Laparoscopic Ultrasonography Research Articles

Laparoscopic ultrasonography-guided myomectomy of submucosal myoma for preserving endometrial integrity

Background: Submucosal myoma is a common gynecological disease that causes menorrhagia and infertility. While hysteroscopic surgery is a minimally invasive and effective method for treating submucosal myomas, its feasibility depends on the size and location of the myomas. Conversely, abdominal procedures enable enucleation of submucosal myomas and preservation of endometrial integrity, but are accompanied by technical difficulties. Herein we report the case of an infertile woman with a submucosal and an intramural myoma who underwent laparoscopic myomectomy using laparoscopic ultrasonography. Case: The patient was a 36-year-old infertile woman. Transvaginal ultrasonography revealed a 15 mm submucosal myoma with a 60% myometrial extension in the anterior uterine wall and a 49 mm intramural myoma in the posterior wall. During myomectomy, the submucosal myoma was not apparent from the external side of the uterus; therefore, laparoscopic ultrasonography was used to detect it. Under ultrasonography, vasopressin was injected between the myoma and the myometrium, thereby separating the layers. Consequently, we were able to resect both myomas without breaching the endometrium. Conclusions: The present case demonstrates the effectiveness of laparoscopic ultrasonography for detecting submucosal myomas and ensuring injection of vasopressin into the proper layer. These advantages allow surgeons to preserve endometrial integrity during laparoscopic myomectomy.

Single-incision laparoscopic enucleation for pancreatic insulinoma with preoperative nasopancreatic stent placement: A case report.

Introduction and importanceMost insulinomas are benign and solitary, with a tumor diameter less than 2 cm; therefore, laparoscopic enucleation, which is a minimally invasive procedure that can preserve the pancreatic parenchyma, is considered an optimal procedure. The key to enucleation is to avoid injury to the main pancreatic duct (MPD). Herein, we present a case in which single-incision laparoscopic enucleation (SILE) was performed for insulinomas, with preoperative nasopancreatic stent (NPS) placement.Case presentationA male patient in his fifties underwent SILE for insulinomas. To prevent injury to the MPD, an NPS was preoperatively placed. All surgical procedures were performed through a single mini-laparotomy site in the umbilicus. NPS placement facilitated identification of the MPD under laparoscopic ultrasonography. Enucleation was successfully completed without any injury to the MPD, and the NPS was removed immediately after confirming that there was no injury to the MPD by the NPS via pancreatography. The postoperative course was uneventful.Clinical discussionThis report serves to highlight the maximum safety and minimal invasiveness of SILE with the preoperative NPS placement. Preoperative NPS placement is useful for avoiding injury to the MPD during enucleation and has the merit of helping to recognize whether leakage occurs by intraoperative pancreatography via the NPS.ConclusionPreoperative NPS placement helps to ensure the safe enucleation of pancreatic insulinomas even in single-incision laparoscopic surgery, with minimal invasiveness and better cosmetic outcomes.

The Role of Intraoperative Ultrasonography Associated with Clampless Technique in Three-Dimensional Retroperitoneoscopic Laparoscopic Enucleation of Completely Endophytic Renal Tumors.

Objectives: To evaluate perioperative and functional outcomes of clampless laparoscopic tumor enucleation for completely endophytic renal tumors with the guide of intraoperative ultrasonography. Methods: We analyzed patients with clinically completely endophytic tumors, renal tumors, who underwent clampless three-dimensional (3D) retroperitoneoscopic laparoscopic tumor enucleation between January 2012 and January 2021. Patients with exophytic tumors were excluded. Intraoperative ultrasonography was used to map out the mass in all surgeries. Results: Overall, 57 patients underwent clampless 3D retroperitoneoscopic laparoscopic tumor enucleation. Mean surgical time was 131 minutes, and mean estimated blood loss was 202 mL. Mean hospital stay was 4.7 days. Major and minor postoperative complications occurred, respectively, in 3 and 10 cases. Only a patient had a positive surgical margin. One-year renal function did not differ from baseline. Conclusion: Our study showed that clampless laparoscopic enucleation guided by laparoscopic ultrasonography ensured satisfactory outcomes for completely intrarenal tumors, with excellent renal function preservation 1 year after surgery.

