Routine Laparoscopic Cholecystectomy Research Articles

Single stage management of suspected gallbladder cancer guided by intraoperative frozen section analysis: A retrospective cohort study.

The management of radiologically suspected gallbladder cancers (GBC) that lack definitive radiological features usually involves performing a first-stage routine laparoscopic cholecystectomy, followed by an open second-stage liver resection (segments IVB and V) and hilar lymphadenectomy (extended cholecystectomy) if subsequent formal histology confirms a malignancy. Performing a cholecystectomy with an intraoperative frozen section to guide the need for conversion to an extended cholecystectomy as a single-stage procedure has multiple benefits compared to a two-stage approach. However, the safety and efficacy of this approach have not yet been evaluated in a tertiary setting. A retrospective cohort study was performed using a database of all consecutive patients with suspected GBC who had been referred to our tertiary unit. Following routine cholecystectomy, depending on the operative findings, the gallbladder specimen was removed and sent for frozen-section analysis. If malignancy was confirmed, the depth of tumour invasion was evaluated, followed by simultaneous extended cholecystectomy, when appropriate. The sensitivity and specificity of frozen section analysis for the diagnosis of GBC were measured using formal histopathology as a reference standard. A total of 37 consecutive cholecystectomies were performed. In nine cases, GBC was confirmed by intraoperative frozen section analysis, three of which had standard cholecystectomy only as their frozen section showed adenocarcinoma to be T1a or below (n=2) or were undetermined (n=1). In the remaining six cases, malignant invasion beyond the muscularis propria (T1b or above) was confirmed; thus, a synchronous extended cholecystectomy was performed. The sensitivity (95% CI 66.4%-100%) and specificity (95% CI 87.7%-100%) for identifying GBC using frozen section analysis were both 100%. The net cost of the single-stage pathway in comparison to the two-stage pathway resulted in overall savings of £3894. Intraoperative frozen section analysis is a reliable tool for guiding the use of a safe, single-stage approach for the management of GBC in radiologically equivocal cases. In addition to its lower costs compared to a conventional two-stage procedure, intraoperative analysis also affords the benefit of a single hospital admission and single administration of general anaesthesia, thus greatly enhancing the patient's experience and relieving the burden on waiting lists.

Critical View of Safety Dissection and Rouviere's Sulcus for Safe Laparoscopic Cholecystectomy: A Descriptive Study.

Objective: To determine the importance of a critical view of safety (CVS) techniques and Rouviere's sulcus (RS) in laparoscopic cholecystectomy (LC) and its relation to biliary duct injuries (BDIs) and to determine the frequency and the type of RS. Design, Setting, and Participants: A descriptive study was carried out among 76 patients presenting to the surgery department of a tertiary care center in Nepal. The study population included all patients in the age group 16-80 years undergoing LC. Outcome Measures: The main outcome of interest was to calculate the percentage of BDIs along with the frequency and the type of RS. Results: A total of 76 patients were enrolled in the study, out of which 57(75%) were female patients with a male-to-female ratio of 1:3 and a mean age of 45.87 ± 15.33 years. Seventy-one (93.4%) patients were diagnosed with symptomatic gallstone disease. The CVS was achieved in 75 (98.7%) of the cases, whereas in 1 case, the CVS could not be achieved, and in the same patient routine LC was converted into open cholecystectomy owing to the difficult laparoscopic procedure. In 56 (73.7%) cases, RS was first visible to the operating surgeons after port installation, alignment, and adequate traction of the gallbladder; in 20 (26.3%) cases, RS was not originally apparent. Conclusion: According to the findings of this study and the literature's critical assessment of safety, this method will soon become a gold standard for dissecting gall bladder components. The technique needs to be extended further, especially for training purposes. Major difficulties can be avoided by identifying RS before cutting the cystic artery or duct during LC.

