Standard Laparoscopic Cholecystectomy Research Articles

A comparison of outcomes including bile duct injury of subtotal cholecystectomy versus open total cholecystectomy as bailout procedures for severe cholecystitis: A multicenter real-world study

BackgroundDense inflammation obscuring the hepatocystic anatomy can hinder the ability to perform a safe standard laparoscopic cholecystectomy in severe cholecystitis, requiring use of a bailout procedure. We compared clinical outcomes of laparoscopic and open subtotal cholecystectomy against the traditional standard of open total cholecystectomy to identify the optimal bailout strategy for the difficult gallbladder. MethodsA multicenter, multinational retrospective cohort study of patients who underwent bailout procedures for severe cholecystitis. Procedures were compared using one-way analysis of variance/Kruskal-Wallis tests and χ2 tests with multiple pairwise comparisons, maintaining a family-wise error rate at 0.05. Multiple multivariate linear/logistical regression models were created. ResultsIn 11 centers, 727 bailout procedures were conducted: 317 laparoscopic subtotal cholecystectomies, 172 open subtotal cholecystectomies, and 238 open cholecystectomies. Baseline characteristics were similar among subgroups. Bile leak was common in laparoscopic and open fenestrating subtotal cholecystectomies, with increased intraoperative drain placements and postoperative endoscopic retrograde cholangiopancreatography(P < .05). In contrast, intraoperative bleeding (odds ratio = 3.71 [1.9, 7.22]), surgical site infection (odds ratio = 2.41 [1.09, 5.3]), intensive care unit admission (odds ratio = 2.65 [1.51, 4.63]), and length of stay (Δ = 2 days, P < .001) were higher in open procedures. Reoperation rates were higher for open reconstituting subtotal cholecystectomies (odds ratio = 3.43 [1.03, 11.44]) than other subtypes. The overall rate of bile duct injury was 1.1% and was not statistically different between groups. Laparoscopic subtotal cholecystectomy had a bile duct injury rate of 0.63%. ConclusionLaparoscopic subtotal cholecystectomy is a feasible surgical bailout procedure in cases of severe cholecystitis where standard laparoscopic cholecystectomy may carry undue risk of bile duct injury. Open cholecystectomy remains a reasonable option.

Near-infrared cholangiography with intragallbladder indocyanine green injection in minimally invasive cholecystectomy.

Laparoscopic cholecystectomy (LC) remains one of the most commonly performed procedures in adult and paediatric populations. Despite the advances made in intraoperative biliary anatomy recognition, iatrogenic bile duct injuries during LC represent a fatal complication and consist an economic burden for healthcare systems. A series of methods have been proposed to prevent bile duct injury, among them the use of indocyanine green (ICG) fluorescence. The most commonly reported method of ICG injection is the intravenous administration, while literature is lacking studies investigating the direct intragallbladder ICG injection. This narrative mini-review aims to assess the potential applications, usefulness, and limitations of intragallbladder ICG fluorescence in LC. Authors screened the available international literature to identify the reports of intragallbladder ICG fluorescence imaging in minimally invasive cholecystectomy, as well as special issues regarding its use. Literature search retrieved four prospective cohort studies, three case-control studies, and one case report. In the three case-control studies selected, intragallbladder near-infrared cholangiography (NIRC) was compared with standard LC under white light, with intravenous administration of ICG for NIRC and with standard intraoperative cholangiography (IOC). In total, 133 patients reported in the literature have been administered intragallbladder ICG administration for biliary mapping during LC. Literature includes several reports of intragallbladder ICG administration, but a standardized technique has not been established yet. Published data suggest that NIRC with intragallbladder ICG injection is a promising method to achieve biliary mapping, overwhelming limitations of IOC including intervention and radiation exposure, as well as the high hepatic parenchyma signal and time interval needed in intravenous ICG fluorescence. Evidence-based guidelines on the role of intragallbladder ICG fluorescence in LC require the assessment of further studies and multicenter data collection into large registries.

