Liver Bed Research Articles

Evaluation of fundus first laparoscopic cholecystectomy in an obscured calot triangle: outcomes

Background: A fundus first laparoscopic cholecystectomy when performed by an experienced surgeon, provides the same level of safety and durability as an open cholecystectomy. When Calot's triangle cannot be safely dissected during laparoscopic cholecystectomy a rescue treatment is advised. Current revisions stress the importance of intraoperative observations in helping surgeons make a rescue decision and minimize additional harm. Objective: To examines the fundus-first strategy in laparoscopic cholecystectomy in an indistinct Calot's triangle and the patient's clinical outcome. Patients and Methods: This is a prospective study that was done in Rizgary Teaching Hospital from January 1st, 2020 to December 31st, 2022, on 68 cases who underwent laparoscopic cholecystectomy where Calot’s triangle was difficult to distinguish during the operation. Fundus: first dissection of the gall bladder down to the infundibulum and after safe ligation of the gall bladder stump and good hemostasis of the liver bed, the gallbladder is removed via a 10-mm port. This research looked at the duration of operation, postoperative pain, rate of conversion to open surgery and duration of the hospital stay. Results: Among 68 cases of fundus first laparoscopic cholecystectomy most of the patients were female 45(66.17%) and 23(33.82%) were male, majority of cases were between 31 and 50 years old, with a mean age of 39±10.44, and the majority of patients were complaining of inflammation with fibrosis at the site of the cystic duct. The duration of operation ranged from 45-60 minutes in 16(23.52%) and 60-80 minutes in 20(29.41%) cases and 130-140 minutes in 2(2.94%) cases. The majority of our cases remained in the hospital and ambulated on day 3-5, and the main hospital stay was 4.68±1.8 days. There was statistical significance in the age distribution with a P-value 0.04. Conclusion: Fundus first laparoscopic cholecystectomy remains a feasible and safe procedure. Surgeon experience and judgement affects the operative time, conversion rate, morbidity and hospital stay in difficult and obscured Calot’s triangle.

SP8.3 - Institutional initial experience and outcomes for the first 100 robotic upper gastrointestinal cases: A single tertiary centre results

Abstract Background Robotic surgery is a widespread technique with potential benefits including shorter admissions, fewer complications as well as better surgeon ergonomics and precision. Evidence suggests that robotic surgery has a rapid learning curve, with number of cases linked to operative time. In this study, we report our preliminary results after initiation of upper gastrointestinal robotic assisted surgery. Methods This retrospective study included all robotic elective upper gastrointestinal cases, performed by two surgeons using Da Vinci XI from August 2022 to May 2023. Cholecystectomy and anti-reflux surgeries were performed. Demographics, console timing, number of cases per list and post-operative complications (Clavien-Dindo Scale) were analysed. Results 100 Robotic UGI cases were analysed consisting of 86 cholecystectomies and 14 anti-reflux surgeries. Females represented the majority of cases (68%). Mean age was 53.0 years (18-78) while mean ASA and BMI were 2 and 30.3 kg/m^2 respectively. Cholecystectomies required 43.0 minutes while anti-reflux surgeries required 119.3 minutes on average. The mean length of stay was 0.90 days for cholecystectomies, and 1.46 days for anti-reflux surgery. There were two readmissions post cholecystectomy for pneumonia and liver bed collection. Only one patient developed a Clavien-Dindo grade >3 complication for port site hernia repair post cholecystectomy. Average console time fell with increasing case number, creating a tangible impact on efficiency as surgeons increased the number of cases per list from three to four. Conclusion Our initial experience has shown favorable outcomes of robotic surgery. There was a noticeable rapid learning curve, encountering only one major post-operative complication. This high effectiveness should stimulate the swift introduction of robotic surgery to other hospitals.

