Laparoscopic cholecystectomy: early and late complications and their treatment

A rare case of postoperative hemorrhage following laparoscopic cholecystectomy - A case report

Laparoscopic cholecystectomy (LC) is widely accepted as the gold standard procedure for gallbladder removal. While LC is generally acknowledged for its safety and efficacy, this surgical intervention still carries the risk of complications, including postoperative hemorrhage, alongside other rare causes of bleeding. Postoperative recurrent bleeding often arises from complex underlying causes and demands swift identification and intervention for effective management. Here, we present a rare case of a patient diagnosed with an overlapping syndrome comprising primary biliary cholangitis (PBC) and autoimmune hepatitis (AIH), along with Sjögren's syndrome (SS). This patient experienced recurrent massive hemorrhage following cholecystectomy and was ultimately diagnosed with acquired hemophilia A (AHA). We provide a detailed account of the diagnostic and management processes involved.

Effect of laparoscopic cholecystectomy on 25-hydroxyvitamin D levels and bone mineral density in post menopausal women

BACKGROUND

Laparoscopic cholecystectomy (LC) is the gold standard management for benign gallbladder diseases. It has been observed that there is alteration in vitamin D levels and bone mineral density after cholecystectomy due to altered enterohepatic circulation. With increase in average age expectancy of the population, low levels of vitamin D levels and osteoporosis after cholecystectomies might cause increased health care burden.

METHODS

A prospective observational study was planned between 1 January 2022 and 30 June 2023 in the Department of General Surgery at PGIMER Chandigarh, a tertiary care hospital in north India. One hundred and three post-menopausal women who underwent LC and met the inclusion and exclusion criteria were included in the study. All participants underwent estimation of vitamin D and bone mineral density preoperatively and third-post operative month (POM).

RESULTS

The mean age of the patients was 58.46 ± 7.44. Pain abdomen was present in 68(66%) patients, 18 had epigastric discomfort and 17 had dyspepsia. The mean levels of vitamin D decreased from 21.92 at the baseline to 20.12 at third POM (p < .001). There was a significant change in t score Femoral Neck (-1.12 vs -1.15, p < .001) and Lumbar spine L1-L4 - 1.98 vs -1.98 (p = .033). z-scores of the femoral neck were -0.34 vs -0.54 (p < .001) and of lumbar spine L1-L4 were -0.95 vs 1.02 (p < .001). The decrease in fracture risk for the femoral neck (p = .344) and the lumbar spine (p = .223) was not statistically significant.

CONCLUSION

There is a significant decrease in vitamin D and BMD levels after LC in post-menopausal females.

Post-cholecystectomy clip migration: an unusual nidus of choledocholithiasis: a case report

Introduction and importance

Laparoscopic cholecystectomy is one of the common surgeries occurring worldwide and the gold standard for the management of gallstone disease. The non-absorbable surgical clips may slip and can migrate causing a variety of problems as such, choledocholithiasis.

Case presentation

The authors report a case of 43-year-old female who presented with the complaint epigastric pain. She had undergone cholecystectomy 7 years back for symptomatic cholelithiasis. Ultrasonography of the abdomen showed a dilated common bile duct following which endoscopic retrograde cholangiopancreatography was done. A single black-colored stone with the metal clip was retrieved.

Clinical discussion

Post-cholecystectomy clip migration should be considered as one of the differentials for choledocholithiasis. Ultrasonography of the abdomen shows the dilated common bile duct. Further management is done by endoscopic retrograde cholangiopancreatography.

Conclusion

Surgical clips acting as nidus for choledocholithiasis is rare these days but should be considered as one of the differentials for pain abdomen.

