing general surgery surgical tray sets at an elective surgical hub in England. This was an analysis of data collected prospectively for a clinical quality improvement project between 25th March and 20th June 2024. Baseline data on use of surgical instruments for four general surgery procedures were collected, and the items categorized as high, medium and low use. Meetings were then held with surgical and operational teams involved in delivering each procedure and a set of surgical instruments for each procedure agreed upon and a rationalized tray was formed. Data were collected for 39 rectal procedures, 42 open hernia repairs, 15 laparoscopic hernia repairs and 14 laparoscopic cholecystectomies. A tailored rectal procedure tray was formed with 16 items from the original53 items small basic tray; the two trays used for open hernia repair were rationalized from 53 to 43 items (small basic tray) and 75 to 60 items (large basic tray). The same laparoscopic tray was used for hernia repairs and cholecystectomies and was rationalized from 55 to 45 items. Estimated base-case annual financial savings were £16,863 and carbon savings 42.6 kgCO2e for these four procedures. Saving of up to £62,648 and 3612.9 kgCO2e annually may be realized if rationalization avoids opening a second tray to obtain items not present for use on a single tray. Rationalization of surgical trays can reduce financial costs and carbon emissions. It may also yield co-benefits in terms of enhancing theater efficiency.

Background: Although Enhanced Recovery After Surgery (ERAS) pathways improve postoperative outcomes, a uniform approach may not adequately reflect the heterogeneity of patients undergoing laparoscopic cholecystectomy (LC). Preoperative risk factors substantially influence recovery trajectories, length of hospital stay (LOS), and discharge readiness, highlighting the need for risk-stratified ERAS implementation. Methods: We conducted a focused, implementation-oriented review of studies published between January 2015 and June 2025, using a structured PubMed search, staged screening, and qualitative synthesis to identify preoperative predictors of prolonged LOS or delayed discharge after LC. Results: Across representative studies, consistently reported preoperative predictors included advanced age, higher American Society of Anesthesiologists physical status, acute cholecystitis, emergency surgery, diabetes mellitus, active smoking, and obesity. These variables were integrated into a pragmatic risk-stratification framework, categorizing patients into standard-, intermediate-, and high-risk groups. ERAS benefits varied across risk strata, with greater reductions in LOS observed in standard-risk patients, whereas safety, monitoring, and complication prevention predominated in high-risk patients. Surgical urgency (elective vs emergency LC) functioned as a contextual modifier within the risk-stratified framework rather than an isolated determinant of outcome. Conclusions: Risk-stratified ERAS implementation for LC enables individualized perioperative care by aligning recovery goals with patient vulnerability, procedural context, and institutional practice. This implementation-focused framework supports safer and more adaptable ERAS application across heterogeneous patient populations and provides a foundation for future prospective validation.

A few studies investigating the perioperative use of lung ultrasound (LUS) have shown loss of lung aeration with decline in diaphragmatic function after general anesthesia. We aimed to measure changes in lung aeration and diaphragmatic functions using LUS in patients undergoing elective laparoscopic cholecystectomy. Forty patients of American Society of Anesthesiologists I/II undergoing elective laparoscopic cholecystectomy under general anesthesia were enrolled. For all patients, LUS examination was performed at 5 time points: preoperative room, after intubation, after deflation of pneumoperitoneum, 30 min after extubation, and 24 h post-extubation. The aeration loss was assessed using the modified LUS score. The diaphragmatic excursion was also evaluated preoperatively, and at 30 min and 24 h post-extubation. A progressive increase in modified LUS score was seen after intubation, after deflation of pneumoperitoneum, 30 min postoperative, after extubation and 24 h post-extubation at postoperative anesthesia care unit (PACU) as compared to preoperative room (P < 0.0001). The maximum modified LUS score was observed postoperatively after 30 min: 8 (5, 10) and 24 h post-extubation in PACU: 8 (4.25, 11.0). No significant change in the diaphragmatic excursion or respiratory complications was observed. Our study found a progressive loss of lung aeration after the induction of general anesthesia in laparoscopic cholecystectomy, extending up to the 24-h perioperative period. However, diaphragmatic excursion remained unchanged. The study also suggests that LUS is a valuable tool for detecting perioperative atelectasis and quantifying the aeration loss.