Safety of cholecystectomy performed by surgeons who prefer fundus first versus surgeons who prefer a standard laparoscopic approach

BackgroundAn alternative method to standard laparoscopic cholecystectomy (SLC) is the “fundus first” method (FFLC). Concerns have been raised that FFLC can lead to misinterpretation of important anatomical structures, thus causing complications of a more serious kind than SLC. Comparisons between the methods are complicated by the fact that FFLC is often used as a rescue procedure in complicated cases. To avoid confounding related to this we conducted a population-based study with comparisons on the surgeon level. MethodIn GallRiks, the Swedish registry for Gallbladder surgery, we stratified all cholecystectomies performed 2006–2020 in three groups: surgeries carried out by surgeons that uses FFLC in <20 % of the cases (N = 150,119), in 20–79 % of the cases (N = 10,212) and in 80 % or more of the cases (N = 3176). We compared the groups with logistic regression, adjusting for sex, age, surgical experience, year of surgery and history of acute cholecystitis. All surgical complications (bleeding, gallbladder perforation, visceral perforation, infection, and bile duct injury) were included as outcome. A separate analysis was done with regards to operation time. ResultsNo difference in incidence of all surgical complications or bile duct injury were seen between groups. The rates of bleeding (OR 0.34 [0.14–0.86]) and gallbladder perforation (OR 0.61 [0.45–0.82]) were significantly lower in the “fundus first > 80% group” and the operative time was shorter (OR 0.76 [0.69–0.83]). ConclusionIn this study including >160,000 cholecystectomies, both methods was found to be equally safe. Key messageDuring laparoscopic cholecystectomy, the standard method of dissection and fundus first dissection are equally safe surgical techniques. Surgeons need to learn both methods to be able to use the one most appropriate for each individual case.

Gallbladder sinistroposition (left-sided) finding in laparoscopic cholecystectomy, a case report

A left-sided gallbladder (LSGB), also known as sinistropostition, is a rare anatomical variant with a reported incidence of 0.2-1.1%. It is defined as a gallbladder located on the left side of the falciform ligament, embedded in the third hepatic lobe, without situs inversus viscerum. A 37-year-old Latino man with a history of bilateral inguinal repair underwent a scheduled laparoscopic cholecystectomy due to multiple gallbladder polyps. Preoperative ultrasound reported a gallbladder of 60x20 mm, wall thickness of 1 mm, with polyps of up to 10 mm. Standard laparoscopic cholecystectomy trocar placement was used. Upon revision of the right hepatic lobe, there was an absence of the GB in the visceral side of segments IV, V, or VI. It was identified to the left of the falciform ligament with adhesions to the anterior and superior portions of the pylorus and lesser curvature. The subxiphoid trocar was adjusted to the left of the falciform ligament, and Calot’s triangle dissection was performed to obtain a critical view of safety. No other anatomical variants were identified. The procedure was performed safely with a satisfactory view of critical cholecystectomy steps and anatomy identification. After the procedure, the surgeon complained of right-hand pain and numbness due to a medial position of the subxiphoid trocar for dissection. The surgical approach of a LSGB in laparoscopic surgery should be individualized for each patient. A minimally invasive approach may be realized successfully when critical thinking by the surgeon is applied and always prioritizing the safety of the patient.

Complications rates following fundus first and standard laparoscopic cholecystectomy: a population-based study of more than 160 000 cholecystectomies

Complications rates following fundus first and standard laparoscopic cholecystectomy: a population-based study of more than 160 000 cholecystectomies

Comparison of quality of life between pre- and post-operative standard laparoscopic cholecystectomy using Short Form-36

Background: Gallstone disease (cholelithiasis) is a wide spectrum of conditions, ranging from asymptomatic cholelithiasis, biliary colic, empyema gallbladder, and gangrene to perforation and peritonitis. Aims and Objectives: The aim of this study was to assess the quality of life before and after a standard laparoscopic cholecystectomy (LC) using the Short Form-36 (SF-36). Materials and Methods: In the study cohort of 100 patients using SF-36 in patients of pre-operative and post-operative standard LC are compared in eight domains of health quality index in Maharani Laxmi Bai Medical College, Jhansi between January 2021 and June 2022. Results: There is finding of significant change in seven domains in mean±1 month, (1) Physical functioning – pre-operative and post-operative, that is, 33.00±31.812 and 88.68±22.40, respectively, (2) Role limitations due to physical health – pre-operative and post-operative, that is, 3.5±18.401 and 98.75±10.546, respectively, (3) Role limitations due to emotional problems – pre-operative and post-operative, that is, 4.67±21.128 and 98.67±11.489, respectively, (4) Energy/fatigue- pre-operative and post-operative, that is, 34.94±16.638 and 83.11±12.456, respectively, (5) Social pre-operative functioning – pre-operative and post-operative, that is, 39.38±20.428 and 98.88±5.196 respectively, (6) Pain – pre-operative and post-operative, that is, 34.73±18.340 and 97.30±15.489, respectively, (7) General health – pre-operative and post-operative, that is, 35.85±35.897 and 67.00±35.511, respectively, and minimal change in one domain (8) Emotional well-being – pre-operative and post-operative, that is, 34.16±15.491 and 39.08±18.694. Conclusion: The pre-operative and post-operative parameters of the SF-36 questionnaire show a significant change in their mean±standard deviation at 1-month postoperatively following standard LC. The maximum significant change occurred in parameters of physical functioning, role emotion, role physical, energy, social functioning, pain, and general health.