Deep hashing for global registration of untracked 2D laparoscopic ultrasound to CT

PurposeThe registration of Laparoscopic Ultrasound (LUS) to CT can enhance the safety of laparoscopic liver surgery by providing the surgeon with awareness on the relative positioning between critical vessels and a tumour. In an effort to provide a translatable solution for this poorly constrained problem, Content-based Image Retrieval (CBIR) based on vessel information has been suggested as a method for obtaining a global coarse registration without using tracking information. However, the performance of these frameworks is limited by the use of non-generalisable handcrafted vessel features.MethodsWe propose the use of a Deep Hashing (DH) network to directly convert vessel images from both LUS and CT into fixed size hash codes. During training, these codes are learnt from a patient-specific CT scan by supplying the network with triplets of vessel images which include both a registered and a mis-registered pair. Once hash codes have been learnt, they can be used to perform registration with CBIR methods.ResultsWe test a CBIR pipeline on 11 sequences of untracked LUS distributed across 5 clinical cases. Compared to a handcrafted feature approach, our model improves the registration success rate significantly from 48% to 61%, considering a 20 mm error as the threshold for a successful coarse registration.ConclusionsWe present the first DH framework for interventional multi-modal registration tasks. The presented approach is easily generalisable to other registration problems, does not require annotated data for training, and may promote the translation of these techniques.

Robust and fast laparoscopic vision-based ultrasound probe tracking using a binary dot array marker

Laparoscopic vision-based ultrasound probe tracking systems have gained considerable attention in ultrasound-guided laparoscopic surgeries as replacements for external tracking systems (e.g. optical tracking and electromagnetic tracking systems), which increase cost and setting time, require additional operation space, and introduce new limitations. Most existing laparoscopic ultrasound (LUS) probe tracking systems rely on fiducial markers, which cannot easily realise fast and robust vision-based tracking in laparoscopic surgery owing to their design limitations. Therefore, we propose a novel binary dot array marker to realise a robust and fast LUS probe tracking system. The binary dot array marker comprises two dots (green and blue), which form multiple unique identification dot subarrays in the binary dot array. The binary dot array marker can be tracked when one of the identification dot subarrays is detected and identified; this novel design makes the binary dot array marker-based probe tracking system robust against occlusions during surgery. The evaluation results indicate that the proposed binary dot marker performs better in terms of robustness, computational efficiency, and tracking accuracy compared to the state-of-the-art fiducial markers used for vision-based probe tracking.

Laparoscopic Ultrasound for Bile Duct Imaging during Cholecystectomy: Clinical Impact in 785 Consecutive Cases.

The influence of laparoscopic ultrasonography (LUS) on the operative management of patients during laparoscopic cholecystectomy (LC) has not been examined in a large unselected series. Seven hundred eight-five consecutive LC operations were reviewed to determine whether the findings of LUS for bile duct imaging altered operative management. Patients were analyzed according to the primary indication for imaging: anatomic identification (group I), possible common bile duct stones (group II), and routine use absent other indications (group III). LUS demonstrated the cystic duct-common bile duct junction, the common hepatic duct, the common bile duct to the ampulla, and the right hepatic artery in 95.8% of cases. Among 56 of 111 (50%) patients in group I for whom initial dissection failed to result in adequate anatomic identification, subsequent LUS provided sufficient anatomic identification to allow completion of a laparoscopic operation in 87.5%. Group I patients were more likely to have acute cholecystitis (p < 0.0001) and Tokyo Guidelines 2018 grade II or III acute cholecystitis (p < 0.001). LUS changed operative management for 19 of 256 (7.5%) group II patients and 10 of 361 (2.8%) group III patients by demonstrating common bile duct stones that resulted in common bile duct exploration with stone clearance. Five patients had common bile duct stones that were not detected by LUS. There were no major bile duct or vascular injuries. The primary value of LUS during LC is for anatomic identification when there are severe local inflammatory conditions. In this setting, LUS imaging can facilitate safe completion of LC or an early decision for an alternate operative strategy. When performed primarily for common bile duct stones or as routine practice, LUS results in CBDE for a limited proportion of patients.