Timing of laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage and the risk of bailout surgery: a restricted cubic spline analysis.

Abstract Background Operating rooms are responsible for a substantial share of hospital waste, with laparoscopic procedures being particularly resource-intensive due to their reliance on disposable instruments. In a laparoscopic cholecystectomy (LC), disposable products account for approximately 40% of emissions, with trocars being key contributors. Reusable trocars lower environmental impact and evidence suggests that costs can be reduced. Accordingly, this study compares the costs of reusable versus disposable trocars during LC in a Dutch academic hospital and develops an adaptable framework for cost evaluation in other healthcare settings. Methods An activity-based costing analysis was conducted to estimate the per-procedure costs (i.e. per LC), including the costs for acquisition, sterilisation, storage, and waste disposal. This was based on an LC using four trocars: two 5 mm and two 12 mm trocars. Resource use was based on expert input, and unit costs were obtained from hospital procurement data. The costing framework was designed to be adaptable to different institutional contexts. Uncertainty in the cost difference was assessed using probabilistic sensitivity analysis with 1000 Monte Carlo simulations, alongside one-way, two-way, and scenario analyses. Results Acquisition costs per LC were substantially lower for reusable trocars (€8.15) than for disposable trocars (€89.55). Although reusable trocars incurred sterilisation costs (€13.31 per procedure), total costs, including all activities involved in LC, remained lower (€683.00 vs €751.43), resulting in savings of €68.80 per procedure. Reusable trocars were cost-saving in all sensitivity analyses. Estimated annual savings were €10,264 at institutional level (based on 150 procedures) and €1.54 million nationally (based on 22,500 procedures). Conclusion Reusable trocars are cost-saving compared to disposable trocars in LC. The adaptable activity-based costing framework developed in this study enables healthcare institutions to evaluate the economic impact of reusable versus disposable surgical instruments within their own settings, supporting both cost reduction and environmental sustainability.

Individualized Enhanced Recovery After Surgery (ERAS) and physiological resilience in a 101-year-old patient undergoing laparoscopic cholecystectomy: a case report.

Laparoscopic cholecystectomy necessitates focused analgesia on the right abdominal wall region to address the somatic component of postoperative pain. Ultrasound-guided preemptive subcostal transversus abdominis plane (TAP) block blocks the anterior branches of thoracic spinal nerves (T6-T9). This study aimed to assess whether a right unilateral subcostal TAP block provides a similar duration of operative site analgesia compared to a bilateral subcostal TAP block during laparoscopic cholecystectomy. A prospective randomized controlled trial was conducted on 50 patients (25 in each group) aged 18-60 years undergoing elective laparoscopic cholecystectomy under general anesthesia. Group A received an ultrasound-guided right unilateral subcostal TAP block with 20 mL of 0.25% bupivacaine, whereas Group B received bilateral subcostal TAP blocks using the same local anesthetic dose on each side. Duration of analgesia, analgesic consumption, and block administration time were assessed over 24 h postoperatively using the Visual Analog Scale. No significant difference was observed in the duration of analgesia between Group A (411.4 ± 24.0 min) and Group B (410.8 ± 24.3 min), with P = 0.93. The time required to administer the block was significantly shorter in the unilateral group (5.68 ± 0.57 min) compared to the bilateral group (11.70 ± 1.24 min), P < 0.001. Total 24-h analgesic consumption was comparable between the groups (Group A: 1.42 ± 0.48 doses vs. Group B: 1.64 ± 0.49 doses, P = 0.063). Right unilateral subcostal TAP block provides similar duration of postoperative analgesia when compared with bilateral subcostal TAP block, with the additional benefits of lower local anesthetic dosage and shorter block procedure time.