Safe laparoscopic cholecystectomy technique and timing for acute cholecystitis: a study in India

Background: Acute cholecystitis patients undergo laparoscopic cholecystectomy (LC) within 72 hours or 6 weeks to 12 weeks after onset is widely considered the optimal timings for LC. However, there has been no clear consensus about it. We aimed to determine safe technique of LC for acute cholecystitis within 72 hours or any time of presentation with no delay in surgery. Methods: Medical records of 100 patients who underwent standard LC were reviewed retrospectively. Patients were divided into group 1, patients undergoing LC within 72 hours of onset; group 2, between 4 days to 14 days; group3, between 3 weeks to 6 weeks; group 4, more than 6 weeks. Results: No significant differences existed between groups in conversion rate to open surgery, operation time, blood loss, or postoperative morbidity, and hospital stay. However, total hospital stays in groups 1 and 2 was significantly shorter than that in groups 3 and 4 (p&lt;0.01). In addition, the total hospital stay in group 3 was also significantly shorter than that in group 4 (p&lt;0.01). Conclusions: Best timing of LC for acute cholecystitis may be within 72 hours, and there is no need to delay LC in patients presenting after 72 hours and with safe technique of dissecting at infundibulum retrieval of stones and cystic duct stump closure with catgut loop there is no significant difference observed retrospectively.

Indocyanine green fluorescent cholangiography: The new standard practice to perform laparoscopic cholecystectomy in pediatric patients. A comparative study with conventional laparoscopic technique

BackgroundThis study aimed to compare outcomes of standard laparoscopic cholecystectomy and indocyanine green fluorescent cholangiography laparoscopic cholecystectomy over a 10-year period. MethodsFrom 2013 to 2023, 173 laparoscopic cholecystectomies were performed in 2 pediatric surgery units: 83 using standard technique (G1) and 90 using indocyanine green fluorescent cholangiography (G2). Patients included 96 girls and 77 boys, with a median age of 12.3 years (range 4–17) and a median weight of 51 kg (range 19–114). The 2 groups were compared regarding the following: (1) perioperative complications rate; (2) overall length of surgery (T1); (3) length of cystic duct isolation, clipping, and sectioning (T2); (4) time of gallbladder removal (T3); (5) degree of visualization of biliary tree; (6) safety and feasibility of indocyanine green fluorescent cholangiography; (7) incidence of anatomical anomalies detected intraoperatively. ResultsAll laparoscopic cholecystectomies were accomplished without conversion to open. The perioperative complications rate was significantly higher in G1 compared with G2 (12% vs 0%; P = .0007). Median T1, T2, and T3 were significantly longer in G1 (90, 37, 35 minutes) compared with G2 (55, 17, 19 minutes) (P = .0001), respectively. The visualization rate of the complete biliary tree was significantly higher in G2 (98.8%) than in G1 (80.7%) (P = .0001). No adverse reactions to indocyanine green were recorded. The incidence of biliary anomalies detected intraoperatively was significantly higher in G2 (7.8%) than in G1 (1.2%) (P = .03). ConclusionIndocyanine green fluorescent cholangiography can be considered the new standard practice to perform laparoscopic cholecystectomy in pediatrics. Indocyanine green fluorescence provided superior visualization of biliary anatomy, increased detection of anatomic variants, faster procedure, and fewer complications compared with conventional technique. Indocyanine green fluorescent cholangiography was safe, feasible, simple, inexpensive, and a timesaving tool.

