Short Cystic Duct Research Articles

Safety and efficacy of using stapler device for wide cystic duct ligation in acute setting of laparoscopic cholecystectomy

This research explores the challenges posed by variations in cystic duct anatomy during laparoscopic cholecystectomy and the potential use of stapler devices to address such complexities. It aims to assess the safety and efficacy of stapler devices, particularly in cases involving short, and wide cystic duct. The study, conducted at King Abdulaziz Medical City in Riyadh, Saudi Arabia, between 2021 and 2023. The study design involved a retrospective cohort approach, and the sample size encompassed all cases meeting the inclusion criteria during the study period. Data was analyzed using SPSS program. The study involving 568 patients, with the predominant technique for ligation being clipping (89.3%). The primary indication for using the Endo GIA stapler was a wide cystic duct (6.2%). Analysis revealed a significant association between stapler device use and hypertension (p = 0.042), diabetes (p = 0.001), CKD (p = 0.011), and obstructive jaundice (p = 0.006). Multivariate regression demonstrated that older patients were 2.1 times more likely to use stapler devices (AOR = 2.125; p = 0.039), while those with obstructive jaundice had a 2.2 times higher likelihood (AOR = 2.168; p = 0.049). Throughout the years, metal clips have shown the best prognosis compared to any other method for securing the cystic duct during closure in laparoscopic cholecystectomy. However, to avoid incomplete sealing of wide, short, or inflamed ducts, other instruments have emerged as possible alternatives for such conditions. Use of Endo-GIA is a safe and effective method for patients with wide, short cystic duct. Selective usage of endo-GIA is considered cost effective and may add a positive impact in decreasing post operative biliary leak.

Evaluation of Variation in the Calot’s Triangle at a Tertiary Care Hospital in Northern Uttar Pradesh, India: A Cross-sectional Study

Introduction: Cholelithiasis is the most common disease worldwide, and laparoscopic cholecystectomy is the standard treatment of choice. To perform laparoscopic cholecystectomy, it is essential to understand the critical view of safety, which primarily involves the dissection of Calot's triangle. Anatomical variations in Calot's triangle exist, and understanding them is crucial to avoid unintended situations during surgery. Mirizzi syndrome, a rare complication in Calot's triangle, can significantly increase mortality and morbidity rates. Aim: To evaluate the anatomical variations in the Calot’s triangle. Materials and Methods: A cross-sectional study was conducted at Mayo Institute of Medical Sciences, Department of General Surgery, from October 2021 to September 2022. The total sample size included 100 patients with gallstone disease who underwent surgical intervention. Intraoperative findings, such as variations in the cystic artery and cystic duct, as well as Mirizzi syndrome grading, were recorded in an Excel sheet and tabulated. The results were expressed in terms of frequency and percentage. Results: The average age of the patients was 39.42±12.11 years, with females outnumbering males. Among them, 28% had a cystic artery lying outside of Calot's triangle, and 96% had a cystic artery originating from the right hepatic artery. The remaining 2% originated from an aberrant right hepatic artery, 1% from the left hepatic artery, and 1% from the gastroduodenal artery. Cystic duct variations were found in 5% of cases. Of these, 2% had a short cystic duct (<2 cm), 1% had a long cystic duct (approximately 5 cm), one patient had an absent cystic duct, and one had a low insertion into the common hepatic duct. Mirizzi syndrome Grade-I and Grade-II patients accounted for 4% and 2% respectively, while Grade-III, Grade-IV, and Grade-V each contributed to 1%. Conclusion: Knowledge of Calot's triangle variations is crucial, especially for aspiring surgeons, as it helps them make decisions promptly when encountering difficulties during surgery. Understanding the Calot's region ensures the safety not only of patients but also of surgeons.

How to avoid iatrogenic injuries of the biliary tract in urgent surgery? The use of indocianine green is an alternative.

Iatrogenic bile duct injury is a rare complication, although feared due to its morbidity and mortality. In urgent surgeries, its incidence can be doubled, so in selected cases we must assess the use of resources such as indocyanine green to minimize the risk of biliary or arterial lesions by allowing the correct identification of the structures. We present the case of a 57-year-old patient with acute cholecystitis who underwent laparoscopic cholecystectomy. Given the difficulty in differentiating structures in Calot's triangle, the decision was made to use indocyanine green, which identifies a very short cystic duct, thus avoiding iatrogenic bile duct injury.