Simultaneous laparoscopic colectomy and liver metastasectomy with natural orifice specimen extraction: A proof-of-concept study

Background, Natural orifice specimen extraction (NOSE) via the anus or vagina is an alternative to conventional transabdominal specimen extraction in laparoscopic colorectal cancer surgery. NOSE has been shown to be safe and effective, resulting in decreased postoperative pain, analgesia use, and improved recovery, without oncological compromise. We aimed to demonstrate the feasibility of NOSE for combined colectomy with liver metastasectomy.Methods, From July 2022 to April 2024, all cases of laparoscopic colorectal cancer resection and synchronous liver metastasectomy with NOSE were included in the study. Selection criteria included a maximum specimen diameter of less than 5 cm and patient body mass index of less than 35 kg/m2.Results, Over the 22-month duration, four consecutive patients (two males, two females) underwent combined resection with NOSE. Mean age and BMI were 74.8 (range 63–81) years and 20.9 (range 19.5–22.3) kg/m2 respectively. Patient A and D underwent anterior resection for sigmoid cancer, Patient B underwent D3 right hemicolectomy for cecal cancer, and Patient C underwent subtotal colectomy for synchronous cecal and descending colon cancer. All patients underwent liver metastasectomy at the same sitting. Patient A and D had transanal NOSE while Patients B and C underwent transvaginal NOSE. Mean operative time and blood loss was 416 (range 330–535) minutes and 338 (range 50–500) ml respectively. All patients recovered gastrointestinal function within the first two postoperative days. Infected seroma of the liver bed occurred in one patient requiring percutaneous drainage. The average maximum colon tumor diameter was 2.9 (range 1.3–4.0) cm. All resection margins were clear. Mean duration of follow-up was 7.5 (range 2–12) months.Conclusions, Simultaneous colectomy and liver metastasectomy with NOSE for colorectal cancer is feasible and safe in highly selected patients, resulting in good postoperative outcomes. This proof-of-concept analysis paves the way for larger studies to draw definitive conclusions.

Progress and controversy in minimally invasive approach to radical cholecystectomy for gallbladder cancer

Surgical treatment is one of the most important forms of treatment in patients with gallbladder cancer. With the development of minimally invasive technology, the feasibility, safety and efficacy of minimally invasive approaches such as laparoscopic or robotic-assisted radical cholecystectomy for gallbladder cancer have received continuous attention.For patients with an early T-stage (Tis or T1a), laparoscopic simple cholecystectomy is safe and economical, with a good prognosis for postoperative patients, and it has been widely accepted and performed. Radical resection of advanced gallbladder cancer requires resection of the gallbladder, its liver bed, and other neighboring invaded organs, as well as clearance of regional lymph nodes, which requires experienced gallbladder cancer treatment teams to strictly grasp the indications, select appropriate patients, and formulate a good surgical strategy to ensure the therapeutic effect. Meanwhile, robot-assisted radical resection for gallbladder cancer has been performed in a few centers and shows good clinical potential, but more high-quality studies are needed to further evaluate its value in gallbladder cancer treatment.

How I Do It: Robotic Choledochoscopy.

As the use of the robotic platform increases among general surgeons, the amount of robotic cholecystectomies is expected to increase as well. The use of intraoperative cholangiography is valuable in assessing for choledocholithiasis. We describe our technique of performing robotic intraoperative cholangiograms with choledochoscopy. Out technique aids in efficiency since no undocking is required. Preoperatively, the decision to perform a cholangiogram is made based on physical exam, labs, and imaging findings. The procedure begins with obtaining a critical view of safety. The robotic arms are positioned in a manner that allows all 4 robotic arms to remain docked. A ductotomy is made and the cholangiocatheter is introduced. The cholangiogram images are then interpreted and if a stone is seen in the common bile duct we will then perform a transcystic common bile duct exploration using the SpyGlass Discover digital. A complete cholangiogram is then performed. The cystic duct is secured and the gallbladder is removed from the liver bed. The patients are watched overnight and discharged on postoperative day 1. A robotic approach to performing a transcystic common bile duct exploration is a safe and reproducible treatment method for choledocholithiasis. Our approach offers an advantage since no undocking is required.

Clinical outcomes of minimally invasive (laparoscopic and robotic) versus open extended cholecystectomy: A multicenter propensity score matched study.