Correlation of serum biochemical characteristics and ABCG8 genetic variant (rs 11887534) with gall stone compositions and risk of gallstone disease in a group of Egyptian patients.

The overexpression of the cholesterol transporter: ATP-binding cassette transporter (ABCG8) due to the effect of ABCG8 genetic variant (rs11887534) leads to the precipitation of cholesterol crystals and gallstone disease (GSD). To evaluate the chemical composition of gallstones and the role of ABCG8 (rs11887534) in the susceptibility to GSD. We enrolled 77 patients with GSD treated with standard laparoscopic or open cholecystectomy and 75 age and sex-matched healthy controls. Chemical analysis of the extracted gallstones was performed. Analysis of the rs11887534 was performed by real-time PCR TaqMan technique for both cases and controls. Pure cholesterol stones were the main type of stones in GSD patients. The CC genotype carriers of rs11887534 were more prone to gallstone formation than other genotypes. The CC genotype carriers were 100 folds at increased risk to develop pure cholesterol stones. The most prevalent type of gallbladder stones is pure cholesterol stone. ABCG8 (rs11887534) could be associated with increased risk for cholesterol gallstones formation, this risk was more pronounced in female patients.

Laparoscopic subtotal cholecystectomy by linear stapler: A simple and feasible technique for difficult cases with severe cholecystitis. A case series

IntroductionLaparoscopic subtotal cholecystectomy (LSC) is recognized as a safe, feasible alternative method for avoiding common bile duct injuries in 'difficult' gallbladders. We describe the details of an LSC technique that uses a linear stapler with the reconstituting method for severe cholecystitis. MethodsWe retrospectively analyzed the cases of 19 Japanese patients diagnosed with acute cholecystitis who underwent LSC (Jan. 2017–Dec. 2020). In each patient, we first attempted to perform a standard laparoscopic cholecystectomy. Four trocars were inserted in all patients. When it was extremely difficult to expose and dissect the triangle of Calot or the neck of the gallbladder due to severe inflammation and fibrosis, an LSC was performed. The gallbladder was divided downward from the gallbladder fundus to the neck. We opened the gallbladder wall at the fundus and removed all gallstones with suction and saline flushing. The gallbladder was transected by a laparoscopic linear stapler. ResultsThe median operation time was 166 min; intraoperative blood loss was 35 mL. One patient (5.3%) had minor bile leakage that promptly resolved after the transpapillary approach. The median postoperative hospital stay was 7 days. ConclusionUsing a linear stapler to divide the gallbladder neck is a simple, feasible strategy for LSCs in difficult gallbladders.

Evaluating the Impact of Surgical Occurrence of Bile Duct Injuries in Laparoscopic Cholecystectomy- A Retrospective Observational study

Background: Laparoscopic cholecystectomy (LC) is the gold standard for treating gallstone disease, offering numerous benefits over traditional open cholecystectomy. However, bile duct injuries (BDIs) are a significant complication, contributing to substantial morbidity and mortality. This study aims to evaluate the incidence, causes, risk factors, treatments, and outcomes of BDIs in laparoscopic cholecystectomy in Bangladesh. Material &amp; Methods: This retrospective observational study was conducted at the Department of Hepatobiliary, Pancreatic and Liver Transplant Surgery, Bangabandhu Sheikh Mujib Medical University, Al-Manar Hospital Limited, and Abeer General Hospital, Dhaka, Bangladesh. During this period, a total of 1255 complete hospital records of laparoscopic cholecystectomy conducted over the last 5 years at the study hospital were selected for the study following inclusion and exclusion criteria. Results: Out of laparoscopic cholecystectomy cases, 20 (1.64%) patients experienced BDIs. The most common cause of BDI was clipping or transection of the duct (33.33%), followed by mistaken anatomy (22.22%) and ischemic injury due to clip (18.52%). Acute cholecystitis was the most prevalent risk factor (37.04%). Standard laparoscopic cholecystectomy was performed in 83.33% of BDI cases, with the remaining 16.67% undergoing single-incision laparoscopic cholecystectomy. The majority of patients (74.07%) had no complications after BDI treatment, while 18.52% experienced minor complications, 5.56% had major complications, and 1.85% resulted in mortality. Conclusion: This study highlights the importance of meticulous surgical technique, early recognition, and appropriate management of bile duct injuries in laparoscopic cholecystectomy. By continually refining our understanding of the factors contributing to BDIs and implementing evidence-based strategies to prevent and manage this complication, we can optimize patient outcomes and ensure the highest standards of care in laparoscopic cholecystectomy.