Anatomical Variations of Cystic Ducts in Magnetic Resonance Cholangiopancreatography: A Retrospective Study With 265 Patients

Background: Anatomical variations of cystic duct (CD) are frequently unrecognized. It is important to be aware of these variations prior to any surgical, percutaneous, or endoscopic intervention procedures. Objectives: The purpose of our study was to demonstrate the imaging features of cystic duct and its variants using magnetic resonance cholangiopancreatography (MRCP) and document their prevalence in our population. Materials and Methods: This study included 265 patients who underwent magnetic resonance cholangiopancreatography due to different indications and variations of cystic duct were documented. Results: Normal lateral insertion of cystic duct at middle third of common hepatic duct was seen in 29.43% of cases. Medial insertion was seen in 2.63% of cases, 2.26% were low medial insertions. Low insertion of cystic duct was noted in 1.51 % of cases. Parallel course of cystic duct was present in 0.38% of cases. High insertion was noted in 0.38% cases and no case of short cystic duct was noted. No case of cystic duct draining into right hepatic duct was seen. Conclusion: Cystic duct variations are common and MRCP is an optimal imaging modality for demonstration of cystic duct anatomy. KEY WORDS: Cystic Duct, Hepatic Duct, Variation, MRCP.

Invited Commentary: Advancing the Safety of Laparoscopic Cholecystectomy-Collaboration between Radiologists and Surgeons.

Invited Commentary: Advancing the Safety of Laparoscopic Cholecystectomy-Collaboration between Radiologists and Surgeons.

Gross Anatomical Variations of Cystic Duct: A Cadaveric Study

Aim: To determine the frequency of anatomical variations of cystic duct. Study design: Descriptive Case Study Place and duration of study: Anatomy Department of King Edward Medical University Lahore and duration of study was from August 2018 to December 2019. Methodology: The dissection of 43 cadavers was done and extra hepatic biliary tract was explored. The length of cystic duct and site of insertion of cystic duct in common hepatic duct was noted. The length of cystic duct <1 cm was taken as short cystic duct and >4cm as long cystic duct. The insertion of cystic duct near porta hepatis is high insertion and near duodenum is low insertion. Results: The mean length of cystic duct was 2.67±0.71 cm. Out of 43 cadavers 2(4.7%) of cadavers had short cystic duct. 41(95.3%) of cadavers had normal length of cystic duct. There was no cadaver observed with long cystic duct. Out of 43 cadavers 39(90.7%) of cadavers had mid insertion of cystic duct, 4(9.3%) of cadavers with high insertion of cystic duct and no cadaver with low insertion. Conclusion: The most common anatomical variation of cystic duct is high insertion of cystic duct 9.3%. Keywords: Anatomical variations, cystic duct, cholecystectomy.

Indocyanine green (ICG) fluorescent cholangiography during laparoscopic cholecystectomy using RUBINA\u2122 technology: preliminary experience in two pediatric surgery centers

BackgroundRecently, we reported the feasibility of indocyanine green (ICG) near-infrared fluorescence (NIRF) imaging to identify extrahepatic biliary anatomy during laparoscopic cholecystectomy (LC) in pediatric patients. This paper aimed to describe the use of a new technology, RUBINA™, to perform intra-operative ICG fluorescent cholangiography (FC) in pediatric LC.MethodsDuring the last year, ICG-FC was performed during LC using the new technology RUBINA™ in two pediatric surgery units. The ICG dosage was 0.35 mg/Kg and the median timing of administration was 15.6 h prior to surgery. Patient baseline, intra-operative details, rate of biliary anatomy identification, utilization ease, and surgical outcomes were assessed.ResultsThirteen patients (11 girls), with median age at surgery of 12.9 years, underwent LC using the new RUBINA™ technology. Six patients (46.1%) had associated comorbidities and five (38.5%) were practicing drug therapy. Pre-operative workup included ultrasound (n = 13) and cholangio-MRI (n = 5), excluding biliary and/or vascular anatomical anomalies. One patient needed conversion to open surgery and was excluded from the study. The median operative time was 96.9 min (range 55–180). Technical failure of intra-operative ICG-NIRF visualization occurred in 2/12 patients (16.7%). In the other cases, ICG-NIRF allowed to identify biliary/vascular anatomic anomalies in 4/12 (33.3%), including Moynihan's hump of the right hepatic artery (n = 1), supravescicular bile duct (n = 1), and short cystic duct (n = 2). No allergic or adverse reactions to ICG, post-operative complications, or reoperations were reported.ConclusionOur preliminary experience suggested that the new RUBINA™ technology was very effective to perform ICG-FC during LC in pediatric patients. The advantages of this technology include the possibility to overlay the ICG-NIRF data onto the standard white light image and provide surgeons a constant fluorescence imaging of the target anatomy to assess position of critical biliary structures or presence of anatomical anomalies and safely perform the operation.