Comparing robotic and open surgical techniques in gallbladder cancer management: a detailed systematic review and meta-analysis

This meta-analysis aims to evaluate the safety and oncological outcomes of robotic surgery compared to open surgery in treating gallbladder cancer (GBC). In October 2023, we performed a literature search across major global databases such as PubMed, Embase, and the Cochrane Library. We employed a Review Manager for parameter comparisons. This study has been registered with PROSPERO under the identifier CRD42023476686. Our final meta-analysis incorporated 5 cohort studies, encompassing a total of 353 patients. Compared to the Open Group (OG), the Robotic Group (RG) had reduced intraoperative blood loss (WMD - 217.72 ml, 95% CI - 371.08 to - 64.35; p = 0.005), shorter hospital stay (WMD - 1.80 days, 95% CI - 2.66 to - 0.95; p < 0.0001), and fewer overall complications (OR 0.31, 95% CI 0.10-0.97; p = 0.04). However, there was no significant difference between the two groups in terms of operation duration, postoperative inpatient days, readmission rate, major complications, 1-year postoperative survival, 2-year postoperative survival, and mortality rates. In our study, we found that for patients with gallbladder cancer, robotic radical cholecystectomy offers certain potential advantages over open radical cholecystectomy. This suggests that robotic radical cholecystectomy might be the optimal choice for treating gallbladder cancer. However, further validation from high-quality randomized clinical trials is required.

Practices and Attitudes of Surgeons With Regard to Spilled Gallstones During Laparoscopic Cholecystectomy: A Cross-Sectional Study From Saudi Arabia

BACKGROUND

Gallbladder perforation and gallstone leakage are frequent complications following laparoscopic cholecystectomy (LC). Failure to remove gallstones may result in several issues that manifest immediately or years later. The goal of this study was to evaluate the attitudes of surgeons and the procedures used by them to deal with gallstone spillage during LC.

METHODS

A cross-sectional design was followed. Surgeons in nine healthcare facilities in the Qassim region of Saudi Arabia were approached through non-probability convivence sampling and the survey was distributed in each of the general surgery divisions. The study included general surgeons who currently performed LC and incomplete responses and interns were excluded. A self-administered questionnaire was developed with 18 questions regarding demographics, center, and designation at the hospital, surgeons' experience of LC, and exposure to gallstone spillage. Furthermore, items regarding knowledge, attitude, and self-reported practices related to gallstone spillage such as incidence, complications, and intervention taken to prevent gallstone spillage were also included. The level of significance was set at P <0.05.

RESULTS

There were 82 participants of both genders, including consultants, specialists, and residents. While only 23 (28%) participants had actually observed patients with complications from spilled stones, 46 (56.1%) participants were aware of this possibility, 53 (64.6%) deemed it inappropriate to bring up gallstone spillage when securing consent for LC, and 67 (81.7%) believed that such an incident needed to be documented in the operation notes. Only 11 (13.4%) thought that the complications arising out of the unretrieved gallstones should fall under the legal purview of the operative surgeon. There were very few complications of spilled gallstones that the participants were aware of, and none of them anticipated problems to arise more than three years after LC.

CONCLUSIONS

Awareness of the risks associated with gallstone spillage during LC needs to be raised, and it is imperative to standardize the practices related to their management.

A Prospective Cohort Analysis of the Prevalence and Predictive Factors of Delayed Discharge After Laparoscopic Cholecystectomy in Italy: The DeDiLaCo Study

BACKGROUND

The concept of early discharge ≤24 hours after Laparoscopic Cholecystectomy (LC) is still doubted in Italy. This prospective multicentre study aims to analyze the prevalence of patients undergoing elective LC who experienced a delayed discharge >24 hours in an extensive Italian national database and identify potential limiting factors of early discharge after LC.

METHODS

This is a prospective observational multicentre study performed from January 1, 2021 to December 31, 2021 by 90 Italian surgical units.

RESULTS

A total of 4664 patients were included in the study. Clinical reasons were found only for 850 patients (37.7%) discharged >24 hours after LC. After excluding patients with nonclinical reasons for delayed discharge >24 hours, 2 groups based on the length of hospitalization were created: the Early group (≤24 h; 2414 patients, 73.9%) and the Delayed group (>24 h; 850 patients, 26.1%). At the multivariate analysis, ASA III class ( P <0.0001), Charlson's Comorbidity Index (P=0.001), history of choledocholithiasis (P=0.03), presence of peritoneal adhesions (P<0.0001), operative time >60 min (P<0.0001), drain placement (P<0.0001), pain ( P =0.001), postoperative vomiting (P=0.001) and complications (P<0.0001) were independent predictors of delayed discharge >24 hours.