Indocyanine green direct injection into gallbladder during laparoscopic cholecystectomy: a safety method to outline biliary anatomy

Background One of the most frequently done operations in digestive surgery is the laparoscopic cholecystectomy (LC). Despite several safety precautions and guidelines, iatrogenic bile duct damage (BDI) during LC still occurs at a very high incidence. Fluorescence of biliary system may minimise surgical difficulties that might emerge owing to unintended harm to the common bile duct. Methods We outline a technique for directly injecting Indocyanine Green (ICG) into the gallbladder to clarify the architecture of the cystic duct and common bile duct. Fifty patients who underwent elective laparoscopic cholecystectomy participated in the study, which was a randomised controlled clinical trial. Patients who had intraoperative direct injection of ICG into the gallbladder were chosen at random using closed envelope technique, then using near-infrared fluorescence (NIF) imaging during LC) and controls (who underwent standard LC technique) Twenty five patients in each limb. Patients were studied pre-operative, intraoperative &amp; postoperative. 50 patients in all, 25 of whom received LC with intracholecystic ICG injection, and 25 of whom underwent standard LC without the use of ICG, were included in our study. Results ICG dye was successful to delineate extrahepatic biliary anatomy well in 20 cases out of 25, while without ICG, 9 cases out of 25 were without clear delineation of common bile duct intraoperative even if cystic duct was clear enough to avoid complications in both groups . Operative Time average in cases with ICG-assisted LC was 78±15.0 min which was less than the average of time consumed in LC without ICG to dissect cystic duct and visualize critical view of safety, 101±11.87 min Conclusion Direct gallbladder ICG infusion enables quick extrahepatic biliary system imaging and clarifies the dissection, increasing protection against BDI and reducing intraoperative dissection time.

To Compare Isobaric Thoracic Spinal Anesthesia Versus General Anesthesia in Laparascopy Cholecystectomy

Background: The laparoscopic cholecystectomy procedure is typically carried out under general anesthesia, but regional techniques, such as low thoracic isobaric spinal anesthesia, have been used to manage patients with significant medical problem like coexisting systemic disease, who are deemed to be high risk in general anesthesia. Segmental spinal anesthesia has great outcomes in terms of post-operative discomfort, the need for analgesics, relatively fewer complications, and shorter hospital stays. Thus the aim of this study to avoid and minimize the risk of general anesthesia who does not have any significant comorbidity. So it might be a substitute for a standard laparoscopic cholecystectomy. Material and Methods: Total 60 adult patient with ASA1 &amp; I I, 18-60 years, with normal coagulation profile, is divided into 2 groups. Group IS (Isobaric) - given 2.5 ml of isobaric preservative free bupivacaine 0.5% (levobupivacaine) + 0.5 mg of Fentanyl at T9-T10/T10-T11 into sub arachnoid space. Group GA – given general anesthesia using propofol, fentanyl citrate and atracurium besylate. After intubation, ventilation was controlled and balanced anesthesia was continued with isoflurane. After completion, neuromuscular block was anatagonized neostigmine methylsulfate and glycopyrrolate at the end of surgery. Results: Isobaric spinal anesthesia showed good control in intraoperative as well as postoperative pain control as compared to general anesthesia. In few patients, there were minor degrees of nausea, vomiting, abdominal pain, shoulder pain, patient anxiety or itchng which were treated with standard medication like fentanyl and midazolam. All patients can resume oral intake on the day of surgery. Conclusions: In conclusion, this study provide evidence that segmental spinal anesthesia can be used in place of general anesthesia in healthy individuals also.

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.