The Study of Laparoscopic Cholecystectomy in Acute Cholecystitis, Complication and Management: Analysis of 150 Cases in the Ibn Sina Medical College, Bangladesh

Background: Laparoscopic Cholecystectomy has now become a better option instead of the Open Cholecystectomy for treatment of Cholelithiasis that it has been a gold standard for the Cholelithiasis condition throughout the Globe. Last century was the most fruitful era for the treatment of the biliary tract disease as it has already proved the progress from the open to laparoscopic surgery with a single port surgery.
 Methods: The purpose of our study is to grading of the Laparoscopic Cholecystectomy in Acute Cholecystits and has been studying the outcome of problematic and challenging Laparoscopic Cholecystectomy cases, its’ complication (s) and management to decide when to converting Laparoscopic Cholecystectomy to Open Cholecystectomy. The study analyzes the conversion rate of Laparoscopic Cholecystectomy in the Ibn Sina Medical College, Kallyanpur, Dhaka, Bangladesh. This is a retrospective study of 150 patients (Male - 75% and Female - 25%) which was conducted during the period from January 2015 to January 2017.
 Results: Out of the 150 cases 140 (93%) had been successfully operated by Laparoscopic Cholecystectomy. And, only 10 (7%) cases (out of a total of 150) got converted from the Laparoscopic to Open Cholecystectomy and they belonged to Grade - E with severely contracted gallbladder, morbid adhesion, short cystic duct and bile duct injury.
 Conclusions: The Laparoscopic Cholecystectomy has familiar as a unique procedure of choice for the management of symptomatic gall bladder. Laparoscopic Cholecystectomy intra operatively for grade A to E where Grade A is very easy level to perform Gall Bladder Surgery to Grade E where conversion is 115% due to bad.
 Bangladesh Journal of Medical Science Vol.20(2) 2021 p.318-322

Anomalous anatomical variation in extrahepatic biliary tree and pancreas and its related vessels: a cadaveric study

Background: Congenital anamolies of extrahepatic biliary apparatus and pancreas have long been recognized and are of clinical importance because when present may surprise the surgeon during surgery and lead to iatrogenic injuries. Surgeries on extra-hepatic biliary apparatus and pancreas are regularly performed throughout the world. Thus insight into the normal anatomy and congenital variations will reduce complication and definitely improve outcome.Methods: Study was conducted in department of surgery GMC Bhopal and dissection was carried out in Department of Forensic Medicine on 100 cadavers with approval from ethical committee.Results: In 100 cases 70 were male and 30 female. The most common variation in extra hepatic biliary apparatus was short cystic duct was found in 6% cases then formation of common hepatic duct by union of right hepatic duct and left hepatic duct was intrahepatic in 3% cases. There was low insertion of cystic duct with common hepatic duct in 1% case. Cystic artery originating from left hepatic artery in 1% case, in 1% case cystic artery was anterior to common hepatic duct. In Pancreas anterior arterial arcade was absent in 2% cases and its origin varied in 2% case. Posterior pancreatic arcade absent in 1% cases and variation in origin was present in 1% case. The variation in pancreatic duct course was present in 22% cases.Conclusions: Thus significant variation was seen and it could definitely be helpful to hepatobiliary, laproscopic surgeons, radiologist and will further contribute to literature on variation of extrahepatic biliary apparatus and pancreas and its related vessels.

Role for laparoscopy in the management of bile duct injuries.