CONCLUSIONS

The majority of delayed discharges >24 hours after LC in our study were unrelated to the surgery itself. ASA class >II, advanced comorbidity, the presence of peritoneal adhesions, prolonged operative time, and placement of abdominal drainage were intraoperative variables independently associated with failure of early discharge.

Role of laparoscopic surgery in the management of gallbladder cancer: Systematic review & meta-analysis

BACKGROUND

This meta-analysis evaluates the safety and short-term oncological outcomes of laparoscopic vs. open surgery for gallbladder carcinoma(GBC).

METHODS

Meta-analysis was performed on laparoscopic(LG) and open group(OG) studies. Data for survival outcomes were extracted from Kaplan-Meier curves and combined with Tierney's method to estimate hazard ratios(HRs) and 95% CIs.

RESULTS

There was no significant difference in overall survival(HR: 1.01), disease-free survival(HR: 0.84), 30-day mortality(RR:1.10), overall recurrence(RR:0.93), intraoperative gallbladder violation(RR:1.17), operative time(WMD:8.32), number of patients receiving adjuvant chemotherapy(RR:1.06) and blood transfusion(RR: 0.81). A significant difference was seen in survival of T3 subgroup(HR:0.77) and number of lymph node dissections (LND)(WMD: 0.63) favoring OG, along with a decrease in postoperative complications(RR:0.65), greater incidence of R0 resections(RR:1.04), lower volume of intraoperative blood loss(WMD: 128.62), lower time in removing drainage tube(WMD: 1.35), shorter diet recovery time(WMD: 1.88), shorter hospital stay(WMD: 3.51), lower incidence of 90-day mortality(RR:0.49) favoring LG. A higher incidence of port-site recurrence(RR:1.99) was reported in LG.

CONCLUSION

Laparoscopic surgery is non-inferior to the open approach in terms of oncological outcomes and has an improved rate of postoperative complications.

Cholecystectomy for asymptomatic gallstones: Markov decision tree analysis

Gallstones are a common public health problem, especially in developed countries. There are an increasing number of patients who are diagnosed with gallstones due to increasing awareness and liberal use of imaging, with 22.6%-80% of gallstone patients being asymptomatic at the time of diagnosis. Despite being asymptomatic, this group of patients are still at life-long risk of developing symptoms and complications such as acute cholangitis and acute biliary pancreatitis. Hence, while early prophylactic cholecystectomy may have some benefits in selected groups of patients, the current standard practice is to recommend cholecystectomy only after symptoms or complications occur. After reviewing the current evidence about the natural course of asymptomatic gallstones, complications of cholecystectomy, quality of life outcomes, and economic outcomes, we recommend that the option of cholecystectomy should be discussed with all asymptomatic gallstone patients. Disclosure of material information is essential for patients to make an informed choice for prophylactic cholecystectomy. It is for the patient to decide on watchful waiting or prophylactic cholecystectomy, and not for the medical community to make a blanket policy of watchful waiting for asymptomatic gallstone patients. For patients with high-risk profiles, it is clinically justifiable to advocate cholecystectomy to minimize the likelihood of morbidity due to complications.

Review of imaging in post-laparoscopy cholecystectomy complications

Laparoscopic cholecystectomy is now considered the procedure of choice for uncomplicated symptomatic gallstone disease worldwide. Various biliary, vascular, gastrointestinal, neurological and local complications may be seen on imaging post surgery. Knowledge of these entities and imaging appearances is indispensable for the radiologist in today's era. We emphasize on the list of potential complications and imaging appearances of this surgical procedure.