Comparative evaluation of propofol, thiopentone and etomidate on induction time, intubation response and recovery time during laparoscopic surgery under general Anaesthesia

: Optimal choice of inducing agent can partially modify the post induction hypotension, having a reported incidence of 9-40% in various studies. So, we compared the induction and recovery profile of the routinely available induction agents.This prospective randomized, comparative study was carried out on 120, ASA 1 and II patients undergoing routine laparoscopic cholecystectomy. Patient received either thiopentone 5 mg/kg, propofol 2.0 mg/kg or 0.3mg/kg injection etomidate at induction in group T, P and E respectively. The time taken from the administration of inducing agent to loss of eyelash reflex was noted. Heart rate, systolic, diastolic and mean arterial pressure, SpO2 was recorded at 1, 2, 3, 4, 5, 6 minutes and every five minutes after intubation. Steward score and the vitals were noted every 5 minutes after extubation till 30 minutes. It was noted that how long it took to get a Steward score of 6.The mean induction time (sec) was 49.85 ±2.54 in group T, 43.45 ±2.66 in group P and 52.675 ±2.11 in group E. (p<0.0001). The increase in mean heart rate from baseline upon induction and intubation was (10%, 31% in group T), (3%, 23% in group E) and (-7%, 16% in group P) (p<0.0001). Post induction decrease in systolic, diastolic and mean blood pressures observed in group T was (-9%, -4.5%, -6%), (-12.8%, -9.8%, -11%), in group P and (-4.6%, -1.7%, -2.9%) in group E. (p<0.0001). Post intubation increase in systolic, diastolic and mean blood pressures was (21.76%, 18%, 19.7%) in group T, (16%, 8.1%, 11.7%) in group E and (9.6%, 0%, 4%) in group P. Mean recovery time in min was 5.87 ±0.23 min with propofol, 6.97 ±0.28 with etomidate and 8.96 ±0.28 with thiopentone. (p<0.0001). : Amongst the three agents, we recommend propofol as preferred agent for induction due to faster induction, better attenuation of intubation response, faster recovery and stable hemodynamic parameters.

Clinical Outcome in Two Incision, Three Port Laparoscopic Cholecystectomy in Gall Stone Disease

Background Conventional laparoscopic cholecystectomy requires four different incisions to insert the four ports for various instruments. It has been seen that fourth trocar which is used to retract fundus of gall bladder is not required at all and laparoscopic cholecystectomy can be performed without using it. Various modification have been done in this regard. The present study is designed to evaluate the feasibility of two incision three port laparoscopic and its outcome in term of postoperative recovery. Methods A prospective study was conducted in a unit in Department of General Surgery, Government Medical College and Hospital, Chandigarh, India. 100 patients of either sex undergoing two incision laparoscopic surgery in gallstone disease from January 2018 to October 2019. Results In the study, two incision, three port laparoscopic cholecystectomy is safe and feasible technique with added advantage of significantly less port site pain, good satisfaction score and less operative time with experienced surgeon. Conclusions Two incision, three port laparoscopic cholecystectomy is feasible, safe and with good aesthetic results using the same instruments of conventional laparoscopic cholecystectomy, without increasing operative time and compromising safety. It could be recommended for routine laparoscopic cholecystectomy in place of conventional four port or three incision laparoscopic cholecystectomy.

Laparoscopic Cholecystectomy after Acute Biliary Pancreatitis in a Patient with Situs Inversus Totalis.

Situs inversus totalis (SIT) is a rare disorder defined as symmetrical transposition of thoracic and abdominal organs. Laparoscopic cholecystectomy (LC) is a routine surgical operation and gold standard for symptomatic gallstones. LC can be challenging in SIT due to patient positioning on the operating table and the surgeon's operating position, especially for right-handed surgeons. In this case, we share our experience of a 60-year male with a history of SIT presenting with acute epigastric pain. Serum amylase and lipase were increased and imaging studies showed multiple millimetric calculi in gallbladder. The patient was diagnosed as having acute biliary pancreatitis and admitted to the surgery ward. Intravenous fluids and symptomatic treatment were given. The patient recovered and a delayed LC was planned. During the operation, trocar sites were mirror images of routine LC and the operation was completed without complications. Diagnosis of acute abdominal pain and abdominal surgery in SIT patients can be demanding. Various transformations in standard LC are possible and SIT is not a contraindication for LC Key Words: Laparoscopy, Cholecystectomy, Situs inversus totalis, Pancreatitis, Gallbladder.