This multicenter study aimed to compare the clinical outcomes of minimally invasive extended cholecystectomy (MI-EC) versus open EC (O-EC) for patients with gallbladder cancer (GBC). Patients who underwent EC (cholecystectomy, wedge resection of the liver bed, and regional lymphadenectomy) for GBC between 2010 and 2020 in three centers were included in the study. The clinicopathological data were compared after propensity score matching. Additional subgroup analysis on laparoscopic and robotic EC (L-EC and R-EC) was performed. A total of 377 patients were included: 308 for O-EC and 69 for MI-EC, respectively. The MI-EC group had a longer operative time (188.9 vs. 238.1 min, p < .001) and shorter hospital stay (9.0 vs. 7.2 days, p = .007), although no differences were found in operative blood loss, complication rate and survival outcome. In subgroup analysis, L-EC patients had a longer operative time (264.4 vs. 202.0 min, p = .001), compared to R-EC patients with comparable perioperative and survival outcomes. Although patients with MI-EC had a longer operation time and higher medical costs, the advantages were enhanced recovery with comparable short- and long-term outcomes. The operation time was less for R-EC patients than for L-EC patients, though the high cost still remains. The surgery type for EC can be selected according to the patient's condition, social status and surgeon's preference.

Clinical observation of gastrointestinal function recovery in patients after hepatobiliary surgery.

The liver is an important metabolic and digestive organ in the human body, capable of producing bile, clotting factors, and vitamins. To investigate the recovery of gastrointestinal function in patients after hepatobiliary surgery and identify effective rehabilitation measures. A total of 200 patients who underwent hepatobiliary surgery in our hospital in 2022 were selected as the study subjects. They were divided into a control group and a study group based on the extent of the surgery, with 100 patients in each group. The control group received routine treatment, while the study group received targeted interventions, including early enteral nutrition support, drinking water before gas discharge, and large bowel enema, to promote postoperative gastrointestinal function recovery. The recovery of gastrointestinal function was compared between the two groups. Compared with the control group, patients in the study group had better recovery of bowel sounds and less accumulation of fluids in the liver bed and gallbladder fossa (P < 0.05). They also had shorter time to gas discharge and first meal (P < 0.05), higher overall effective rate of gastrointestinal function recovery (P < 0.05), and lower incidence of postoperative complications (P < 0.05). Targeted nursing interventions (early nutritional support, drinking water before gas discharge, and enema) can effectively promote gastrointestinal function recovery in patients undergoing hepatobiliary surgery and reduce the incidence of complications, which is worthy of promotion.

Initial experience of robotic-assisted cholecystectomy in a tertiary care teaching hospital

Abstract Background: Robotic surgery was designed to overcome some of the major limitations of laparoscopy in terms of visibility, dexterity and precision. However, its potential limitations include high costs and low tactile feedback. at a tertiary care teaching hospital. Methods: In this retrospective study, we assessed the safety and feasibility of robotic-assisted cholecystectomy using the Versius Surgical Robot System® at our tertiary care teaching hospital between 2 September 2021 and 22 August 2022. Results: Of the 30 patients studied, 11 were males. The mean body mass index of the patients was 25.7. Intraoperative complications were noted in one case (haemorrhage from the liver bed) and conversion to laparoscopic surgery was noted in the same case. The median docking time was 16 min and the median console time was 72 min. No post-operative complications were noted. Both docking time and console time significantly decreased throughout this study. Conclusions: This study shows that the robotic-assisted cholecystectomy is a promising, safe and feasible alternative to traditional laparoscopic cholecystectomy.

Decoding surgical skill: an objective and efficient algorithm for surgical skill classification based on surgical gesture features -experimental studies.

Various surgical skills lead to differences in patient outcomes and identifying poorly skilled surgeons with constructive feedback contributes to surgical quality improvement. The aim of the study was to develop an algorithm for evaluating surgical skills in laparoscopic cholecystectomy based on the features of elementary functional surgical gestures (Surgestures). Seventy-five laparoscopic cholecystectomy videos were collected from 33 surgeons in five hospitals. The phase of mobilization hepatocystic triangle and gallbladder dissection from the liver bed of each video were annotated with 14 Surgestures. The videos were grouped into competent and incompetent based on the quantiles of modified global operative assessment of laparoscopic skills (mGOALS). Surgeon-related information, clinical data, and intraoperative events were analyzed. Sixty-three Surgesture features were extracted to develop the surgical skill classification algorithm. The area under the receiver operating characteristic curve of the classification and the top features were evaluated. Correlation analysis revealed that most perioperative factors had no significant correlation with mGOALS scores. The incompetent group has a higher probability of cholecystic vascular injury compared to the competent group (30.8 vs 6.1%, P =0.004). The competent group demonstrated fewer inefficient Surgestures, lower shift frequency, and a larger dissection-exposure ratio of Surgestures during the procedure. The area under the receiver operating characteristic curve of the classification algorithm achieved 0.866. Different Surgesture features contributed variably to overall performance and specific skill items. The computer algorithm accurately classified surgeons with different skill levels using objective Surgesture features, adding insight into designing automatic laparoscopic surgical skill assessment tools with technical feedback.