The critical view of safety during laparoscopic cholecystectomy: Strasberg Yes or No? An Italian Multicentre study

BACKGROUND

Laparoscopic cholecystectomy is considered the gold standard for the treatment of gallbladder lithiasis; nevertheless, the incidence of bile duct injuries (BDI) is still high (0.3-0.8%) compared to open cholecystectomy (0.2%). In 1995, Strasberg introduced the "Critical View of Safety" (CVS) to reduce the risk of BDI. Despite its widespread use, the scientific evidence supporting this technique to prevent BDI is controversial.

METHODS

Between March 2017 and March 2019, the data of patients submitted to laparoscopic cholecystectomy in 30 Italian surgical departments were collected on a national database. A survey was submitted to all members of Italian Digestive Pathology Society to obtain data on the preoperative workup, the surgical and postoperative management of patients and to judge, at the end of the procedure, if the isolation of the elements was performed according to the CVS. In the case of a declared critical view, iconographic documentation was obtained, finally reviewed by an external auditor.

RESULTS

Data from 604 patients were analysed. The study population was divided into two groups according to the evidence (Group A; n = 11) or absence (Group B; N = 593) of BDI and perioperative bleeding. The non-use of CVS was found in 54.6% of procedures in the Group A, and 25.8% in the Group B, and evaluating the operator-related variables the execution of CVS was associated with a significantly lower incidence of BDI and intraoperative bleeding.

CONCLUSIONS

The CVS confirmed to be the safest technique to recognize the elements of the Calot triangle and, if correctly performed, it significantly impacted on preventing intraoperative complications. Additional educational programs on the correct application of CVS in clinical practice would be desirable to avoid extreme conditions that may require additional procedures.

The Role of Endoscopic Retrograde Cholangiopancreatography in the Management of Biliary Complication Post-Laparoscopic Cholecystectomy

BACKGROUND: Laparoscopic cholecystectomy considers a golden surgery for gallbladder removal nowadays, and it carries some complications like biliary injuries, which can manage successfully by endoscopic retrograde cholangiopancreatography. AIM: To estimate the role of endoscopic management of bile duct injury (BDI) following laparoscopic cholecystectomy. PATIENT AND METHODS: A prospective study conducted at Al-Sader Medical City, Najaf City, Iraq, during the period between September 2018 and December 2020, included 44 patients complicated by the biliary injury resulting in a persistent biliary leak and/or jaundice after laparoscopic cholecystectomy and evaluated by endoscopic retrograde cholangiopancreatography (ERCP). RESULTS: Findings revealed that 25% of cases had complete BDI, only one managed by plastic stent placement, the other 10 referred for open surgical constructions, 61% had partial injury associated with the biliary leak, all managed by sphincterotomy and plastic stent placement through ERCP, almost 7% had a partial clipping of bile duct all managed with sphincterotomy, balloon dilatation/stone extraction, and plastic stent placement, 5% had slipped clips of cystic duct stump, are managed with sphincterotomy and plastic stent placement. Moreover, only one patient, 2%, had distal common bile duct stone with bile leak, managed by sphincterotomy and stone extraction. CONCLUSIONS: Laparoscopic cholecystectomy, a gold standard therapeutic option for symptomatic cholecystolithiasis, is associated with an increased risk of biliary injury due to many factors. ERCP is a safe means of diagnosing the cause of bile leakage after laparoscopic cholecystectomy. It also offers definitive treatment in most cases by endoscopic sphincterotomy and plastic stent placement.

Role of Transarterial Embolization in the Management of Hepatic Artery Pseudoaneurysm Postlaparoscopic Cholecystectomy

Purpose To assess the safety and effectiveness of transarterial embolization (TAE) in the management of hepatic artery pseudoaneurysms following laparoscopic cholecystectomy (LC).

Materials and Methods This is a retrospective study consisting of 13 patients who had undergone TAE for management of pseudoaneurysms of the hepatic artery or its branches following LC. Patients presented with symptoms such as hypotension, hematemesis, melena or gradual anemia post LC. Abdominal CT revealed hepatic artery pseudoaneurysm in all patients. TAE was performed with either coils or N-butyl cyanoacrylate or both. We evaluated technical and clinical effectiveness and complications of TAE.