Common bile duct (CBD) injury is the most serious complication of laparoscopic cholecystectomy. Recently, laparoscopic techniques have been used in the management of postoperative bile leak and CBD injury; this literature has not been reviewed. We reviewed the literature on CBD injury, the approach to its diagnosis and management, and reports of laparoscopic management techniques. We combined this review with our experience in laparoscopic methods to highlight diagnostic and therapeutic options. Laparoscopic techniques can be used to prevent, diagnose and treat CBD injuries. Intraoperatively, CBD injury can be prevented in the case of short cystic duct with the use of a loop ligature or transfixing suture, and it can be diagnosed using intraoperative cholangiography or other visualization techniques. When CBD injury is suspected postoperatively, repeat laparoscopy can be used to control sepsis with abdominal washout; as a diagnostic tool to guide management; and, in some settings, as a therapeutic tool for suturing small duct leaks, drain insertion and postoperative endoscopic retrograde cholangiopancreatography with sphincterotomy. Definitive laparoscopic repair is possible when certain criteria are met. Open surgery should be considered when the CBD is small, the injury occurred more than 72 hours previously, injury or anatomy are complex, port positioning is awkward for repair, or local experience is limited with laparoscopic management. There is an emerging role for laparoscopy in the management of CBD injuries. More case reports and series are needed to show the safety and efficacy of this technique, encourage its wider adoption, and allow outcomes assessment on a larger scale.

Acute Care Surgeon: Use of the Endo GIA Stapler for Cystic Duct Ligation in Emergent Cholecystectomy

ABSTRACT Introduction Endo GIA stapler use is a method to ligate cystic ducts during laparoscopic cholecystectomy in the elective and emergent setting. Its use has not been widely described in the acute care surgery (ACS) setting. Our study aims to determine factors predicting Endo GIA use by acute care surgeons and evaluate when applied its safety and efficacy in emergent cholecystectomy. Additionally, we investigate the use of Endo GIA stapler with respect to conversion to open surgery, reduction in postoperative morbidity, and impact on length of stay in an ACS setting. Materials and methods A retrospective chart review was conducted for laparoscopic cholecystectomy performed by ACS in a public university training hospital over 1 year. Variables associated with Endo GIA stapler use were identified through multivariate logistic regression and subsequently, assessed after optimizing the model to control for confounding effects. Results Of the 118 laparoscopic cholecystectomies performed, the Endo GIA Stapler was used for cystic duct ligation in 20 cases. Surgeons’ dictated reason for stapler use included dilated cystic duct (45%), short cystic duct remnant (15%), inadequate room for clip ligation and division (10%), and nonspecific (45%). Patient demographic variables for Endo GIA stapled and clipped groups were not significantly different. Logistic regression revealed a significantly higher likelihood of Endo GIA stapler use in patients with comorbid biliary duct disease, preoperative endoscopic retrograde cholangiopancreatography (ERCP), and a trend towards significance in patients with previous emergency department (ED) visits. There was no significant difference in conversion to open surgery, postoperative morbidity, and postoperative length of stay. Conclusion Comorbid biliary duct disease, previous ED visits, and preoperative ERCP are predictive of patients requiring use of the Endo GIA stapler for cystic duct ligation during emergent cholecystectomy. The use of Endo GIA stapler by Acute Care Surgeons is safe and effective. How to cite this article Truche P, Blitzer D, Scott E, Hanna J, Gracias V, Peck G. Acute Care Surgeon: Use of the Endo GIA Stapler for Cystic Duct Ligation in Emergent Cholecystectomy. Panam J Trauma Crit Care Emerg Surg 2017;6(1):44-48.

Dome down approach for difficult laparoscopic cholecystectomy

Background Visualization of anatomical structures during laparoscopic cholecystectomy may be impaired by difficulties including severe inflammation in Calot's triangle, a short cystic duct, tenting of the ductal structures, or Mirizzi's syndrome. Purpose To evaluate the feasibility, safety, and outcome of dome-down laparoscopic cholecystectomy in difficult cholecystectomy. Patients and methods A total of 60 patients with difficult laparoscopic cholecystectomy as decided intraoperatively were enrolled. The dome-down technique was used after a trial of the conventional procedure. Results There were 33 women (55%) and 27 (45%) men. Their age ranged from 18 to 68 years. Preoperative prediction of difficulty of the operation was anticipated in 37 cases (61.7%). The mean operative time was 102.84 (92-150) min. The conversion rate was 8.3%. The mean hospital stay was 2.5 (2-5) days. Conclusion Dome-down laparoscopic cholecystectomy is a feasible and applicable procedure during difficult cholecystectomy, and yet it needs a learning curve for optimum results.