Ketorolac tromethamine injection-induced peptic ulcer with bleeding remains rarely reported in clinical case studies. Controversy persists, particularly regarding its analgesic use in patients with a history of gastric ulcer, even after clinical cure. Herein, this article presents a case of peptic ulcer with bleeding after supra-therapeutic dosage of ketorolac tromethamine injection for post‑cholecystectomy analgesia in a patient with a clinically "healed" gastric ulcer, emphasizing the need for cautious and rational prescribing. A 70-year-old male patient with a history of peptic ulcer and gallstones presented with recurrent right upper quadrant pain for over 2 years. Previous treatment with oral Xiaoyan Lidan Tablets (an anti-inflammatory and choleretic agent) did not prevent symptom recurrence. Peptic ulcer with bleeding, Gallstones with chronic cholecystitis, Hypertension (Grade 2). The patient underwent a laparoscopic cholecystectomy under general anesthesia. For postoperative analgesia, intramuscular ketorolac tromethamine injection was administered at 30 mg twice daily, which exceeded the recommended dosage range. Appropriate symptomatic therapies, including anti‑infection, hepatoprotection, hemostasis, and fluid replacement therapy, were administered as clinically indicated. On the fourth postoperative day, the patient developed gastrointestinal bleeding with a hemoglobin level of 62 g/L. Based on the medication history, the gastrointestinal bleeding was considered associated with the application of ketorolac tromethamine injection. The drug was discontinued for observation, and the patient was started on pantoprazole for acid suppression and gastric protection, along with carbazochrome sodium sulfonate for hemostasis. As the gastrointestinal bleeding symptoms did not improve, the regimen was adjusted to esomeprazole for acid suppression and gastric protection, supplemented with hemostatic therapy using somatostatin and hemocoagulase. Following this adjustment, the patient gastrointestinal bleeding symptoms gradually improved. Gastrointestinal bleeding was controlled, and the patient was discharged following clinical improvement. This case supports a potential causal relationship between the use of ketorolac tromethamine injection and the occurrence of peptic ulcer with bleeding, especially in patients with clinically cured gastric ulcer: a risk often overlooked in drug selection. Particular emphasis should be placed on individualized medication, risk assessment, and multidisciplinary collaboration to enhance patient safety and treatment efficacy.

BACKGROUND While laparoscopic cholecystectomy (LC) is the gold standard procedure for symptomatic gallbladder pathologies, the pursuit of minimizing invasiveness and improving cosmetic outcomes has led to techniques like single-port (SP) and modified two-port (MTP) LC. However, their comparative efficacy against the conventional three-port (TP) approach, particularly the novel MTP technique, requires further validation. AIM To compare the cosmetic, operative, and clinical outcomes of MTP, SP, and TP LC. METHODS This retrospective cohort study included 142 patients with symptomatic gallbladder disease who underwent MTP, SP, or TP LC from January 2024 to January 2025. All procedures were performed by a single experienced surgeon. The primary outcome was cosmetic satisfaction at one month. Secondary outcomes included operative time, intraoperative blood loss, hospital stay, and postoperative complications. Multivariable analyses were performed following adjustment for age, sex, and body mass index, with a Bonferroni correction applied. RESULTS All procedures were completed laparoscopically. MTP LC demonstrated the shortest operative time (52.5 ± 19.5 minutes), which was significantly shorter than that of SP LC (103.1 ± 34.9 minutes, P = 0.009) and comparable to that of TP LC (55.2 ± 23.0 minutes, P = 0.566). MTP LC also yielded the shortest hospital stay (1.2 ± 0.5 days). Cosmetic outcomes were superior for MTP and SP LC vs TP LC(P &lt; 0.05). Blood loss was minimal (&lt; 10 mL) in all groups. One case of postoperative infection occurred in the SP LC group. After adjustment for confounding factors, MTP LC maintained a shorter operative time vs SP LC (β = -48.2, P &lt; 0.001) and exhibited comparable safety to TP LC (odds ratio: 1.02, P = 0.31). CONCLUSION MTP LC balances the cosmetic benefit of SP LC with the efficiency and safety of TP technique, though its generalizability requires prospective validation.