Results TAE was successful both technically and in stopping bleeding in all patients (100% technical and clinical success). No patient had rebleeding after TAE. Four patients required laparotomy for draining hemoperitoneum and clots. Endoscopic retrograde cholangiopancreatography (ERCP) for hemobilia or bile duct injury was done in eight patients. Following TAE, hepatic infarct was observed in three patients. Postembolization syndrome was seen in four patients and one patient died due to sepsis.

Conclusions TAE is effective for treatment of hepatic artery pseudoaneurysms after LC. Hepatic infarcts and postembolization syndrome are the most common complications and can be managed conservatively.

A 61-year-old Female with Right Upper Abdominal Pain

Case Presentation

A 61-year-old female presented to the emergency department with right upper quadrant abdominal pain following a cholecystectomy 18 days prior. Computed tomography (CT) of her abdomen demonstrated a large abscess in her post-hepatic fossa. She was admitted to the general surgery service and received an image-guided percutaneous drain placement with interventional radiology with immediate return of purulent material. She was discharged home after a three-day hospital course with outpatient antibiotics and follow-up.

Discussion

Patients may have multiple complications following cholecystectomy, including infection, bleeding, biliary injury, bowel injury, or dropped stone. The emergency clinician must consider cholecystectomy complications including gallbladder fossa abscess in patients presenting with abdominal pain in the days to weeks following cholecystectomy, especially if they present with signs of sepsis. Critical actions include obtaining CT and/or ultrasonography, initiating broad spectrum antibiotics, and obtaining definitive source control by either surgery or interventional radiology.

Risk factors for conversion to open surgery in laparoscopic cholecystectomy: A single center experience

Objectives

This study aimed to demonstrate the demographic characteristics for laparoscopic cholecystectomy surgeries performed in the general surgery clinics of our hospital and to identify the rate of conversion to open surgery and the main reasons for convert to open surgery.

Material and Methods

Medical records of a total of 1.294 patients who underwent laparoscopic cholecystectomy in our hospital between October 2013 and May 2017 were retrospectively reviewed, and the rates of conversion to open surgery based on age groups were recorded.

Results

Of these patients, 1191 were females (92.0%) and 103 (7.9%) were males. Mean age was 48.6 ± 13.2 (range: 18 to 89) years. Indications for surgery were cholelithiasis in 1195 patients (92.4%), acute cholecystitis in 56 patients (4.4%), and gallbladder polyps in 43 patients (3.3%). The procedure was conversion to open surgery in 41 patients (3.16%), while 12 (0.9%) developed intraoperative complications. There was no mortality. Mean length of hospital stay was 1.2 (range: 1 to 6) days. The main reasons for conversation to open surgery were as follows: adhesions in the Calot's triangle (n= 3), acute cholecystitis (n= 29), choledocholithiasis (n= 2), adhesions due to previous surgery (n= 1), dissection difficulty (n= 2), organ damage (n= 2), anatomic variation (n= 1), and stone expulsion (n= 1).

Conclusion

Acute cholecystitis appears to be the significant factor increasing the rate of conversation to open surgery during LC procedures. Male sex and older age are the other factors increasing the risk of con- vert to open surgery. However, LC should be still the first choice of intervention.

Is Nighttime Really Not the Right Time for a Laparoscopic Cholecystectomy?

PURPOSE

The impact of an out-of-hours laparoscopic cholecystectomy on outcome is controversial. We sought to determine the association between an out-of-hours procedure and postoperative complications within 90 days.

METHODS

Between 2014 and 2016, 1553 laparoscopic cholecystectomies were performed. Therapeutic, operative, and outcome data were prospectively collected and analyzed. We defined out of hours as during weekends, national holidays, and daily between 5PM and 8AM.