Surgical anatomy of sub-hepatic biliary system

IntroductionThe anatomy of liver and extra-hepatic biliary apparatus has always been the focus of attention among anatomists and surgeons. It has gained greater significance in the recent years in view of technical refinements in the field of cholecystectomy, hepatic surgery and transplantation. Present study emphasizes the normal as well as variations of extra-hepatic biliary apparatus, as most of the published work on the surgical anatomy of the extra-hepatic biliary apparatus refers various ethnic groups variations. Literature on this topic in western U.P. subjects is scanty. MethodA study was conducted on 59 individuals undergoing hepatobiliary surgery after informed consent in the Department of Surgery and on 30 cadavers in the Department of Anatomy, LLRM Medical College Meerut, and Saraswathi Institute of Medical Sciences, Hapur during September 2004 to May 2011. ResultThe study revealed that in all cases, the union of hepatic ducts was extra-hepatic, of which 10% were angular low union and 5% parallel low union. In 95% cases cystic duct had angular union and 4% had parallel type of union with common hepatic duct and in one case cystic duct united with accessory hepatic duct. 16% cases had short cystic duct i.e. 1–2 cm in length. 94% cases show usual relation in hepatoduodenal ligament and in 6% common bile duct was to the left of hepatic artery. DiscussionThe obtained results presented variations regarding certain parameters when compared to previous studies and they represent the ethnic parameters of western UP.

Abnormal Anatomical Variations of Extra-Hepatic Biliary Tract, and Their Relation to Biliary Tract Injuries and Stones Formation.

BackgroundTo determine the most common abnormal anatomical variations of extra-hepatic biliary tract (EHBT), and their relation to biliary tract injuries and stones formation.MethodsThis is a retrospective review of 120 patients, who underwent endoscopic retrograde cholangiopancreaticography (ERCP) and/or magnetic resonance cholangiopancreaticography (MRCP), between July 2011 and June 2013. The patients’ ERCP and MRCP images were reviewed and evaluated for the anatomy of EHBT; the medical records were reviewed for demographic data, biliary tracts injuries and stones formation.ResultsOut of 120 patients, 50 were males (41.7%) and 70 were females (58.3%). The mean age was 54 years old (range 20 - 88). Abnormal anatomy was reported in 30% (n = 36). Short cystic duct (CD) was found in 20% (n = 24), left CD insertion in 5% (n = 6), CD inserted into the right hepatic duct (RHD) in 1.7% (n = 2), duct of Luschka in 3.33% (n = 4) and accessory hepatic duct in also 3.33% (n = 4). Biliary tract injuries were reported in 15% (n = 18) and stones in 71.7% (n = 86). Biliary tract injuries were higher in abnormal anatomy (P = 0.04), but there was no relation between abnormal anatomy and stones formation.ConclusionAbnormal anatomy of EHBT was found to be 30%. The most common abnormality is short CD followed by left CD insertion. Surgeons should be aware of these common abnormalities in our patients, hence avoiding injuries to the biliary tract during surgery. The abnormal anatomy was associated with high incidence of biliary tract injury but has no relation to biliary stone formation.

3-T MRI of the biliary tract variations

The gallbladder and the biliary tract are structures in close connection with the adjacent organs and may show a number of variations and anomalies. It is therefore important for surgical purposes to know their anatomy and variations in detail. Various methods are used in the imaging of the variations of the biliary tract and its pathologies, including ultrasonography, computed tomography; direct cholangiographic methods like endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, intravenous cholangiography and T-tube cholangiography, as well as indirect methods like magnetic resonance cholangiopancreatography (MRCP) or cholescintigraphy. The aim of this study is to investigate the frequency of the anatomic variations of the biliary tract using 3-T MRCP and to compare the findings with the data in the literature. For the purposes of this study, patients who underwent MRCP at our hospital (Dicle University Hospital) between November 2009 and February 2012 were investigated retrospectively. A total of 590 patients (between 6 and 88 years of age; mean age: 51 ± 9 years) were included in the study. The MRCP imaging was carried out with an magnetic resonance imaging (MRI) device supplied with 3-T magnetic power and by obtaining T2-weighted images through the single-shot fast spin echo technique using the standard body coil. The axial and coronal source images and the reformatted images were evaluated together in terms of the possible anatomic variations. Among the 590 patients included in the study, of 233 (39.5 %) showed anatomic variations at different levels in the intra- and extrahepatic biliary tracts. Among these variations, a right posterior hepatic duct insertion to the left hepatic duct at the level of the bifurcation has been observed in 71 patients (12.1 %), trifurcation was observed in 30 patients (5.1 %) and insertion into the main hepatic duct at the proximal aspect of the cystic duct was observed in 18 patients (3.1 %). At the level of the cystic duct, medial insertion of the cystic duct was viewed in 58 patients (9.8 %), distal medial insertion was seen in 40 patients (6.8 %), a short cystic duct was detected in 10 patients (1.7 %), pancreatobiliary junction anomaly was viewed in two patients (0.4 %) and duplicate anatomic variations have been observed in 42 patients (7.2 %). MRCP studies conducted using 3-T MRI devices may reveal similar or greater numbers of variations when compared to the existing MRCP studies in the literature. 3-T MRI shows a couple of variations. Pointing out these anatomical variations before the surgical intervention may prevent possible iatrogenic traumas. Donors with unsuitable variations for liver transplant may be spotted out at an early phase through the MRCP and certain operations with a high morbidity rate may thus be avoided.