A RARE CASE OF ADENOSQUAMOUS VARIANT OF GALLBLADDER CARCINOMA

The most prevalent cancer of the extrahepatic biliary tract is gallbladder carcinoma with adenocarcinoma as the most common variant while adenosquamous carcinoma of the gallbladder represents the rare variant of gallbladder cancers. We are presenting the instance of a 61-year-old woman who has complained of abdominal pain from umbilical and epigastric region and radiating towards the back since 7 days. Ultrasonography showed heterogeneously hyperechoic collection in gallbladder fossa and CECT whole abdomen showed a well defined rounded heterogenous enhancing mass lesion arising from fundus of gallbladder with adjacent liver bed suspecting neoplastic etiology. Laproscopic cholecystectomy was done under general anaesthesia. The sample was forwarded to the pathology department for histopathological analysis and diagnosis ofAdenosquamous carcinoma of gallbladder was made.

OGBN P26 Institutional initial experience and outcomes for the first 100 Upper gastrointestinal Cases: A single tertiary center results

Abstract Background Robotic surgery is widely spreading in many centers across the United Kingdom. Potential benefits include shorter admissions, fewer complications as well as better surgeon ergonomics and dexterity. Evidence suggests that robotic surgery has a rapid learning curve when first implemented with the number of cases linked to operative time. In this study, we report our preliminary results after implementation of robotic surgery at our upper gastrointestinal unit. Methods This retrospective study included all robotic elective upper gastrointestinal cases since the introduction of robotic surgery at our unit. All cases were performed by two surgeons using Da Vinci XI starting in August 2022. The first 100 cases were completed in 10 months. Both surgeons completed Intuitive training prior to initiating their independent operating lists. Cholecystectomy and anti-reflux surgeries were the main surgeries performed during the study period. Demographics, number of cases per list, console timing and postoperative complications were collected and analysed. Console timing was obtained by Intuitive software. Postoperative complications were graded using the Clavien-Dindo scale. Results 100 UGI robotic surgery cases were analysed consisting of 86 cholecystectomies and 14 anti-reflux operations. Females represented the majority of cases (68%). Mean age was 53.0 years (18-78) while mean ASA and BMI were 2 and 30.3 kg/m2 respectively. Mean console time was 53.3 minutes. Cholecystectomies required 43.0 minutes and anti-reflux surgeries required 119.3 minutes on average. The mean length of stay was 0.90 days for cholecystectomies, and 1.46 days for anti-reflux surgery. There were two readmissions post cholecystectomy for pneumonia and liver bed collection. One cholecystectomy patient developed a Clavien-Dindo grade &amp;gt;3 complication for port site hernia repair. Conclusions Our initial experience has shown favourable outcomes of robotic surgery. There was a noticeable rapid learning curve, encountering only one major post-operative complication. This high effectiveness should stimulate the swift introduction of robotic surgery to other hospitals.

Developing a generic business case for an advanced chronic liver disease support service

IntroductionLiver disease deaths are rising, but specialist palliative care services for hepatology are limited. Expansion across the NHS is required.MethodsWe surveyed clinicians, patients and carers to design an ‘ideal’ service....

A multifactorial evaluation of objective performance indicators and video analysis in the context of case complexity and clinical outcomes in robotic-assisted cholecystectomy.