RESULTS

Most patients operated on were female (n=988; 63.6%) and the majority of procedures were electives (n=1341; 86.3%). Although all procedures were performed with a laparoscopic intent, 42 (2.7%) were converted to open procedure. In total, 145 (9.3%) procedures were out of hours, all nonelective, and in most cases for acute cholecystitis (n=111; 7.1%). Overall, there were 212 complications in 191 patients (12.3%), most (n=153; 9.9%) classified as minor. The conversion rate in the out-of-hours group was significantly higher (9.7% vs 2.0%; p<0.001). While univariate analyses revealed out-of-hours procedure (OR=1.83; p=0.008) to be associated with an increased risk of complications, when controlling for confounding factors by multivariate analysis, this association was not found. However, operation by surgical staff (OR=1.71) and conversion to laparotomy (OR=3.74) were found to be independently associated with an increased risk of complications (both p<0.05), while an emergency procedure tended to be associated with postoperative morbidity (OR=1.82; p=0.069).

CONCLUSION

An out-of-hours laparoscopic cholecystectomy was not found to be an independent risk factor for developing postoperative morbidity and time of day should therefore only be a relative contraindication.

Use of oxidized regenerated cellulose to achieve hemostasis during laparoscopic cholecystectomy: a retrospective cohort analysis

OBJECTIVE

Laparoscopic cholecystectomy is the first-choice treatment for symptomatic cholelithiasis. Though generally safe, this procedure is not without complications, with bleeding the most frequent cause of conversion to open cholecystectomy. Oxidized regenerated cellulose (ORC) added to conventional hemostatic strategies, is widely used to control bleeding during surgery despite limited evidence supporting its use. This retrospective study analyzed patients undergoing laparoscopic cholecystectomy in an Italian center over a 16-month period, between October 2014 and February 2016, who experienced uncontrollable bleeding despite the use of conventional hemostatic strategies, requiring the addition of ORC gauze (Emosist®).

RESULTS

Of the 530 patients who underwent laparoscopic cholecystectomy, 24 (4.5%) had uncontrollable bleeding from the liver bed. Of these, 62.5% had acute cholecystitis and 33.3% chronic cholecystitis; 1 patient was diagnosed with gallbladder carcinoma, postoperatively. Most patients had comorbidities, 16.7% had liver cirrhosis, and 37.5% used oral anticoagulants. The application of ORC rapidly controlled bleeding in all patients. Patients were discharged after a mean duration of 2.2 days. ORC was easy to use and well tolerated. Bleeding complications remain a relevant issue in laparoscopic cholecystectomy. ORC was able to promptly stop bleeding not adequately controlled by conventional methods and appears, therefore, to be a useful hemostat.

Post-operative telephone review is safe and effective: prospective study - Monash outpatient review by phone trial

INTRODUCTION

Studies have shown that post-operative telephone follow-up is satisfactory and effective. As high quality evidence is scant, we conducted a randomized controlled trial to compare it against outpatient clinic review for emergency laparoscopic appendicectomy or cholecystectomy.

METHOD

Patients who received emergency laparoscopic appendicectomy or cholecystectomy were eligible for this study. Once recruited, they were randomly allocated to either clinic review or telephone follow-up on discharge. Participants were reviewed at 2 weeks after operation and contacted again at 4 weeks after initial follow-up for satisfaction survey.

RESULTS

One hundred and seventy-nine participants were recruited with one withdrawn consent and six excluded. Ninety-six underwent laparoscopic appendicectomy and 76 had laparoscopic cholecystectomy. Ninety-six attended clinic review and 76 had telephone follow-up. The two groups were similar in baseline variables. Non-attendance rate was higher for clinic review cohort (24% vs 6.6%, P = 0.002). Participants who received telephone review reported higher satisfaction level (9.31 vs 8.85, P = 0.002), and most patients prefer telephone follow-up (73.1%, P < 0.0001). No difference was detected for missed complications (P = 0.354).

CONCLUSION

Telephone follow-up post laparoscopic appendicectomy or cholecystectomy is safe, satisfying and effective.

Complications of Laparoscopic Cholecystectomy: Our Experience from a Retrospective Analysis

AIM:

The aim of this study was to evaluate the intraoperative and postoperative complications of laparoscopic cholecystectomy, as well as the frequency of conversions.