Difficult Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy is the treatment of choice for gall bladder stone disease. Difficult cholecystectomy is associated with serious complications and a high conversion rate. The aim of this study was to review the current strategies to manage difficult cholecystectomy. A Medline search was conducted to review all published English literatures relevant to difficult cholecystectomy through 1993 to 2009. The search words were "laparoscopic cholecystectomy," "difficult cholecystectomy," "difficult laparoscopy," "subtotal laparoscopic cholecystectomy," "fundus first cholecystectomy," and "causes of conversion of laparoscopic cholecystectomy." Ninety-one studies, which included 324,553 patients, were selected for this review. Five major categories of difficulty were identified. Conversion rate and iatrogenic injuries during laparoscopic cholecystectomy are still high despite significant improvement over the last 10 years. Depending on the technique of cholecystectomy, the degree of gall bladder inflammation, patient comorbidities, and surgical experience, the conversion rate was reported between 0.18% and 30%, whereas the incidence of iatrogenic injuries was from 0% to 0.6%. Subtotal cholecystectomy, antegrade and fundus first techniques, and peroperative cholangiogram were associated with lower complications and conversion rate. Risk factors for difficulty were male sex, increased age, acute and thick wall chronic cholecystitis, wide and short cystic duct, cholecystodigestive fistula, previous upper abdominal surgery, obesity, liver cirrhosis, anatomic variation, cholangiocarcinoma, and low surgeon's caseload. No consensus is found among surgeons on how to manage difficult laparoscopic cholecystectomy. Iatrogenic injuries and conversion rate can be reduced depending on the surgeon's experience, special techniques, and intraoperative investigations. Subtotal cholecystectomy, antegrade or fundus first techniques, and peroperative cholangiogram significantly reduced the complications and conversion rate.

Laparoscopic Cholecystectomy In Acute Cholecystitis – Experience From A Single Centre

A total of 140 patients with acute inflammation of the gall bladder were subjected to laparoscopic cholecystectomy. The majority of the patients (62.85%) were in the third and fourth decade of their life with 88 females and 52 males. Pain in the right hypochondrium (RHC), nausea/vomiting, and tenderness of the RHC were present in all patients. Fever (>100F) was noted in 80%, Murphys sign in 71.4%, and a lump in the RHC in14.2% of the cases.All the patients had a total leukocyte count (TLC) of >10,000/cu mm and 11.4% had elevated serum bilirubin, transaminases, and alkaline phosphatase (ALP). Ultrasonography revealed edematous gallbladder (GB) with thickened wall, GB distension, gall stones, and sonographic Murphys sign in all patients. Six (8.57%) cases had mucocele of the GB. A stone impacted at the neck of the GB was seen in 85.7%. The majority of the patients (77.1%) were operated within 48 to 72 hours of admission and the rest before 48 hours. Intra-operative findings included adhesions (100%), distended GB (77.1%), edematous GB wall (97.1%), inflamed GB(100%), and pericholecystic edema (42.8%). Mucocele was present in 8.5% and GB empyema in 68.5% of cases. All patients had gall stones of which 97.1% had them impacted at the neck of GB. Significant bleeding from the liver bed occurred in 34.2% and a short cystic duct was encountered in 5.7%. GB inflammation involved only fundus and body in 71.2%, extending up to the neck in 22.8% and further up to the cystic duct in 5.7%. During surgery, modifications in operative technique included GB decompression in 60%, closed suction drain used in 97.1%, and haemostatic agent used in 24.3%. The procedure was converted to open cholecystectomy in four (2.85%) patients. The mean operative time was 69.2± 8.9 min. Postoperative complications included abdominal pain in 12 (8.57%), fever in 16 (11.4%), basal pneumonitis in 4 (2.85%), biliary fistula in 4 (2.85%) and faecal fistula in 1 (0.71%) of the patients. The mean hospital stay was 5.4±3.7 days.

