Successful Laparoscopic Cholecystectomy Research Articles

Cholelithiasis Diagnosis and Management in Thalassemia

Background: Cholelithiasis, while infrequently found in children, carries a significant risk for those with underlying conditions like thalassemia compared to the general population. This study aimed to described the manifestations of cholelithiasis in thalassemic children. Case: A 12-year-old girl with beta-thalassemia major presented with recurrent right upper quadrant abdominal pain and vomiting. Imaging revealed cholelithiasis and choledocholithiasis. Due to complications related to her thalassemia, she underwent endoscopic retrograde cholangiopancreatography (ERCP) for gallstone removal followed by laparoscopic cholecystectomy. Post-operative management addressed post-ERCP pancreatitis and bleeding concerns. The patient recovered well and is scheduled for follow-up. Discussion: Increased bilirubin production, iron overload, and altered bile properties in beta-thalassemia contribute to cholelithiasis risk. The patient presented with typical symptoms and underwent successful laparoscopic cholecystectomy after initial management with ERCP, which led to post-ERCP pancreatitis. Conclusion: This case underscores the elevated risk of cholelithiasis in thalassemic children and the importance of early diagnosis and intervention for optimal outcomes.

CONVERSION TO OPEN CHOLECYSTECTOMY - A SAFE ALTERNATIVE, NOT A FAILURE!

Background: Understanding factors that predict conversion in laparoscopic cholecystectomy (LC) to an open procedure is important as it allows better patient selection, preparation, operating list planning, referral, counseling and lowers the threshold for a safe conversion, thereby minimizing undue prolongation of attempts at laparoscopic completion and inadvertent complications.Methods: Records of 1010 consecutive patients who were taken up for LC, at a tertiary care teaching institute in northern India, were reviewed retrospectively. Preoperative and intraoperative characteristics of patients who underwent a successful LC were compared with those who required conversion to open surgery.Results: The conversion rate was 7.5% (76 patients). The most common reason for conversion was the inability to define the ‘Critical view of safety’ in 48, (63%) of patients. Other reasons included dense peri-cholecystic 9 (12%) and intra-abdominal 8 (11%) adhesions, suspicion of bile duct injury 4 (5%) or malignancy 3 (4%). Prior upper abdominal surgery, intraoperative finding of a contracted and thick-walled gallbladder (GB), empyema GB, Mirizzi’s syndrome, cholecysto-enteric fistula, and a prior endoscopic common bile duct stone clearance were significant predictors of conversion. Xanthogranulomatous cholecystitis was found more commonly (43% vs 5%) in the conversion group.Conclusion: Conversion to an open procedure during LC should always be treated as an integral component of sound judgement to achieve the safest outcome in a particular patient. Due consideration of pre-operative and intra-operative factors predictive of a higher chance of conversion assists pre-operative patient preparation and counseling as well as surgical planning, conduct and mentoring of residents-in-training.

A Rare Case of Bilobed Gallbladder with Two Cystic Ducts

Bilobed or duplicate gallbladders are the rare anomalies of the biliary system occurring between the 5th and 6th weeks of embryonic life, of which Type 2 ductular variant is the commonest. Patients may be asymptomatic or symptomatic, with majority of the cases being detected intraoperatively or during re-operation. Once suspected a detailed preoperative evaluation is a must to avoid both intraoperative and postoperative complications. We report a case of a 34-year-old female who presented with acute onset of abdominal pain and was detected with symptomatic bilobed gallbladder (H Type) with cholelithiasis, with a resolution of symptoms after a successful laparoscopic cholecystectomy. The case emphasizes the importance of detailed preoperative evaluation in the form of ultrasound and magnetic resonance cholangiopancreatography to be considered during the management of biliary pathologies to avoid any intra- and post-operative complications.