Laparoscopic Ultrasonography as a Primary Imaging Modality in Intermediate and High Risk Patients of Choledocholithiasis

Introduction: As well known, the management of choledocholithiasis is mainly determined by the availability of equipment and the experience of staff in a particular medical facility. We are sharing our 7-year experience in using laparoscopic ultrasonography (LUS) as a primary diagnostic tool in patients with a significant risk of choledocholithiasis.

Management of Choledocholithiasis in a Single Institution: Comparison of Efficacy and Safety of ‘Endoscopy First’ and ‘One-step Laparoscopy’ Approaches

Introduction: The management of choledocholithiasis varies despite the existing guidelines. The aim of this study was to compare the ’endoscopy first’ and ’one-step laparoscopy’ approaches. Methods: Retrospective analysis was done to compare two treatment options for patients with suspected choledocholithiasis from 2012 till 2018, including a two-year follow-up. Patients were divided in two groups: Group 1 patients underwent endoscopic clearance before laparoscopic cholecystectomy; Group 2 patients underwent ‘one-step laparoscopy’ with laparoscopic ultrasonography (LUS) and optional bile duct clearance. Efficiency and safety of the methods were analysed and compared. Results: Cohort was 231 patients. Endoscopic approach was successful in 63 (88.7%) of all Group 1 (n 71) patients. No stones were found in two cases and in six patients (8.3%) endoscopic approach was unsuccessful. We found 5.6% complications rate related to papillotomy. Afterward, by LUS during surgery in Group 1 patients residual stones were found in 13 cases. In Group 2 patients (n 160), bile duct clearance was necessary in 97 (60.6%) cases. We found clearance rate of 90 (92.8%). We found no complications related to one-step approach. Postoperative endoscopic clearance was indicated for 10 (6.3%) patients. We found p < 0.05 in terms of operating time, shorter in Group 1. Also, hospitalization length we obtained was shorter in Group 2, p < 0.05. Readmission’s rate was significantly higher in Group 1 patients, p<0.05. Conclusion: Both approaches have proved to be safe and efficient, ‘one-step laparoscopy’ had less readmissions and shorter hospital stay, but longer operation time.

Intraoperative Laparoscopic Ultrasound Increases Fibroid Detection During Laparoscopic Myomectomy.

Objective:To assess the utility of intraoperative laparoscopic ultrasound in detecting additional fibroids during laparoscopic myomectomy (LM).Methods:Forty-two patients were enrolled in this prospective cohort study. All cases were performed by the same surgeon at a university affiliated hospital between April 1, 2019 and February 29, 2020. Following routine laparoscopic myomectomy, the laparoscopic ultrasound was then introduced, and ultrasonography was performed directly on the uterus. Any additional fibroids discovered were enucleated.Results:Using the laparoscopic ultrasound, an additional 54 fibroids among 27 (64%) of the 42 patients were found, with a median of 2 additional fibroids per patient (interquartile range [IQR] 1,3). Median fibroid size detected by laparoscopic ultrasound was 1.5 centimeters (IQR 1–3) and the most common types were FIGO grades 3 and 2 (43% and 33% respectively). The median surgical time was longer among patients in whom additional fibroids were found (170 minutes (IQR 137–219) vs 150 minutes (IQR 120–193), p = .044). When ≥ 2 fibroids were removed by usual methods, the laparoscopic ultrasound found additional fibroids 80% of the time, compared to 25% when < 2 fibroids were removed by usual methods (p < .001).Conclusion:Intraoperative laparoscopic ultrasonography is a useful tool in detecting additional fibroids that would have otherwise been missed. It is particularly helpful in identifying smaller intramural fibroids and in patients with multiple fibroids. By detecting additional fibroids, laparoscopic ultrasonography can help maximize the effectiveness of laparoscopic myomectomy and help decrease the rates of residual fibroids.