The increased digitization in robotic surgical procedures today enables surgeons to quantify their movements through data captured directly from the robotic system. These calculations, called objective performance indicators (OPIs), offer unprecedented detail into surgical performance. In this study, we link case- and surgical step-specific OPIs to case complexity, surgical experience and console utilization, and post-operative clinical complications across 87 robotic cholecystectomy (RC) cases. Videos of RCs performed by a principal surgeon with and without fellows were segmented into eight surgical steps and linked to patients' clinical data. Data for OPI calculations were extracted from an Intuitive Data Recorder and the da Vinci ® robotic system. RC cases were each assigned a Nassar and Parkland Grading score and categorized as standard or complex. OPIs were compared across complexity groups, console attributions, and post-surgical complication severities to determine objective relationships across variables. Across cases, differences in camera control and head positioning metrics of the principal surgeon were observed when comparing standard and complex cases. Further, OPI differences across the principal surgeon and the fellow(s) were observed in standard cases and include differences in arm swapping, camera control, and clutching behaviors. Monopolar coagulation energy usage differences were also observed. Select surgical step duration differences were observed across complexities and console attributions, and additional surgical task analyses determine the adhesion removal and liver bed hemostasis steps to be the most impactful steps for case complexity and post-surgical complications, respectively. This is the first study to establish the association between OPIs, case complexities, and clinical complications in RC. We identified OPI differences in intra-operative behaviors and post-surgical complications dependent on surgeon expertise and case complexity, opening the door for more standardized assessments of teaching cases, surgical behaviors and case complexities.

A comparison between real-time intraoperative voice dictation and the operative report in laparoscopic cholecystectomy: a multicenter prospective observational study

PurposeThe current operative report often inadequately reflects events occurring during laparoscopic cholecystectomy (LC). The addition of intraoperative video recording to the operative report has already proven to add important information. It was hypothesized that real-time intraoperative voice dictation (RIVD) can provide an equal or more complete overview of the operative procedure compared to the narrative operative report (NR) produced postoperatively.MethodsSONAR is a multicenter prospective observational trial, conducted at four surgical centers in the Netherlands. Elective LCs of patients aged 18 years and older were included. Participating surgeons were requested to dictate the essential steps of LC during surgery. RIVDs and NRs were reviewed according to the stepwise LC guideline of the Dutch Society for Surgery. The cumulative adequacy rates for RIVDs were compared with those of the postoperatively written NR.Results79 of 90 cases were eligible for inclusion and available for further analysis. RIVD resulted in a significantly higher adequacy rate compared to NR for the circumferential dissection of the cystic duct and artery (NR 32.5% vs. RIVD 61.0%, P = 0.016). NR had higher adequacy rates in reporting the transection of the cystic duct (NR 100% vs. RIVD 77.9%, P = < 0.001) and the removal of the gallbladder from the liver bed (NR 98.7% vs. RIVD 68.8%, P < 0.001). The total adequacy was not significantly different between the two reporting methods (NR 78.0% vs. RIVD 76.4%, P = 1.00).ConclusionOverall, the adequacy of RIVD is comparable to the postoperatively written NR in reporting surgical steps in LC. However, the most essential surgical step, the circumferential dissection of the cystic duct and artery, was reported more adequately in RIVD.

Intraperitoneal Bupivacaine in Laparoscopic Cholecystectomy, Efficacy and Feasibility

Abstract Background Laparoscopic Cholecystectomy among the most frequently performed elective daycare surgeries. After laparoscopic cholecystectomy shoulder and abdominal pain causes considerable distress, to determine the efficacy of intraperitoneal bupivacaine instillation on management of early postoperative pain in patient undergoing laparoscopic cholecystectomy. Aim of the Work To determined the efficacy of intraperitoneal bupivacaine instillation on management early postoperative pain in patient with laparoscopic cholecystectomy. Patients and Methods This is a prospective randomized study with sample size of 50 patients underwent elective laparoscopic cholecystectomy. We recruited patients from surgery department at Agouza Hospital. We randomly assigned patients to undergo laparoscopic cholecystectomy with bupivacaine and 25 ml of physiological saline (0.9% normal saline) on liver bed or without bupivacaine. Results Fifty patients finally met our inclusion criteria. In bupivacaine group, mean age was 35 (± 6.6), 64% were females and 36% were males. While in non-bupivacaine group mean age was 37.6 (± 6.6), 68% were females and 32% were males with no statistically significant difference between both groups; age (P value=0.22) and age (P value=0.77), In bupivacaine group there was significant pain reduction compared to non-bupivacaine group in terms of VAS at 2 h (p value=0.04), 12 h (p value=0.02), 24 h (, p value=0.01) and VRS at 2 h (p value&amp;lt;0.01), 12 h (p value&amp;lt;0.01), 24 h (p value&amp;lt;0.01). Hospital stay was lower hospital stay in bupivacaine group 0.94 (± 0.16) than nonbupivacaine group 1.21 (± 0.41) (p value&amp;lt;0.01). Need for additional analgesia was lower in bupivacaine group (P value &amp;lt;0.01). Conclusion Intraperitoneal route for administration of local anaesthetic is a safe and effective approach. Bupivacaine is an effective treatment option to achieve postoperative analgesic, limit the duration of hospital stay and the need for additional analgesia. But it did not significantly lower the incidence of nausea and vomiting.