BACKGROUND Sinistroposition of the gallbladder (SPGB), defined as localization of the gallbladder to the left of the falciform ligament in the absence of situs inversus, is an uncommon congenital anomaly that may complicate laparoscopic cholecystectomy due to altered biliary anatomy and an increased risk of bile duct injury. Routine preoperative imaging frequently fails to identify this variant. CASE REPORT A 53-year-old woman with a long history of symptomatic cholelithiasis underwent elective laparoscopic cholecystectomy. Preoperative ultrasonography demonstrated cholelithiasis without evidence of anatomic variation or biliary obstruction. Intraoperatively, the gallbladder was observed entirely to the left of the round ligament, beneath hepatic segment III, consistent with true SPGB. Careful dissection of Calot's triangle was performed, and the Critical View of Safety was achieved with clear identification of the cystic duct and artery. No biliary anatomic anomalies or intraoperative complications were encountered. The procedure proceeded uneventfully without requiring intraoperative cholangiography. The patient was discharged on postoperative day 1 and remained asymptomatic, with normal laboratory parameters at follow-up. CONCLUSIONS SPGB is a rare anatomic variant that is often diagnosed intraoperatively. Recognition of this condition and strict adherence to safe cholecystectomy principles, particularly achievement of the Critical View of Safety, are essential to prevent bile duct injury and ensure favorable surgical outcomes. Advanced imaging modalities may facilitate preoperative diagnosis and surgical planning.

Laparoscopic cholecystectomy (LC) is the standard treatment for symptomatic gallstone disease. Achieving the critical view of safety (CVS) - clearing the hepatocystic triangle, freeing the gall bladder's lower third and identifying only the cystic duct and artery - is essential to prevent vasculobiliary injury. The guidelines advocate CVS but do not specify where to initiate dissection. We compared two dissection strategies. We retrospectively analysed 350 consecutive laparoscopic cholecystectomies for acute cholecystitis (2020-2021 and 2024-2025) performed by two surgeons at community hospitals. In Method 1, n = 100, the lower third of the gall bladder was mobilised before dissecting Calot's triangle; in Method 2, n = 150, the triangle was dissected first and the lower gall bladder was then mobilised. Cases with severely inflamed or 'frozen' anatomy were treated with domedown or subtotal cholecystectomy (Method 3 salvage/bailout, n = 100). The outcomes included attainment of CVS, bile duct injury (BDI) and post-operative bile leak. CVS was documented in all Method 1 and Method 2 procedures, but not in the salvage group. No BDIs occurred. Post-operative bile leak rates were 2% for Methods 1 and 2 and 9% for Method 3; all salvage cases had intraoperative spillage and 3% required conversion to open surgery. Differences in leakage between the two planned techniques were not statistically significant. Both lower-end-first and Calot's triangle-first dissection strategies reliably achieve the critical view and allow the safe completion of LC. When inflammation prevents these approaches, domedown or subtotal cholecystectomy provides a safe bailout, with no BDI risk.

Background: Failure to incise ventral to the Rouvière’s sulcus and maintain the dissection plane on the gallbladder (GB) surface predisposes patients to bile duct injuries (BDIs), particularly during trainee-performed laparoscopic cholecystectomy (LC). No existing artificial intelligence (AI) tools offer Tokyo Guidelines 2018 (TG 2018)-anchored real-time guidance. We developed and externally validated an AI navigation system that highlights the alert zone (AZ) – the hepatoduodenal-ligament tissues lying below an imaginary line from the roof of the Rouvière’s sulcus to the base of segment 4 and the infundibulum–cystic duct junction – and GB surface specified in the TG 2018. Materials and Methods: Seventy-three LC videos (January 2022–March 2024) were used to train the DeepLab v3 + segmentation model. The AZ and GB surface were manually annotated. The performance was tested on 10 independent videos (100 frames) with an intersection-over-union (IoU) metric. A two-arm pilot usability study randomized 10 fifth- or sixth-year postgraduate surgeons to answer video-based safety questions with or without AI assistance (20 tasks each). Results: The AI achieved a mean IoU of 0.703 (AZ) and 0.735 (GB) compared to the developer ground truth and 0.706 (AZ) and 0.730 (GB) compared to the external ground truth. With AI navigation, the correct selection of a safe incision point increased from 58% to 90%, and contour recognition of the GB surface increased from 70% to 92% (both P &lt; 0.05). Conclusion: The AI navigation system based on the TG 2018 reliably delineated critical landmarks and markedly improved intraoperative trainee decision-making. Prospective real-time trials should determine whether this technology reduces BDIs.

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