A methodology and clinical dataset with ground-truth to evaluate registration accuracy quantitatively in computer-assisted Laparoscopic Liver Resection

ABSTRACT Augmented Reality (AR) can assist Laparoscopic Liver Resection (LLR) by registering a preoperative 3D model with laparoscopic images. Evaluating the accuracy of the registration methods requires measuring Target Registration Error (TRE). Previous work evaluates TRE on simulated, phantom and animal data but not on clinical data. Our contribution is a methodology for groundtruth acquisition using Laparoscopic Ultrasound (LUS) in clinical LLR, two evaluation criteria, a four-patient dataset and an evaluation of two existing registration methods. The LUS is coregistered with the laparoscope and its observations are made transferable to 3D laparoscope coordinates. The average position error in our LUS registered images is estimated to be about 1 mm, which is far better than the measured errors for the state-of-the-art registration methods, making our dataset relevant for their evaluation. We ran a preliminary evaluation of two registration methods. The dataset is available publicly at http://igt.ip.uca.fr/ab/code_and_datasets/datasets/llr_reg_evaluation_by_lus.

The utility of laparoscopic ultrasound during minimally invasive liver procedures in patients with malignant liver tumors who have undergone preoperative magnetic resonance imaging.

The aim of this study was to assess the utility of laparoscopic ultrasound (LUS) during minimally invasive liver procedures in patients with malignant liver tumors who underwent preoperative magnetic resonance imaging (MRI). Medical records of patients with malignant liver lesions who underwent laparoscopic liver surgery between October 2005 and January 2018 and who underwent an MRI examination at our institution within a month before surgery were collected from a prospectively maintained database. The size and location of tumors detected on LUS, as well as whether they were seen on preoperative imaging, were recorded. Univariate and multivariate regression analyses were performed to identify factors that were associated with the detection of liver lesions on LUS that were not seen on preoperative MRI. A total of 467 lesions were identified in 147 patients. Tumor types included colorectal cancer metastasis (n = 53), hepatocellular cancer (n = 38), neuroendocrine metastasis (n = 23), and others (n = 33). Procedures included ablation (67%), resection (23%), combined resection and ablation (6%), and diagnostic laparoscopy with biopsy (4%). LUS identified 39 additional lesions (8.4%) that were not seen on preoperative MRI in 14 patients (10%). These were colorectal cancer (n = 20, 51%), neuroendocrine (n = 11, 28%) and other metastases (n = 8, 21%). These additional findings on LUS changed the treatment plan in 13 patients (8.8%). Factors predicting tumor detection on LUS but not on MRI included obesity (p = 0.02), previous exposure to chemotherapy (p < 0.001), and lesion size < 1cm (p < 0.001). This study demonstrates that, despite advances in MRI, LUS performed during minimally invasive liver procedures may detect additional tumors in 10% of patients with liver malignancies, with the highest yield seen in obese patients with previous exposure to chemotherapy. These results support the routine use of LUS by hepatic surgeons.

Excision of an Occult, Obstructed Hemivagina Under Laparoscopic Ultrasound Guidance in a Patient with Ohvira Syndrome