Effect of Electrocoagulation and Direct Pressure Application on Bleeding from Liver Bed During Laparoscopic Cholecystectomy.

To compare the efficacy of electrocoagulation and direct pressure application in controlling haemorrhage from the liver bed during laparoscopic cholecystectomy. Randomized controlled trial. Place and Duration of the Study: Department of General Surgery, Sir Ganga Ram Hospital, Lahore, Pakistan, from July 2021 to December 2021. A total of 218 patients of either gender, aged 18 to 60 years and with bleeding from the liver bed during laparoscopic cholecystectomy were randomly allocated to two groups of haemorrhage control techniques. In group A, electrocoagulation was used and in group B, direct pressure was applied to the bleeding area for 5 minutes. Efficacy in controlling bleeding was compared in both groups. The mean age of all study participants was 44.6 + 13.5 years. The majority of the patients were females (89%). The mean body mass index (BMI) of all participants was 25.3 ± 3.09 kg/m2. Intraoperative bleeding was secured in 86.2% of patients in Group A vs. 81.7% of patients in Group B. However, the difference was not statistically significant (p=0.356). In 27 (12.4%) cases, bleeding could not be controlled by both of these techniques. In these cases, endosuturing was applied in 19 (70.4%) cases, spongostan in 6 (22.2%) cases, and endo-clips in 2 (7.4%) cases. Intraoperative drain and conversion to open procedure was required in 1 patient each, both belonging to the direct pressure application group. The efficacy of electrocoagulation in securing haemorrhage from the liver bed is better than the direct pressure application technique. Laparoscopic cholecystectomy, Haemorrhage, Electrocoagulation, Surgical hemostasis, Liver bed.

Rouviere's Sulcus Analysis: A Critical Safety Analysis and a Guide to Safe Laparoscopic Cholecystectomy.

Laparoscopic cholecystectomy (LC) is the most frequent surgical operation in general surgery. The focus of recent research has been on improving the procedure's safety. Over 80% of healthy livers have Rouviere's sulcus (RVS), which is a natural notch in the right lobe that is present in proximity to the confluence of the bile duct. It is frequently considered an important component of safety during LC. RVS demarcates the area of the common bile duct (CBD) from the liver bed for the gall bladder. This research intends to evaluate the frequency, its relation to CBD, and the critical view of safety (CVS) during LC. An observational study was performed in a cohort of 50 patients listed for LC between September 2021 and September 2022. The presence of RVS was confirmed after liver retraction and dissection commenced. After the creation of CVS, its relationship with CBD was documented. Additionally, the position of the cystic lymph node was also documented during the dissection. The findings of this study revealed that out of 50 patients, only 40 (80%) had RVS. However, cystic lymph nodes were present more frequently in 48 (96%) patients. CVS was achieved in all the patients, and it revealed the presence of RVS above the cystic duct-CBD junction in 37 (74%), at the level of the junction in 11 (22%), and in two (4%) where the junction could not be demarcated. RVS is a reliable marker to dissect laterally to CBD while doing LC, which does not require any dissection and can be appreciated early during the procedure. However, its presence along with the cystic lymph node gives a better anatomical understanding of the area of CBD, thereby assisting in conducting the procedure safely.