Conversion rate and the probable factors for conversion from laparoscopic to open cholecystectomy

Background and objective: In western countries, the incidence of Cholelithiasis is found to be more than 10% in general populations. After performing the first successful laparoscopic cholecystectomy (L.C.) in Germany by Muhe in 1986, it rapidly became the procedure of choice in treating symptomatic gall stone. L.C. has a lot of advantages, including minimal trauma, rapid recovery, less analgesic requirement with a good esthetic outcome, however even in the hands of a best surgeon still there is a small percentage of conversion to open laparotomy, some risk factors has been recognized as a reason for the conversion to open laparotomy. This study aims to evaluate the rate with the underlying risk factors that increase the chance of conversion to open cholecystectomy. Methods: A total of 1400 patients for whom L.C. was attempted, 54 were enrolled in this prospective study from January 2014 to January 2020. The exclusion criteria were malignancy or existence of gallbladder polyps detected pathologically. Patient demographics, indications for cholecystectomy, concomitant diseases, and histories of previous abdominal surgery were collected. The rates of conversion to open cholecystectomy with the underlying reasons for conversion were analyzed. Results: The overall rate of conversion to open cholecystectomy was 3.86% (54 patients). Out of 54 cases nearly two-thirds (61.1%) of the patients (33) were males and 38.9% of the patients (21) were females. Male: female ratio is 1.57:1. In the study sample, the conversion rate among obese (14/54) patients was 25.9% compared with the rate of 74.1% among non-obese (40/54) patients. Out of 3.86% of the conversion rate, 2.86% were non-obese and 1% were obese patients. The commonest etiology for conversion was thickened gall bladder due to severe gall bladder inflammation with fibrosis (21 patients) 38.9% followed by Acute cholecystitis (8 patients) 14.8%, then fibrosis (7 patients) 13% with aberrant anatomy at the calot’s triangle (6 patients) 11.1%. Conclusion: A thickened gall bladder was found to be the commonest risk factor for conversion to open cholecystectomy, the conversion from L.C. to O.C. should not be regarded as a failure of the procedure or as a complication, rather it should be regarded as a prudent maneuver for achieving the desired objective namely safe removal of the gall bladder.

Successful laparoscopic cholecystectomy in a patient with ventriculoperitoneal shunt: a case report

With advances in medical care there is a significant increase in life expectancy of patients with hydrocephalus. Many patients survive and live a meaningful life even after a decade of ventriculoperitoneal (VP) shunt placement. In this scenario, there are all the chances that these patients may need abdominal surgeries for pathologies unrelated to VP shunt. Laparoscopic cholecystectomy is one of the most common abdominal surgeries being performed. In patients with VP shunt in situ, before performing laparoscopic cholecystectomy factors such as type of shunt, shunt function, presence of shunt infection and possibility of shunt malfunction needs to be assessed. Laparoscopic cholecystectomy in a patient with previous VP shunt is not a well answered question. Some authors favor this while the others disagree. With proper anesthetic management and monitoring it is safe to perform laparoscopic cholecystectomy in these patients, even though literature gives little information about it. So, this case report is our sincere effort to strengthen the available data and stabilize a ground that can we can safely perform laparoscopic cholecystectomy in patient with VP shunt.

Neuroendocrin Tumor of the Gallbladder: A Case Report

Background: Neuroendocrine tumors (NETs) of the gallbladder are rare and account for less than 1% of all gallbladder tumors. These tumors are typically asymptomatic and are often discovered incidentally during imaging for other reasons. The majority of NETs of the gallbladder are non-functioning, meaning that they do not produce hormones or cause hormonal symptoms. Case Presentation: A 32-years old woman presented with a six-month history of non-specific abdominal pain without a remarkable prior history. Ultrasonographic examination of the abdomen revealed the gallbladder containing multiple stones, with wall thickening. A laparoscopic cholecystectomy was performed, and histopathological examination of the resected gallbladder confirmed the presence of a neuroendocrine tumor. Conclusion: This case report highlights the importance of considering neuroendocrine tumors as a differential diagnosis for gallbladder masses. The patient underwent a successful laparoscopic cholecystectomy and had a good outcome. Close follow-up is necessary to detect any recurrence as these tumors have a tendency to recur locally.