To evaluate the incidence of gallbladder content spillage and the factors contributing to it during laparoscopic cholecystectomy

Aim: To evaluate the incidence of gallbladder content spillage and the factors contributing to it during laparoscopic cholecystectomy.Materials and methods: The research comprises 100 consecutive laparoscopic cholecystectomy patients. The data was collected prospectively in accordance with the proforma, which documented the patient's detailed diagnosis, preoperative physical and ultrasound abdomen findings, intra-operative details such as technique, spillage of stones, cause of spillage, method and port of specimen extraction, duration of surgery, and postoperative events and complications. A one-week, one-month, six-month, and one-year postoperative follow-up was undertaken.Results: In our research, 100 consecutive laparoscopic cholecystectomy procedures were performed. There were 63 female patients and 37 male patients among them. The research group's average age was 49.85±11.58 years. The majority of the patients had several 1 cm movable gallstones. In 88% of patients, the procedure lasted between 30 and 60 minutes. Adhesions of varied degrees were found in 78% of the cases, resulting in a 7% conversion rate. Minimal bleeding was seen in 51% of the instances, significant haemorrhage in 37% of the cases, and no bleeding was observed in 12% of the cases. Gallstone leakage happened in 20% of the instances. In our research, the complication rate for laparoscopic cholecystectomy was 3%; however, the complication rate from spilled gallstones was 1%. At 1, 6, and 12 months of post-operative follow-up, no complaints about the procedure were noted.Conclusion: Leakage of gallstones and bile after routine laparoscopic cholecystectomy is uncommon and usually results in very minor problems. To prevent difficulties after a spill, it is crucial to remove the stones and do a peritoneal toileting.

UNEXPECTED GALL BLADDER CARCINOMA – A SURPRISING HISTOPATHOLOGICAL DIAGNOSIS

Objective: To determine the frequency of gall bladder carcinoma incidentally diagnosed in patients undergoing routine laparoscopic cholecystectomy. Material and Methods: Histopathology section of Pathology Department, Azra Naheed Medical College Raiwind Road, Lahore from January 2018 to July 2021. A total of 214 simple or laparoscopic cholecystectomy specimens were included. Detailed gross & microscopic examination was done. All diagnoses including benign histopathological findings and incidental gall bladder carcinoma were analyzed. The important findings like resection margin involvement, maximum wall thickness of gallbladder, type of adenocarcinoma and TNM staging were noted. Results: Out of 214 simple or laparoscopic cholecystectomy specimens, there were three (1.4%) cases of incidental gallbladder carcinoma exclusively found in females. Mean age recorded was 45.7 years. Maximum thickness of gall bladder wall was 4.7 cm and maximum stage was pT2. Conclusion: According to our study there were three cases of incidental gallbladder carcinomas out of 214 cholecystectomy specimens. Considering this, histopathological study of gall bladder is essential not to miss any carcinoma, keeping in view the grim prognosis. Key Words: Gall bladder, Incidental carcinoma, Cholecystectomy, Cholelithiasis.

A Study of the Safety and Morbidity Profile of Closed versus Open Technique of Laparoscopic Primary Peritoneal Access Port in Patients Undergoing Routine Laparoscopic Cholecystectomy at a Tertiary Care Hospital in Northeastern India.

Introduction Laparoscopic cholecystectomy (LC) is the gold standard operation for gallstone disease. Primary port placement into the abdomen is a blind procedure and is challenging with chances of unforeseen complications. The complication rate has remained the same during the past 25 years. Both closed/Veress and open/Hasson's techniques are commonly employed and have their typical indications for use. Materials and Methods This prospective study was carried out in the Department of General Surgery, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS), Shillong, from January 2014 to January 2016, with the aim to compare the safety profile of closed/Veress and open/Hasson's methods of access to the abdomen during laparoscopic cholecystectomy (LC). The study had 400 eligible cases undergoing LC who were randomly allotted into 2 groups with 200 cases each: group A: closed/Veress needle method and group B: open/Hasson's method. Results Closed/Veress and open/Hasson's method of establishing pneumoperitoneum in laparoscopic cholecystectomy is equally safe in terms of major complications. The closed/Veress method gives faster access to the abdomen as compared to the open method (5.62 ± 2.23 minutes and 7.18 ± 2.52 minutes, respectively, p value <0.0001). The open/Hasson's method is associated with more primary port site complications (9/200 vs. 0/200, p value 0.0036) and troublesome intraoperative gas leaks (39/200 vs. 2/200, p value <0.0001). The open technique for primary peritoneal access port for laparoscopic cholecystectomy does not impart any additional benefits in terms of safety and morbidity profile in patients undergoing LC. Conclusion The closed/Veress method of establishing pneumoperitoneum in laparoscopic cholecystectomy is equally safe in terms of major complications and gives quicker access to the abdomen as compared to the open method.