A Study of Extra Biliary Complications of Laparoscopic Cholecytectomy

Background: Laparoscopic cholecystectomy has rapidly become the procedure of choice for gallbladder removal and has become the most common major abdominal procedure performed throughout the world. To observe the extrabiliary complications of laparoscopic cholecystectomy this research work was done. Materials and methods: This observational study was carried out in the Department of Surgery, Chittagong Medical College Hospital, Chattogram, duration December 2015 to November 2016. A total of 100 Gall stone diseased patients were enrolled in this study and they were randomly allocated. Post operatively patients were observed, Data were collected, and Statistical analysis were obtained by using window based computer software devised with Statistical Packages for Social Sciences (SPSS-22). Results: Among 100 patients male to female ratio was 4.6:1 with maximum age group of third and fourth decade. Seventeen patients were associated with other disease e.g. diabetes mellitus and hypertension. Per-operative complication rate was 5(5.0%) among those, per-operative port site bleeding 2(2.0%), cystic artery bleeding 1(1.0%), liver bed bleeding was in 2(2.0%) cases. All these complications were managed successfully and smooth recovery within normal time.Post-operative complication rate was 1(1.0%). Among those port sites infection were in 1(1.0%) case. Conclusion: The findings of this study are expected to help taking perioperative measure to prevent extra-biliary complications. There may be some other devastating complications which may cripple the patients as well as surgeon. IAHS Medical Journal Vol 5(1), June 2022; 45-48

The Surgical outcomes of fundus-first technique in lowering the rate of bile duct injuries and bleeding during open cholecystectomy that facing intraoperative difficulties: A single-center prospective study

Background: The problem of difficult gallbladder is not clearly defined and associated with real missing of therapeutic approaches that decreased morbidity. Moreover, the difficult gallbladder was reported as a contributing risk factor for biliary injury due to raised difficulty in surgical dissection within Calot’s triangle. The aim of this study is to determine the surgical outcomes of the open fundus-first cholecystectomy in lowering the rate of lethal intraoperative risks.&#x0D; Subjects and Methods: Our prospective study conducted during the period of January 2019 to December 2022 at Ibn Sina specialized hospital, Khartoum, Sudan, for two hundred and fifty-three patients underwent elective open fundus-first cholecystectomy for intraoperative difficulties.&#x0D; Results: the majority of cases had long-standing cholelithiasis with intraoperative difficulties revealed by pre-operative TUS and MRCP which required open fundus-first cholecystectomy in 173 (68.4%) of patients, (P-value &lt;0.05). The operative surgical time was 120 minutes in 103 patients (40.7%), (P-value &lt;0.05). During open cholecystectomy, variable intraoperative difficulties were found in all patients, (P-value &lt;0.05) and were divided into: (A) Contracted intra-hepatic gallbladder seen in 157 (62.1%) of cases; (B) Distorted anatomy within Calot's triangle seen in 135 (53.4%) of patients; and (C) Intraoperative bleeding from the liver bed was observed as bloody oozing form in 150 (59.3%) of cases. Our patients had minimal postoperative complications like mild wound infection in 8 (3.2%) of cases and mortality rate was zero. &#x0D; Conclusions: There is a need for appropriate therapeutic and preventive strategies in healthcare systems for safe dealing with difficult cholecystectomy. Unclear anatomy due to severe inflammatory dense adhesions at Calot’s triangle and CBD stones needing difficult surgeries are the most important limiting factors for fundus-first laparoscopic cholecystectomy. Hence, we humbly recommend an open approach of fundus-first cholecystectomy as safe surgical option to reduce the incidence of bile duct injuries and intra-operative bleeding.

Intraoperative and Postoperative Complications of Three Dimensional (3D) Laparoscopic Cholecystectomy

Aim: To determine the intraoperative and postoperative complications of three dimensional (3D) laparoscopic cholecystectomy. Methodology: This prospective observational study was carried out General Surgery Department of multiple hospitals of Sindh during the time period of 1st July, 2021 to 30th June 2022. Cholelithiasis were included in the study were included. The baseline and specific assessments in all patients, especially abdominal ultrasound for diagnosis of gallstone disease were done. All prepared were 3D laparoscopic cholecystectomy. Results: Sixty nine (88.46%) were females and 9(11.53%) were males with mean age was 37.32±4.03 years. Common intraoperative complications were gallbladder rupture observed in 3(3.84%) cases tight adhesions around gallbladder, bleeding from liver bed in 2(2.56%) cases. Post-operatively 4(5.12%) patients had nausea, postoperative fever in 5(6.40%) cases, port-site bleeding in 3(3.84%) cases and port site infection in 4(5.12%) cases. Conclusion: Intraoperative and postoperative complications are more common in patients with older age and male gender. Keywords: Intraoperative complications, Postoperative complications, 3D laparoscopic cholecystectomy