Successful laparoscopic cholecystectomy for gallbladder hemorrhage from a Dieulafoy lesion in a patient on hemodialysis: a case report

BackgroundPatients on long-term dialysis are prone to hemorrhagic complications, particularly uremic bleeding, but gallbladder hemorrhage is rare, even in patients on dialysis. There have been occasional reports of a Dieulafoy lesion being a cause of gastrointestinal hemorrhage, but its occurrence within the gallbladder is quite rare. This report describes a case of gallbladder hemorrhage from a Dieulafoy lesion in a patient on hemodialysis that was diagnosed early and successfully treated by laparoscopic cholecystectomy.Case presentationThe patient was a 68-year-old woman on long-term hemodialysis with end-stage renal failure who presented with epigastralgia and back pain. There was no history of trauma or oral administration of antiplatelet or anticoagulant agents. There were no signs of an inflammatory reaction or hyperbilirubinemia. Contrast-enhanced computed tomography revealed a slightly hyperdense area in the distended gallbladder and extravasation within the gallbladder lumen but no gallstones. A severe atherosclerotic lesion was also found. She was diagnosed to have gallbladder hemorrhage and emergency laparoscopic cholecystectomy was performed. Although the postoperative course was complicated by drug fever, she was discharged on postoperative day 10 in a satisfactory condition. Histology revealed hemorrhagic ulceration with an exposed blood vessel accompanied by abnormal arteries in the submucosa. Arteriosclerosis with eccentric intimal hyperplasia in a small-sized artery was also seen. The diagnosis was gallbladder hemorrhage from a Dieulafoy lesion.ConclusionsA Dieulafoy lesion should be kept in mind as a cause of gallbladder hemorrhage in a patient with severe arteriosclerosis and a bleeding diathesis, particularly if on dialysis, and treated as early as possible.

Laparoscopic cholecystectomy in a patient with situs inversus totalis: report of a case with surgical tips

Background: Situs inversus totalis (SIT) is a rare congenital anomaly characterized by the mirror-image transposition of organs. To date, approximately 100 cases of laparoscopic cholecystectomy (LC) have been reported in patients with situs inversus. Although laparoscopic surgery was successfully completed in all these cases, the operation is known to be technically challenging in patients with situs inversus. Herein, we report a case of cholelithiasis with SIT in a patient who underwent successful LC. Additionally, we have discussed surgical tips that could serve as guidelines for clinicians who encounter such cases in surgical practice.

Efficacy and Safety of Near-Infrared Florescence Cholangiography Using Indocyanine Green in Laparoscopic Cholecystectomy: A Systematic Review and Meta-Analysis.

Background: Achieving critical view of safety is a key for a successful laparoscopic cholecystectomy (LC) procedure. Near-infrared fluorescence cholangiography using indocyanine green (NIF-ICG) in LC has been extensively used and accepted as beneficial auxiliary tool to visualize extrahepatic biliary structures intraoperatively. This study aimed to analyze its safety and efficacy. Materials and Methods: Searching for potential articles up to March 25, 2022 were conducted on PubMed, Europe PMC, and ClinicalTrials.gov databases. Articles on the near infrared fluorescence during laparoscopy cholecystectomy were collected. Review Manager 5.4 software was utilized to perform the statistical analysis. Results: Twenty-two studies with a total of 3457 patients undergo LC for the analysis. Our meta-analysis revealed that NIF-ICG technique during LC was associated with shorter operative time (Std. Mean Difference -0.86 [95% confidence interval (CI) -1.49 to -0.23], P = .007, I2 = 97%), lower conversion rate (risk ratio [RR] 0.28 [95% CI 0.16-0.50], P < .0001, I2 = 0%), higher success in identification of cystic duct (CD) (RR 1.24 [95% CI 1.07-1.43], P = .003, I2 = 94%), higher success in identification of common bile duct (CBD) (RR 1.31 [95% CI 1.07-1.60], P = .009, I2 = 90%), and shorter time to identify biliary structures (Std. Mean Difference -0.52 [95% CI -0.78 to -0.26], P < .0001, I2 = 0%) compared with not using NIF-ICG. Conclusions: NIF-ICG technique beneficial for early real-time visualization of biliary structure, shorter operative time, and lower risk of conversion during LC. Larger randomized clinical trials are still needed to confirm the results of our study.

Necrotizing Gallbladder Torsion Masking as Acalculous Cholecystitis: A Review of Two Cases Treated with Successful Laparoscopic Cholecystectomy

Gallbladder torsion is a rare disease and it is very difficult to diagnose preoperatively because the signs, symptoms, and image findings are very similar to the other cases of acute cholecystitis. However, in cases of gallbladder torsion, conservative treatments such as intravenous antibiotics and percutaneous cholecystostomy could be ineffective and result in even fatal. Hence, for urgent surgical management, gallbladder torsion must be considered especially in the elderly female patients with radiologic findings such as acalculous cholecystitis and a free-floating gallbladder. The author presents two cases of necrotizing gallbladder torsion in an elderly female patient who was treated successfully with laparoscopic cholecystectomy.