<h3>Study Objective</h3> To demonstrate the use of laparoscopic ultrasound guidance for identification and excision of an oblique vaginal septum in a patient with a congenital uterine anomaly. <h3>Design</h3> Case presentation. <h3>Setting</h3> Academic-affiliated tertiary care center. <h3>Patients or Participants</h3> A 27-year-old P0000 who presented to an outside facility with 7 months of abnormal uterine bleeding, pelvic pain, and increased vaginal discharge. A complex left adnexal mass was seen on ultrasound. The patient was taken to the OR and found to have a uterine didelphys, pelvic wall adhesions, and a 3cm left ovarian cyst. Three months later, when the patient had persistent LLQ pain, MRI demonstrated presence of a double cervix, obstructed and dilated left hemivagina, and left renal agenesis. Referral to a tertiary center was made for further evaluation. <h3>Interventions</h3> At the tertiary center, diagnostic hysteroscopy through the single visible cervix demonstrated a right uterine cavity and ostium. Transvaginal ultrasound did not identify the hematocolpos in a way that aided surgical exploration. During diagnostic laparoscopy, a BK 4-way 10mm OD articulated laparoscopic ultrasound transducer (I12C4F) was attached to the BK 5000 imaging system. The transducer was directed toward the pelvic floor revealing the minimally dilated hematocolpos allowing for image-guided positioning of a needle and injection of sterile water making the mass adequately tense to allow easy identification via the vagina. A portion of the oblique vaginal septum was removed, the opening was secured with interrupted absorbable sutures, and hysteroscopy was performed on the left side through the exposed left cervix demonstrating a left uterine cavity and ostium. <h3>Measurements and Main Results</h3> The patient did well postoperatively. Both cervices were readily seen and the area of resection healed appropriately. No further interventions anticipated. <h3>Conclusion</h3> This video demonstrates the utility of laparoscopic ultrasound to assist with the management of selected Müllerian anomalies, particularly when important features may not be palpable or visible vaginally, hysteroscopically, or laparoscopically.

Laparoscopic ultrasound-guided superselective portal vein injection combined with real-time indocyanine green fluorescence imaging and navigation for accurate resection of localized intrahepatic bile duct dilatation: a case report

BackgroundPrimary intrahepatic bile duct dilatation can be very harmful to patients although it belongs to benign biliary disease. It can occur in any part of the liver, intraoperative laparoscopic ultrasound (LUS) guidance combine with real-time indocyanine green (ICG) fluorescence navigation are the means of choice for accurate surgical resection.Case presentationHerein we reported a 43-year-old female patient presented with repeated right upper abdominal pain and distension for 3 years and aggravated for half a year, without fever and jaundice. A diagnosis of localized bile duct dilatation with lithiasis in segment 4 (S4) was made on the basis of preoperative imaging. Correspondingly, we selected to perform a laparoscopic surgery with LUS guided real time ICG fluorescence imaging (ICG-FI) and navigation to make the operation more simply and accurately, as well as to retain normal tissues in a certain extent. Laparoscopic resection of S4b and partial S4a was successfully performed, without any complications.ConclusionLaparoscopic anatomical surgery for intrahepatic bile duct dilatation is a technically challenging operation. The combined use of preoperative three-dimensional computerized tomography (CT) planning, intraoperative LUS guided super-selection, ICG hepatic segment staining and real-time fluorescence navigation could help surgeons accurately complete the segmentectomy or subsegmentectomy with minimized trauma and maximized liver tissue preservation.

Mastery skill assessment in hepato-pancreato-biliary surgical ultrasound: It's a Matter of Entrustment

BackgroundA formative hepato-pancreato-biliary (HPB) ultrasound (US) skills practicum is offered annually to graduating HPB fellows, using entrustment assessments for open (IOUS) and laparoscopic (LAPUS) US. It is hypothesized that validity evidence will support the use of these assessments to determine if graduating fellows are well prepared to perform HPB US independently. MethodsExpert faculty were surveyed to set Mastery Entrustment standards for fellow performance. Standards were applied to fellow performances during two annual US skills practicums. Results11 faculty questionnaires were included. Mean Entrustment cut scores across all items were 4.9/5.0 and 4.8/5.0 and Global Entrustment cut scores were 5.0/5.0 and 4.8/5.0 for IOUS and LAPUS, respectively. 78.5% (29/37) fellows agreed to have their de-identified data evaluated. Mean fellow Entrustments (across all skills) were 4.1 (SD 0.6; 2.6–4.9) and 3.9 (SD 0.7; 2.7–5), while the Global Entrustments were 3.6 (SD 0.8; 2–5) and 3.5 (SD 1.0; 2–5) for IOUS and LAPUS, respectively. ConclusionsTwo cohorts of graduating HPB fellows are not meeting Mastery Standards for HPB US performance determined by a panel of expert faculty.