Irrigation with Bupivacaine at the Surgical Bed for Postoperative Shoulder Tip and Abdominal Pain Relief after Laparoscopic Cholecystectomy

Gallstones in western countries are primarily composed of cholesterol. However, mixed or pigment stones, which contain a higher proportion of bilirubin, are more frequently seen in developing nations and Asia than in western countries. Abdominal and shoulder tip pains (STPs) are common complaints following the standard laparoscopic cholecystectomy procedure. To date, all pain management modalities have proven variable outcomes. This prospective randomized study included 82 patients who underwent elective laparoscopic cholecystectomy. The control group received 20 mL of normal saline, whereas the study group received a 20-mL instillation of 0.5% bupivacaine at the gallbladder bed after surgical resection. The Visual Analog Scale (VAS) was used to analyze abdominal pain and STP. The mean age ranged from 20 to 80 years. Abdominal VAS at 6, 12, 18, 24, 30, 36, and 48 hours were statistically insignificant. The majority were discharged on postoperative day 1 (32 studies, 37 control). Follow-up VAS after 1 week for STP VAS and abdominal pain VAS in both groups were statistically insignificant. Even with small numbers of a well-conducted randomized trial, we demonstrated that bupivacaine irrigation at the gallbladder bedpost laparoscopic cholecystectomy does not affect pain relief.

To Evaluate the Feasibility of Flip Technique in Dissection of Gall Bladder from the Liver Bed in Laparoscopic Cholecystectomy and Its Comparison with Standard Laparoscopic Cholecystectomy

Background: Laparascopic cholecystectomy is one of the commonly performed surgery and is the procedure of choice for gall bladder disease. Time to time advancements are being made in this procedure to ease this surgery and also decrease its complication rate. And with the same purpose, a special technique named as “Flip Technique” has been introduced in which, in order to make the dissection of gall bladder easier near the fundus, the gall bladder is flipped over the liver surface after initial dissection of the gall bladder from the liver bed. The study to find out the feasibility of this flip technique of gall bladder removal in laparoscopic cholecystectomy was done in 100 patients admitted in department of general surgery, Govt Medical College and Rajindra Hospital, Patiala. Aim: This study aims to evaluate the feasibility of Flip technique for dissection of gall bladder from the liver bed in laparoscopic cholecystectomy with regard to operative time, intraoperative bleeding, bile duct injury, liver bed injury, injury to gall bladder wall, duration of hospital stay and mortality (if any).Methods:The present study was prospective, observational and comparative trial and was conducted on 100 patients of either sex diagnosed as case of GBD and planned for laparoscopic cholecystectomy, admitted in surgical ward of Rajindra Hospital, Patiala.Results:Latrogenic GB rupture occurred in 2% of patients in group A (cases) and 12% of patients in group B (control). The difference was statistically significant (p value 0.05). Site of rupture in group A is fundus of gall bladder in 2% of patients and none of gall bladder rupture is seen at body or Hartman’s pouch. In group B gall bladder rupture was found at fundus in 6% of patients, at body in 4% patients and Hartman’s pouch in 2% of patients.Conclusions:The use of Flip technique was more advantageous as compared to standard method of gall bladder dissection from liver bed in laparoscopic cholecystectomy with the mean duration of surgery being shorter in Flip technique.

Change in quality of life between primary laparoscopic cholecystectomy and laparoscopic cholecystectomy after percutaneous transhepatic gall bladder drainage.

One of the most important reasons for avoiding percutaneous transhepatic gall bladder drainage (PTGBD) is the deterioration of quality of life (QOL). However, there is no study comparing the QOL between primary laparoscopic cholecystectomy (LC) and LC following PTGBD.Among the LC patients, 69 non-PTGBD patients and 21 PTGBD patients were included after excluding the patients with malignant disease or who needed additional common bile duct procedures. Clinicopathologic characteristics and surgical outcomes were compared. QOL was evaluated with questionnaire EORCT-C30 before and after surgery.The included patients comprised 69 non-PTGBD and 21 PTGBD patients. The PTGBD group include older and higher morbid patients. PTGBD group needed longer operation times than the non-PTGBD group (72.4±34.7 minute vs 52.8±22.0 minute, P = .022) Regarding the overall incidence of complication, the PTGBD group had a significantly higher complication rate than the non-PTGBD group (38.1% vs 10.1%, P = .003) However, there was no significant difference in severe complication). Regarding the QOL, both the functional and global health scales were improved following surgery compared to the preoperative evaluation. Comparative analysis of the 2 groups showed no significant difference in global heath scale either preoperative or postoperatively, while the functional scale and emotional scale were better in the PTGBD group compared to the non-PTGBD group. Regarding the symptom scale, postoperative dyspnea and perioperative diarrhea were better in the PTGBD group.LC following an interval from earlier PTGBD that targets acute cholecystitis or complicated GB had little to no impact on QOL when compared to standard LC.