Laparoscopic Cholecystectomy in a Patient With Situs Inversus Totalis Presenting With Cholelithiasis: A Case Report

Laparoscopic cholecystectomy is the standard treatment for cholelithiasis. A very rare condition named situs inversus should not be considered as a contraindication for laparoscopic cholecystectomy. Here, we reported a case of successful laparoscopic cholecystectomy in a patient with situs inversus totalis. We also described the technical advantages of this treatment and reviewed the literature.

Surgical assistant manipulator with diagonal joints and multi-stage telescopic screws for laparoscopic solo surgery.

A surgeon in a sterilized area can perform robotically assisted laparoscopic solo surgery while controlling a laparoscope-holding robot for view stabilization and a forceps robot for pulling organs. At present, no locally operated surgical assistant manipulator with a mechanical remote center of motion (RCM) is available to operate within a small space while providing a wide range of movement. The present study describes a new locally operated detachable end-effector manipulator (LODEM) with diagonal joints and multi-stage telescopic screws. A forceps manipulator attached to commercial surgical forceps was developed. This manipulator uses RCM diagonal joints for the yaw and pitch axes, providing an intuitive pivot point and free rotation, and telescopic nested screws with multiple sliders clamp the commercial forceps for the axis of insertion. The manipulator placed above the abdominal wall using a fixed arm connected to a bed rail is motor controlled by a handheld interface with button switches for precise traction and is controlled manually for easy rough positioning. Positional accuracy at the tip with a load of 5N was under 0.5mm. Mechanical deflection was under 2.1mm. The manually controlled force was under 4.4N. Successful simulated laparoscopic cholecystectomy using the prototype manipulator to handle the target and maintain stability was performed on a surgically realistic gallbladder model. A LODEM with diagonal joints and multi-stage telescopic screws was developed to facilitate minimally invasive, robotically assisted laparoscopic solo surgery by a surgeon working near the patient. This electric motor-controlled laparoscopic instrument holder by the surgeon in the surgical field could be used for such applications.

Distal right hepatic artery pseudoaneurysm in a postcholecystectomy patient presenting with severe gastrointestinal hemorrhage: a rare case report.

Background: Hepatic artery pseudoaneurysm (HAP) is an unusually rare vascular complication following laparoscopic procedures with a few yet gradually increasing incidences. Case Presentation: We report a case of a 63-year-old male with distal right HAP-mediated massive gastrointestinal bleeding after a successful laparoscopic cholecystectomy. He was treated successfully with selective endovascular coil embolization and percutaneous thrombin administration. Conclusion: The risk of rupture and bleeding from HAP can be a potentially life-threatening scenario and needs prompt diagnosis with emergent intervention. The documentation of this case may be useful for practicing surgeons to be cautious about the possibility of pseudoaneurysmal changes during the post-operative period.

Surgical outcome of Mirizzi syndrome: Value of endoscopic retrograde cholangiopancreatography and laparoscopic procedures.

Laparoscopic cholecystectomy (LC) with associated procedures and endoscopic retrograde cholangiopancreatography (ERCP) have been the standard treatments for both common and rare biliary diseases. Mirizzi syndrome (MS) is a rare and complex biliary condition. We report our experience with MS treatment and investigate the value of laparoscopic procedures and ERCP in patient management. From 2004 to 2017, 100 consecutive patients with MS were diagnosed by ERCP and underwent surgery in a referral center. Sixty patients were treated with intended LC, and 40 patients were treated with open cholecystectomy (OC). The clinical manifestations, ERCP and associated procedures, surgical procedures, and postoperative outcomes were investigated. The surgical mortality rate was 1%, while the surgical morbidity rate was 15%. The patients treated with intended LC suffered from less morbidity (5%). The percentage of postoperative residual biliary stones was 32% (n=32), and only three patients underwent re-operation (laparotomy) for stone removal. The laparotomy conversion rate in the intended LC group was 16.7% (10/60). The length of hospitalization for the patients with successful LC was significantly shorter than that for the patients with conversion and intended OC. Csendes classification was a risk factor for conversion from LC to OC (type I vs types II to V, P<.0001). A combination of a laparoscopic procedure and ERCP may provide therapeutic benefits for patients with MS.