Laparoscopic ultrasonography-guided cryoablation of locally advanced pancreatic cancer: a preliminary report.

To evaluate safety and feasibility of laparoscopic ultrasonography (LUS)-guided cryoablation of locally advanced pancreatic cancer (LAPC). From April 2018 to December 2018, ten patients (five women, five men; mean age 58.2 ± 9.4years) with LAPC underwent the operation. LUS was used to guide the cryoablation. Computed tomography (CT) imaging, biochemical analysis and pain score analysis by numeric rating scale (NRS) were used to assess treatment outcomes at 1week and 3months after the operation. Cryoablation was performed by the operation in all cases. Seven patients received complete ablation and the success rate of operation was 70%. Two cryoablation cycles and an average of 1.4 ± 0.5 cryoprobes were used. The average freezing time and operation time were 23.8 ± 1.0 and 110.5 ± 24.7min, respectively. The mean blood loss was 52.0 ± 16.6ml. No major complications were observed after the operation. The mean maximum tumor diameter determined by CT decreased from 4.9 ± 0.7cm before the operation to 4.7 ± 1.0cm at 1week and 4.6 ± 1.3cm at 3months, with P values of 0.53 and 0.51 (relative to the preoperative values), respectively. Postoperative CT imaging results suggested tumor necrosis in cryoablation-treated areas. The mean CA19-9 levels decreased from 347.5 ± 345.7 U/mL before operation to 190.4 ± 153.8 U/mL at 1week and 182.7 ± 165.6 U/mL at 3months, with P values of 0.15 and 0.14 (relative to the preoperative values), respectively. The average pain scores declined from 6.9 ± 1.1 before operation to 1.3 ± 1.2 at 1week and 2.0 ± 0.8 at 3months, with both P values of < 0.01 (relative to the preoperative values). This preliminary study suggested that LUS-assisted cryoablation was a safe and feasible treatment for LAPC.

Laparoscopic anatomical S8 segmentectomy by Glissonian approach after dissection of the midplane of the liver

Anatomical resection of the liver in HCC is important in terms of oncologic benefit. However, laparoscopic anatomical segment 8 (S8) resection is anatomically complex and technically difficult. Ultrasonography guided dye or ICG injection technique can be a good option, but it is technically demanding and experience dependent. A 56-year-old female with underlying chronic hepatitis B virus was diagnosed with 1.8 cm sized HCC in S8. The tumor was suspected of the microvascular invasion near the middle hepatic vein (MHV) in MRI. Laparoscopic ultrasonography was used to identify the location of mass and the relation to the vasculature. The lower 2/3 of the midplane of the liver was dissected. The branches of MHV draining S4 were divided to get resection margin. After dissection around the right anterior Glissonian pedicle, ligation of S8 pedicle was done. Then, lateral border of S8 was dissected along the ischemic line. MHV was crossed over during the dissection of the upper 1/3 of the midplane of the liver. S8 was anatomically resected. The operative time was 185 minutes, and the estimated blood loss was 100 mL. The final pathology was HCC and the size of tumor was 18 mm with 2 cm safety margin. Follow up CT scan showed congestion in S4 and S5, but no other problems. The patient was discharged on postoperative day 5 without complication. Laparoscopic anatomical resection of S8 using Glissonian approach after dissection of the midplane of the liver was feasible and it is simpler and easier to apply than dye injection technique.

Laparoscopic treatment for celiac artery stenosis caused by median arcuate ligament compression with Adachi V type vascular anomaly: a case report

BackgroundMedian arcuate ligament syndrome (MALS), which results from compression of the median arcuate ligament (MAL), is a rare cause of abdominal pain and weight loss. Treatment is dissection of the MAL; however, the laparoscopic procedure is not yet established and it involves the risk of major vascular injury, especially in cases with an anomaly.Case presentationA 47-year-old man was evaluated at the hospital for epigastric pain. Contrast computed tomography scan revealed stenosis of the celiac artery origin due to the MAL. An Adachi V type vascular anomaly was also observed. Laparoscopic treatment was performed to release pressure on the celiac artery. Laparoscopic ultrasonography was used to less invasively confirm the release of the MAL. Despite a concomitant Adachi V type vascular anomaly, surgery was safely performed using the laparoscopic magnification view and intraoperative ultrasonography. Follow-up ultrasonography confirmed the celiac artery stenosis has not recurred.ConclusionsA rare case of MALS with an Adachi V type vascular anomaly is presented and the laparoscopic treatment is detailed.