ROLE OF PROPHYLACTIC GATIFLOXACIN IN LAPAROSCOPIC CHOLECYSTECTOMY – A COMPARATIVE STUDY WITH CEFTRIAXONE

Objectives: The objective of this study was to evaluate and compare the effectiveness of gatifloxacin and ceftriaxone as prophylactic antibiotic in elective clean surgical procedures. Methods: Sixty patients, undergoing laparoscopic cholecystectomy, were recruited consecutively and divided into two groups, that is, Group A and Group B of 30 patients each. In Group A, a pre-operative dose of injection ceftriaxone 1 g was administered intravenously half an hour before induction of anesthesia and second dose was given 12 h postoperatively. In Group B, pre-operative dose of tablet Gatifloxacin 400 mg was administered night before operation and another tablet postoperatively when the patient started orally in the evening. If not accepting orally then single intravenous infusion of Gatifloxacin was given in the evening. Results: In Group A, one patient (3.33%) had grade 1 and two patients (6.66%) had grade 2 infection. Similarly in Group B, one patient (3.33%) had grade 1 and two patients (6.66%) had grade 2 infection. None of the patients in both the groups had severe post-operative wound infection (grade 3 and grade 4). Conclusion: Prophylactic gatifloxacin is non-inferior to the “current gold standard ceftriaxone” as far as effectiveness of the drug is concerned. In addition, it had a similar side effect profile and was equally safe as a prophylactic antibiotic in preventing wound infection following routine elective laparoscopic cholecystectomy.

Clinical outcome of subtotal cholecystectomy for difficult gallbladder

When the Calot triangle structures cannot be found and a critical evaluation of patient safety cannot be achieved, surgeons perform a subtotal cholecystectomy (SC). objective Evaluation and analysis of the outcomes of subtotal cholecystectomy at the GIT and Hepatology teaching Hospital is to be conducted. Retrospective analysis of patient data and research methodologies thirteen hundred and eighty onsecutive cholecystectomy patients at GIT &amp; Hepatology Hospital (Oct.2017 to Apr.2020). 53 of the 1380 people investigated underwent a partial cholecystectomy. Routine laparoscopic or open cholecystectomy patients (13.27) could not be included in the study. An individual patient's medical history is mined for information on their preoperative features. Results 53 individuals had subtotal cholecystectomy, with 29 males (55.7%) and 24 women (24.8%) both undergoing the procedure (45.2 percent ). Patients in the research, who ranged in age from 20 to 69, had an average age of 43.5 years. The bulk of the 45 patients (87.2%) had elective surgery, whereas only 8 (15%) had emergency surgery. There were 33 cases of laparoscopic subtotal cholecystectomy and only 20 cases of open subtotal cholecystectomy in this study (6 patients had conversion subtotal cholecystectomy).

The effect of checklists on the surgical performance during laparoscopic cholecystectomy: A systematic review