Application and Prospect of Robotic Technology in Medical Clinic

&lt;p class="18"&gt;&lt;span lang="EN-US"&gt;In the process of gradually improving the level of clinical medical treatment and continuously developing industrial technology, the application of less invasive and non-invasive surgical methods in medical clinic is increasingly widespread. In the face of this situation, the inevitable trend of the development of surgery has been inclined to minimally invasive surgery. Under the background of a large number of new technologies in the clinical application of medicine, the application space of surgical minimally invasive surgery technology has become more and more extensive. The first successful laparoscopic cholecystectomy in 1987 is an important sign of the arrival of the era of minimally invasive surgery. The research and development of surgical robots based on this is a predictor of the gradual beginning of the era of surgical information processing. At this time, it will inevitably promote the qualitative improvement of surgical accuracy, and a new era of minimally invasive surgery will gradually open. At present, the latest “Da Vinci” surgical robot developed by ISRG company has been widely used in medical clinic.&lt;/span&gt;&lt;/p&gt;

Predictive factors of conversion in laparoscopic cholecystectomy for acute calculous cholecystitis

Purpose: Identify the predictive factors for conversion and to evaluate conversion’s impact on postoperative morbidity and mortality. Method: A retrospective study in the surgical department at Mongi Slim Hospital. We enrolled 300 patients who underwent LC for ACC between January 2015 and December 2018. Patients were divided into two groups: “Laparoscopy” for the 282 successful Laparoscopic cholecystectomies (LC) and “Conversion” for the 18 Convertions to open (CTO). A descriptive analysis of preoperative, intraoperative and postoperative data was performed, followed by a bivariate and a multivariate analysis comparing the two groups. The significance level was set at 0.05. Results: The conversion rate was 6%. The sex-ratio was 0.47. The median age was 50 years with interquartile range of 38-62 years. Bivariate analysis identified the following factors: male gender (p=0.001), age over 57 years (p=0.002), right upper quadrant tenderness (p=0.009), right upper quadrant guarding (p=0.006), leukocytosis ≥ 18000 cells /mL (p=0.002), leukopenia (<0.001), serum creatinine level > 20 mg/L (p=0.045), ultrasonographic findings like laminated gallbladder wall (p=0.033), pericholecystic abscess (p=0.045), liver abscess (p<0.001), intra-abdominal effusion (p=0.001), ACC grade II (p=0.009) and intraoperative findings like pericholecystic adhesions (p<0.001), gangrenous ACC (p=0.001), pericholecystic abscess (p=0.005), localized peritonitis (p=0.028), pediculitis (p=0.006), difficulties in identifying anatomical structures (p=0.014) and bile duct injuries (p<0.001). Multivariate analysis determined as predictive factors: male gender (OR=3.715; 95% CI [1.101-12.541]; p=0.03) and age over 57 years (OR=1.038; 95% CI [1-1.077]; p=0.04). There were no differences between the two groups in terms of postoperative morbidity and mortality. However, CTO was associated with a prolonged length of stay (p=0.02). Conclusion: The predictive factors of CTO are not modifiable. Their identification may help conduct a better communication with the patient and optimize the planning of the procedure.

Evaluating the advantages of treating acute cholecystitis by following the Tokyo Guidelines 2018 (TG18): a study emphasizing clinical outcomes and medical expenditures.

Acute cholecystitis (AC) is a common surgical emergency. The Tokyo Guidelines 2018 (TG18) provides a reliable algorithm for the treatment of AC patients to achieve optimal outcomes. However, the economic benefits have not been validated. We hypothesize that good outcomes and cost savings can both be achieved if patients are treated according to the TG18. This retrospective study included 275 patients who underwent cholecystectomy in a 15-month span. Patients were divided into three groups (group 1: mild AC; group 2: moderate AC with American Society of Anesthesiologists (ASA) physical status class ≤ 2 and Charlson Comorbidity Index (CCI) score ≤ 5; and group 3: moderate AC with ASA class ≥ 3, CCI score ≥ 6, or severe AC). Each group was further divided into two subgroups according to management (followed or deviated from the TG18). Patient demographics, clinical outcomes, and hospital costs were compared. For group 1 patients, 77 (81%) were treated according to the TG18 and had a significantly higher successful laparoscopic cholecystectomy (LC) rate (100%), lower hospital cost ($1896 vs $2388), and shorter hospital stay (2.9 vs 8days) than those whose treatment deviated from the TG18. For group 2 patients, 50 (67%) were treated according to the TG18 and had a significantly lower hospital cost ($1926 vs $2856), shorter hospital stay (3.9 vs 9.9days), and lower complication rate (0% vs 12.5%). For group 3 patients, 62 (58%) were treated according to the TG18 and had a significantly lower intensive care unit (ICU) admission rate (9.7% vs 25%), but a longer hospital stay (12.6 vs 7.8days). However, their hospital costs were similar. Early LC in group 3 patients did not have economic benefits over gallbladder drainage and delayed LC. The TG18 are the state-of-the-art guidelines for the treatment of AC, achieving both satisfactory outcomes and cost-effectiveness.