Vessel segmentation for automatic registration of untracked laparoscopic ultrasound to CT of the liver

Purpose:Registration of Laparoscopic Ultrasound (LUS) to a pre-operative scan such as Computed Tomography (CT) using blood vessel information has been proposed as a method to enable image-guidance for laparoscopic liver resection. Currently, there are solutions for this problem that can potentially enable clinical translation by bypassing the need for a manual initialisation and tracking information. However, no reliable framework for the segmentation of vessels in 2D untracked LUS images has been presented.Methods:We propose the use of 2D UNet for the segmentation of liver vessels in 2D LUS images. We integrate these results in a previously developed registration method, and show the feasibility of a fully automatic initialisation to the LUS to CT registration problem without a tracking device.Results:We validate our segmentation using LUS data from 6 patients. We test multiple models by placing patient datasets into different combinations of training, testing and hold-out, and obtain mean Dice scores ranging from 0.543 to 0.706. Using these segmentations, we obtain registration accuracies between 6.3 and 16.6 mm in 50% of cases.Conclusions:We demonstrate the first instance of deep learning (DL) for the segmentation of liver vessels in LUS. Our results show the feasibility of UNet in detecting multiple vessel instances in 2D LUS images, and potentially automating a LUS to CT registration pipeline.

Commentary: Application of Indocyanine Green Fluorescence as an Adjuvant to Laparoscopic Ultrasound in Minimally Invasive Liver Resection by Piccolo et al.

Commentary: Application of Indocyanine Green Fluorescence as an Adjuvant to Laparoscopic Ultrasound in Minimally Invasive Liver Resection by Piccolo et al.

Safety, quality and efficiency of intra-operative imaging for treatment decisions in patients with suspected choledocholithiasis without pre-operative magnetic resonance cholangiopancreatography

Cholecystectomy is the accepted treatment for patients with symptomatic gallstones. In this study, we evaluate a simplified strategy for managing suspected synchronous choledocholithiasis by focussing on intra-operative imaging as the primary decision-making tool to target common bile duct (CBD) stone treatment. All elective and emergency patients undergoing laparoscopic cholecystectomy (LC) for gallstones with any markers of synchronous choledocholithiasis were included. Patients unfit for surgery or who had pre-operative proof of choledocholithiasis were excluded. Intra-operative imaging was used for evaluation of the CBD. CBD stone treatment was with bile duct exploration (LCBDE) or endoscopic retrograde cholangiopancreatography (LC + ERCP). Outcomes were safety, effectiveness and efficiency. 506 patients were included. 371 (73%) had laparoscopic ultrasound (LUS), 80 (16%) had on-table cholangiography (OTC) and 55 (11%) had both. 164 (32.4%) were found to have CBD stones. There was no increase in length of surgery for LC + LUS compared with average time for LC only in our unit (p = 0.17). 332 patients (65.6%) had clear ducts. Imaging was indeterminate in 10 (2%) patients. Overall morbidity was 10.5%. There was no mortality. 142 (86.6%) patients with stones on intra-operative imaging proceeded to LCBDE. 22 (13.4%) patients had ERCP. Sensitivity and specificity of intra-operative imaging were 93.3 and 99.1%, respectively. Success rate of LCBDE was 95.8%. Effectiveness was 97.8%. Eliminating pre-operative bile duct imaging in favour of intra-operative imaging is safe and effective. When combined with intra-operative stone treatment, this method becomes a true 'single-stage' approach to managing suspected choledocholithiasis.