Laparoscopic cholecystectomy (LC) is known to be one of the most widely performed general surgical operations. However, it is associated with an increased incidence and severity of complications especially during the period of a surgeon's proficiency-gain curve. Certain complications could be prevented by decreasing the incidence and consequences of surgeon errors. We aimed to systematically review the application of checklists during LC and their effect on the surgical task performance. A systematic review was performed in compliance with the PRISMA guidelines. A search was performed on PubMed, ScienceDirect and the Cochrane-Library databases. English language articles published to November 2020 were included in this study. The terms included: ‘Checklist and laparoscopic cholecystectomy’, ‘checklist and laparoscopic surgery’, ‘checklist and cholecystectomy’ and checklist and minimally invasive surgery’’. MERSQI score was applied for quality assessment. The research protocol was registered with PROSPERO register (CRD42021209118). The systematic search resulted in 8862 citations, of which 23 relevant citations were assessed for eligibility. A final 9 articles (1079 procedures) were included. The endpoints were equipment-related-risk events, numbers and types of adverse events, rate of conversion to open cholecystectomy, team communication and coordination, the number of consequential and inconsequential errors. MERSQI mean score was 10.8 (range 5 to 13). The positive effect of checklists on the performance during LC was supported with 5 high-quality studies. The effect of the checklists application during LC showed a significant improvement of the surgical task performance by decreasing the surgeons’ errors. A combination of pre-operative safety and intra-procedural checklists can be the subject of future research for possible application during routine laparoscopic cholecystectomy.

P-BN59 Danger is there, do we want to know about it? Routine intra operative cholangiography highlights dangerous biliary anatomy for safer cholecystectomy

Abstract Background Normal biliary anatomy is uncommon. Different classification for biliary anatomy has been described, with Huang Types A4 &amp; A5 of great interest for laparoscopic cholecystectomy (LC) due to the proximity of aberrant bile duct to Cystic duct (CD). These types of dangerous anatomy might contribute to bile duct injury. This study aims to analyse the prevalence of dangerous biliary anatomy. Methods Prospectively collected data for all patients who underwent laparoscopic cholecystectomy was analysed. All LC were performed by single surgeon or under his direct supervision, between 01/07/2020 and 20/08/2021. Index admission and single session management of cholelithiasis disease with routine Laparoscopic cholecystectomy + intra operative cholangiography (IOC) +/- LCBD exploration were standard practice. Results Laparoscopic cholecystectomy was performed in 137 patients. Mean age was 56y (17-84). 62% were females. 66% of Laparoscopic cholecystectomies were emergency. IOC was performed in 92% of cases. Abnormal biliary anatomy was found in 54% : Huang A1 - 48%, A2 - 29%, A3 - 12%, A4 - 9.7% and A5 - 0.7%. Dangerous anatomy (A4 and A5) was found in 10.5%, 78 % were females. Female with dangerous anatomy were younger than males 49 y, 60y respectively. Nassar difficulty grading for dangerous anatomy was as follows: G2 28%, G3 42% and G3 28% Abnormal cholangiogram was found in 48%, due to filling defect in 58%, no contrast flow into duodenum in 4%, Cystic duct stone in 4%, and short CD in 8%. CBD stones were treated using transcystic approach in 92% of cases. No intra-operative or post operative complications were recorded for patients with dangerous anatomy. Conclusions This study demonstrates that dangerous biliary anatomy, that could lead to bile duct injury is relatively common, occurring in 10.7% of LCs. Routine intra-operative cholangiography highlights these high-risk variations in biliary anatomy and may prevent inadvertent bile duct injury in such cases.

Predictors of Difficult Laparoscopic Cholecystectomy on Humanitarian Missions to Peru Difficult Laparoscopic Cholecystectomy in Surgical Missions

Laparoscopic cholecystectomy (LC) is the gold standard treatment of gallstone disease. On short-term surgical missions (STSMs), it is unclear what factors can predict safety of LC. This study evaluates patient risk factors of difficult LC in Northern Peru, towards optimizing outcomes. A retrospective review was performed of patients who underwent LC during short-term surgical missions to Peru from 2016-2019 under the International Surgical Health Initiative (ISHI). Difficult and routine LC groups were compared for: age, weight, gender, symptom duration, pain on presentation, history of abdominal or pelvic surgery, diabetes and hypertension. 68 of 194 patients underwent LC; 42 patients (62%) were classified as difficult with OR (operating room) time > 70 min (90%), 2 cases converted to open (5%) and 2 aborted cases (5%). Higher weight class was found to correlate with difficult LC. Increased patient weight was correlated to longer operative time during STSMs. Patients undergoing LC must be selected carefully to mitigate risks of difficult operations on STSMs.