Assessment of predictive factors for difficult laparoscopic cholecystectomy

Background: The present study was conducted to assess predictive factors for difficult laparoscopic cholecystectomy. Materials & Methods: 84 patients having symptomatic gallstone disease were included. After the surgery, patients were group into 2 groups those who had a successful laparoscopic cholecystectomy and those cases who had conversion to open cholecystectomy. Results: Total 6 cases underwent conversion. Out of 15 patients with age >50 years, 3 underwent conversion and out of 69 patients with age 50 years were predictive factors for conversion.

Laparoscopic cholecystectomy in patients with portal cavernoma without portal vein decompression

Introduction:Laparoscopic cholecystectomy (LC) in patients with extrahepatic portal vein obstruction causing portal cavernoma (PC) is considered high risk because of portosystemic collateral veins in the hepatocystic triangle. The literature is limited to isolated case reports. We describe our experience of LC in patients with PC.Patients and Methods:Data of patients with PC who underwent LC for symptomatic gallstones or related complications was reviewed. Patients with simultaneous cholecystectomy with splenorenal shunt and open cholecystectomy were excluded. Pre-operative evaluation consisted of complete blood count, international normalisation ratio and liver function tests, ultrasound of the abdomen with Doppler, contrast-enhanced computerised tomography, magnetic resonance cholangiopancreatography and esophagogastroscopy as indicated. A standard four-port LC was performed. The technical principles followed were to avoid injury to the collateral veins, liberal use of energy sources and division of dominant collateral veins between clips.Results:Seven adult patients including three females underwent LC. Three patients had thrombosis of previous surgical shunt with persistent PC. The remaining four patients did not have any indication for shunt surgery. Successful LC was performed in six patients. The median duration of surgery was 170 (130–250 min). Blood transfusion was not required. All the patients had uneventful post-operative recovery. The histopathology of gall bladder consists of acute cholecystitis in three patients and chronic cholecystitis in four.Conclusion:LC is feasible in patients with PC at a centre with experience in both laparoscopic and portal hypertension surgeries. Excellent outcome with low rate of conversion to open surgery can be achieved.

Incidence of double cystic artery: a clinical study

Background: A successful laparoscopic cholecystectomy is associated with the knowledge about anatomic structures and the congenital anomaly of the biliary tract. The aim of this study was to become familiar with vascular variations in laparoscopic cholecystectomy.Methods: This was a retrospective clinical study. The files of patients who underwent laparoscopic cholecystectomy due to benign gallbladder diseases were analyzed. The characteristics and complications of the patients with double cystic artery were recorded and examined.Results: A total of 360 patients, 76 males and 284 females were included in the study. The mean age was 51.2 (25-81). When the files of the patients were examined, it was found that double cystic arteries were detected during the operation in two male (2.63%) and nine female patients (3.16%). Gall bladder polyp was found as an indication for operation in one of 11 patients, while multiple gallbladder stones were found as an indication for operation in the other patients. The laparoscopic cholecystectomy was converted to conventional cholecystectomy in two from 11 patients (18.1%) with double cystic arteries due to bleeding. The mean duration of hospital stay in the patients with double cystic artery is 5.2 (3-11) days, and (2.7 days) longer compared to the patients without a double cystic artery.Conclusions: Cystic artery variations and other variations can coexist. Awareness of cystic artery variations can reduce the possibility of uncontrolled intraoperative bleeding, extrahepatic biliary injury, and switching to conventional cholecystectomy.