Initial Experience with Single-Incision Laparoscopic Cholecystectomy

Single-incision laparoscopic surgery is now increasingly used as an approach for cholecystectomy, based on anecdotal reports of decreased pain, reduced need for hospitalization, and a better cosmetic result. This is a report of a single surgeon's (JKE) initial experience with single-incision laparoscopic cholecystectomy (SILC). We collected concurrent data on 238 consecutive patients undergoing SILC by 1 surgeon in a community hospital over 12 months. From June 2008 to June 2009, 238 consecutive patients underwent an attempted SILC for biliary colic or dyskinesia (75%) or acute cholecystitis (25%) by a single surgeon. Conversion to a standard laparoscopic cholecystectomy was necessary in 6 patients (2.5%) for inflammation or bleeding (n = 4) or short cystic duct (n = 2). Conversion to an open cholecystectomy was necessary in 1 patient (0.42%) for a short cystic duct. No injuries to the common bile duct occurred, the average operative time was 40 minutes, and 95% of patients (n = 226) were discharged home on the day of operation. Postoperative port site hematomas occurred in 3 patients (1.3%), and dehiscence of the umbilical skin incision in 2 (0.8%). No perioperative deaths occurred. This initial experience with SILC documents that the results of the procedure are equivalent to those with the standard procedure using 4 widely-spaced ports when performed by an experienced laparoscopic surgeon. Randomized trials will be necessary to document the suggested benefits of decreased pain and shorter hospitalization.

Endoscopic and surgical management of bile duct injury after laparoscopic cholecystectomy

Laparoscopic cholecystectomy has become the first choice of management for symptomatic cholecystolithiasis. While it is associated with decreased postoperative morbidity and mortality, bile duct injuries are reported to be more severe and more common (0-2.7%), when compared to open cholecystectomy (0.2-0.5%) [New Engl. J. Med. 234 (1991) 1073; Am. J. Surg. 165 (1993) 9; Surg. Clin. N Am. 80 (2000) 1127]. These bile duct injuries include leaks, strictures, transection and removal of (part of) the duct, with or without vascular damage. Bile duct injury might be due to misidentification of the biliary tract anatomy due to acute cholecystitis, large impacted stones, short cystic duct, anatomical variations, but also due to technical errors leading to bleeding with subsequent clipping and coagulation trauma [Ann. Surg. 237 (2003) 460]. Early recognition and adequate multidisciplinary approach is the cornerstone for the optimal final outcome. Suboptimal management of injuries often leads to more extensive damage to the biliary tree and its vasculature with as consequences biliary peritonitis, sepsis, abscesses, multiple organ failure, a more difficult (proximal) reconstruction and in the long run, secondary biliary cirrhosis, and liver failure. Despite increasing experience in performing laparoscopic cholecystectomy, the frequency of bile duct injuries has not decreased [Ann. Surg. 234 (2001) 549]. Therapy encompasses endoscopic stenting, percutaneous transhepatic dilatation (PTCD) and surgical reconstruction.

Value of intravenous cholangiography prior to laparoscopic cholecystectomy.

We performed a retrospective study on 163 patients for evaluation of the benefit of intravenous cholangiography prior to laparoscopic cholecystectomy. Radiographic evaluation of the various areas of the biliary system was classified regarding resolution of anatomic structures: well detailed (excellent), impaired image but reliable interpretation possible (good), insufficient contrast with limited assessment (poor), no reliable judgment possible (insufficient). The common bile duct could be described as "good" in 96.3%, whereas the cystic duct could be described as "good" in only 54.6%. Concrements of the gallbladder were recognized in 72.4%, and common bile duct stones were diagnosed in only two of three patients. A distal junction of the cystic duct was found in nine cases, but there was no influence on the following operative procedure. Only one of two patients with a short cystic duct was identified. We found no improvement after routine use of intravenous cholangiography concerning the evidence of common bile duct stones or the avoidance of lesions of the common bile duct. Hence routine use of intravenous cholangiography prior to laparoscopic cholecystectomy is not justified.