Gallbladder Torsion Masking as Acalculus Cholecystitis: A Review of Two Cases Including Unsuccessful Management With Percutaneous Cholecystostomy

Gallbladder torsion is a rare cause of abdominal pain; however, it is important to diagnose pre-operatively. We report two cases of gallbladder torsion, both of which were not recognized until the time of surgery. Both patients were elderly thin females, presenting with right upper quadrant pain, and on examination had a positive Murphy’s sign, and pre-operative imaging was suggestive of acalculus cholecystitis. One patient was initially managed by percutaneous insertion of a cholecystostomy tube, with progression to a laparoscopic cholecystectomy after a failure of resolution of symptoms. The second patient was taken to theater shortly after presentation, with the gallbladder torsion recognized intra-operatively. In both cases, the gallbladder was distorted and a routine laparoscopic cholecystectomy was performed with good recovery following. These two cases highlight the need for gallbladder torsion to be considered as a diagnostic possibility in those presenting with right upper quadrant pain, particularly those groups at most risk, including elderly thin females. Whilst other causes of cholecystitis can be managed non-operatively, at least in the acute phase, gallbladder torsion requires urgent operative intervention. J Med Cases. 2021;12(6):223-225 doi: https://doi.org/10.14740/jmc3683

Gallbladder carcinoma - when to use laparoscopic approach?

To assess how laparoscopy has altered the presentation of patients with gallbladder cancer and determine whether radical resection in patients with gallbladder cancer is beneficial. 47 patients underwent surgery because of suspected gallbladder cancer. Cancer was found incidentally in 29 patients (61.7 %) during routine laparoscopic cholecystectomy using frozen biopsy. Gallbladder cancer had been diagnosed preoperatively in the other 18 patients (38.3 %). Patients in whom carcinoma was found incidentally at laparoscopic cholecystectomy had a significant increase in survival when compared with those who were admitted electively with a known diagnosis. All patients who presented with a known diagnosis had stage II or higher, and 38.3 % of these were in stage IV. However, 58.6 % of those patients who were found incidentally were in stage I or II. The overall 2-year survival for all patients was 45 %; those discovered incidentally at laparoscopic cholecystectomy (Tis-T2) had a 2-year survival of 87 %. Laparoscopic cholecystectomy resulted in an earlier discovery of gallbladder cancer in some patients, resulting in increased probability of survival. Adjunctive radical surgical resection, either at the time of cholecystectomy or subsequently, increases survival significantly in early stage disease (Tab.2, Fig. 2, Ref. 24). Text in PDF www.elis.sk Keywords: gallbladder carcinoma, laparoscopic approach.

Incidental carcinoma of gallbladder following laparoscopic cholecystectomy: A single center study

Background: Gallbladder adenocarcinoma is the most common malignant tumor of the biliary tract. Most of gall bladder cancers are detected incidentally only after pathological examination of the excised surgical specimens. In this study we investigated the characteristics of incidental gallbladder cancers in our center. Material &amp; methods: We retrospectively reviewed all of the cholecystectomy specimens in sent for histopathology following laparoscopic cholecystectomy in the study period from January 2015 to October 2019. Clinicopathological characteristics were extracted from the patients' clinical charts, which included symptoms, radiological findings, laboratory data, and surgical procedures as well as outcome. Results: We identified 6 cases of incidental gall bladder cancer, consisting of 4 women and 2 men ranging in age from 28 to 77 years (mean age 60.5 after pathological study of 1530 resected gall bladders. Out of the 6 cases, 1 case was carcinoma in situ of gall bladder, 1 was T1b and other 4 cases were T2 carcinoma. Conclusions: The rate of incidental gallbladder carcinoma in our study was 0.39%. This lower incidence could in part be due to increasing use of routine laparoscopic cholecystectomy for symptomatic gallbladder. This strategy of increased early intervention further adds to the advantage of higher chances of gallbladder cancer detection in early stages, and thus better prognosis.