Routine extensive dissection of the cystic duct during laparoscopic cholecystectomy to reduce the risk of residual choledocholithiasis: an unnecessary step and a potentially hazardous concept.

IntroductionPost-cholecystectomy choledocholithiasis can occur from retained stones at the cystic duct stump remnant; however, most surgeons would not proceed with extensive dissection of the cystic duct during routine cholecystectomy, mainly in fear of inadvertent bile duct injuries, given the frequent anatomical variations of the extrahepatic biliary tree.AimTo determine the need and feasibility of extensive dissection of the cystic duct during laparoscopic cholecystectomy, to reduce the risk of post-cholecystectomy choledocholithiasis.Material and methodsWe performed a retrospective review of our institutional database of all patients who had magnetic resonance cholangiopancreatography (MRCP) prior to cholecystectomy over a 3-year period (03/2016-04/2019), assessing the anatomical variations of the cystic duct and the incidence of cystic duct stones.ResultsDuring the study period, from a total of 763 patients who underwent cholecystectomy for symptomatic gallstones, 284 had undergone pre-operative MRCP and were all included in the final analysis. The typical right lateral insertion of the cystic duct in the midpoint between the confluence of the main hepatic ducts and the ampulla of Vater was identified in less than 50% of the patients. In our series, cystic duct stones were present only in 1.8% of our patients.ConclusionsThe presence of significant anatomical variations and the low likelihood of incidental cystic duct stones render prophylactic extensive dissection of the cystic duct during standard laparoscopic cholecystectomy a rather unnecessary and probably hazardous step.

Application of Design Structure Matrix to Simulate Surgical Procedures and Predict Surgery Duration.

Background The complexities of surgery require an efficient and explicit method to evaluate and standardize surgical procedures. A reliable surgical evaluation tool will be able to serve various purposes such as development of surgery training programs and improvement of surgical skills. Objectives (a) To develop a modeling framework based on integration of dexterity analysis and design structure matrix (DSM), to be generally applicable to predict total duration of a surgical procedure, and (b) to validate the model by comparing its results with laparoscopic cholecystectomy surgery protocol. Method A modeling framework is developed through DSM, a tool used in engineering design, systems engineering and management, to hierarchically decompose and describe relationships among individual surgical activities. Individual decomposed activities are assumed to have uncertain parameters so that a rework probability is introduced. The simulation produces a distribution of the duration of the modeled procedure. A statistical approach is then taken to evaluate surgery duration through integrated numerical parameters. The modeling framework is applied for the first time to analyze a surgery; laparoscopic cholecystectomy, a common surgical procedure, is selected for the analysis. Results The present simulation model is validated by comparing its results of predicted surgery duration with the standard laparoscopic cholecystectomy protocols from the Atlas of Minimally Invasive Surgery with 2.5% error and that from the Atlas of Pediatric Laparoscopy and Thoracoscopy with 4% error. Conclusion The present model, developed based on dexterity analysis and DSM, demonstrates a validated capability of predicting laparoscopic cholecystectomy surgery duration. Future studies will explore its potential applications to other surgery procedures and in improving surgeons' performance and training novices.

Mini-laparoscopic cholecystectomy: evolution of a new technique

BackgroundSince the first laparoscopic cholecystectomy (LC) in 1985, there has been much advancement in laparoscopic surgery in terms of reduction in number and size of ports. We report a new technique of performing mini laparoscopic cholecystectomy using only three ports, 5 mm each. The indications of this procedure include GB polyps, GB dyskinesia, microlithiasis, and idiopathic pancreatitis.Case presentationIn this case report, we present a new technique that has been performed safely in a 49-year-old male patient with pancreatitis caused by microlithiasis. This was performed using a novel three port procedure consisting of only 5 mm ports, and he was discharged as a day case without complications. Informed patient consent was obtained.ConclusionsThe fundamentals of this mini-LC technique remain the same as that of a standard laparoscopic cholecystectomy throughout the procedure. It is a feasible option in selected cases, and it has the potential to further augment the inherent benefits of minimal access surgery namely less analgesia, improved cosmesis and faster recovery. Further trials will help ascertain its potential advantages.