Surgical Management of Gallbladder Carcinoma

Gallbladder carcinoma is the commonest malignancy of the hepatobiliary system. It is plagued by the dismal outcome in terms of 5-year survival and high recurrence rate. The varying presentation from an incidental surprise during routine laparoscopic cholecystectomy for gallstone disease to presentation in advance stage. Surgical resection remains the only curative alternative; however, it is only possible in few patients at the time of diagnosis. Although, radical cholecystectomy is said to be the standard of surgical care, yet the extent of liver resection, lymphadenectomy, bile duct resection, adjacent organ resection, and palliative surgical treatment needs to be elaborately discussed. The resection of tumor with R0 margin with appropriate lymphadenectomy is the only hope for long-term survival. Revision surgery should be considered in patients who underwent simple cholecystectomy with incidentally diagnosed gallbladder carcinoma that invaded muscularis propria or beyond. The advance lesions are treated non-operatively with palliative intension. This review discusses the current surgical treatment options in patients with gallbladder cancer depending on the stage of disease.

Benign Bile Duct Strictures

Bile duct strictures can prove to be an extremely difficult diagnostic problem. The majority of Benign bile duct strictures (80%) are unfortunately iatrogenic, the injury occurring after a routine laparoscopic (incidence 0.4-0.6%) or open (incidence 0.2-0.3%) cholecystectomy. The existence of a number of anatomical variations add to the incidence of biliary injury either in isolation or with associated vascular injury. There are also a number of other causes of both iatrogenic and non-iatrogenic causes of benign bile duct strictures. Improved imaging modalities have aided the recognition of the anatomical extent of the stricture and in planning the treatment. Classification of bile duct injury was described by Bismuth in 1982, further modifications were described by Strasberg in 1995. Associated vascular injuries were classified both by Stewart-Way and Bektas et al in the Hannover Classification in 2007. Treatment of biliary stricture depends on the time of diagnosis and type of final injury. While surgery provides the mainstay of treatment, certain select conditions may lend themselves to endoscopic therapy and interventional therapy.

Iatrogenic Right Hepatic Duct, Right Posterior Hepatic Duct, Right Hepatic Artery and Duodenum Injury during Routine Laparoscopic Cholecystectomy Due to Symptomatic Gallstones: Rare but Serious Complication - Case Report and Literature Review

Laparoscopic cholecystectomy is a very frequent surgical procedure with a low complication rate. The reasons for such complications range from anatomical anomalies, obesity, poor exposure of anatomic structures, bleeding or lack of surgical experience. If complications arise, prompt recognition and correct management are essential. Early and correct treatment allows avoidance of serious complications, such as secondary biliary cirrhosis, hepatic failure, and ultimately death. In this paper is presented a case of a 40-years-old male patient, who sustained iatrogenic major bile duct, right hepatic artery and duodenum injury during routine laparoscopic cholecystectomy due to symptomatic gallstones.

Patients support transfer of care for unexpected findings in laparoscopic cholecystectomy.

Surgeons often assume patients may be dissatisfied if their operations were stopped due to suspicious intraoperative findings requiring transfer of care. We sought to assess patient opinions regarding transfer of care for unexpected intraoperative findings during laparoscopic cholecystectomy with and without bile duct injury (BDI). The investigators developed two clinical scenarios comparing transfer of care for unexpected intraoperative findings during elective laparoscopic cholecystectomy: without BDI and with BDI requiring open repair. A multi-institutional structured telephone interview process was conducted with patients ≥ 18years of age who had an outpatient, uncomplicated laparoscopic cholecystectomy within the last year. The first scenario presented a case of suspicious findings prompting the surgeon to stop and transfer for specialized care; whereas the second case was a BDI requiring transfer of care. Textual and thematic analysis as well as descriptive statistics was used for analysis, with significance set at p < 0.05. Forty-five patients completed the survey. Satisfaction with transfer of care for unexpected intraoperative findings without BDI was 69%, and over 95% of respondents were satisfied their surgeon stopped the procedure to initiate transfer due to safety concerns; 64% of patients would return to that surgeon for postoperative care; and 78% would see that surgeon again. In the scenario with BDI requiring open repair, 86% were satisfied with their surgeon's decision to stop the operation; 91% of patients were satisfied with transfer of care; and 32% would see their first surgeon again. Themes of prioritizing safety and transparency were frequently cited. Patients prioritize safety and are satisfied with halting a procedure to facilitate transfer of care for suspicious intraoperative findings during routine laparoscopic cholecystectomy.