MATERIAL AND METHODS:

Medical records of 740 patients who had laparoscopic cholecystectomy were analysed retrospectively. We evaluated patients for the presence of potential risk factors that could predict the development of complications such as age, gender, body mass index, white blood cell count and C-reactive protein (CRP), gallbladder ultrasonographic findings, and pathohistological analysis of removed gallbladders. The correlation between these risk factors was also analysed.

RESULTS:

There were 97 (13.1%) intraoperative complications (IOC). Iatrogenic perforations of a gallbladder were the most common complication - 39 patients (5.27%). Among the postoperative complications (POC), the most common ones were bleeding from abdominal cavity 27 (3.64%), biliary duct leaks 14 (1.89%), and infection of the surgical wound 7 patients (0.94%). There were 29 conversions (3.91%). The presence of more than one complication was more common in males (OR = 2.95, CI 95%, 1.42-4.23, p < 0.001). An especially high incidence of complications was noted in patients with elevated white blood cell count (OR = 3.98, CI 95% 1.68-16.92, p < 0.01), and CRP (OR = 2.42, CI 95% 1.23-12.54, p < 0.01). The increased incidence of complications was noted in patients with ultrasonographic finding of gallbladder empyema and increased thickness of the gallbladder wall > 3 mm (OR = 4.63, CI 95% 1.56-17.33, p < 0.001), as well as in patients with acute cholecystitis that was confirmed by pathohistological analysis (OR = 1.75, CI 95% 2.39-16.46, p < 0.001).

CONCLUSION:

Adopting laparoscopic cholecystectomy as a new technique for treatment of cholelithiasis, introduced a new spectrum of complications. Major biliary and vascular complications are life threatening, while minor complications cause patient discomfort and prolongation of the hospital stay. It is important recognising IOC complications during the surgery so they are taken care of in a timely manner during the surgical intervention. Conversion should not be considered a complication.

Prospective survey to study factors which could influence same-day discharge after elective laparoscopic cholecystectomy in a tertiary care hospital of a developing country

All laparoscopic cholecystectomy (LC) patients in our hospital setting are admitted overnight. This article assesses the contribution of factors like postoperative nausea and vomiting (PONV), postoperative pain and surgical complications to overnight stay after elective LC. This 1-year observational study included patients having normal liver functions undergoing elective LC before 1400 h. The collected data included patient demographics, co-morbidities, PONV, pain scores, complications, surgical time, anesthesia technique, use of prophylactic antiemetics, analgesics, patient satisfaction and desire to have this surgery as day case or in-patient procedure. From 930 LC done per annum, 45.2 % (430/950) patients were included in this study. Prophylactic antiemetic was given in 91.6 %, intraoperative narcotics in 94.2 % patients and multimodal analgesia in 85.3 %. The mean pain score in the recovery and ward was maintained to <4. In the ward, 99.1 % patients were able to start oral fluids after 6 h and were started on oral non-steroidal anti-inflammatory drugs and paracetamol, and none required parental opioid. The PONV score of more than 2 was observed in only 3.2 % of patients in the ward requiring parenteral antiemetic. Surgical complications in the form of bleeding, visceral injury and bile duct leak were observed in 2 % of patients, which was treated intra-operatively. Satisfaction was observed in 99.3 % and desire to stay overnight in 87.4 % of patients. Factors like postoperative pain, PONV and surgical complications were well managed and were not associated with significant morbidity to justify routine overnight admission. However, majority of the patients desired to stay overnight, which could be improved by counseling and education.

AMBULATORY LAPAROSCOPIC CHOLECYSTECTOMY IS SAFE AND COST-EFFECTIVE: a Brazilian single center experience

ABSTRACT Background - Laparoscopic cholecystectomy is the treatment of choice for gallstone disease, and has been perfomed as an outpatient surgery in many Institutions over the last few years. Objective - This is a retrospective study of a single center in Brazil, that aims to analyze the outcomes of 200 cases of ambulatory laparoscopic cholecystectomy performed by the same Hepato-Pancreato-Biliary team, evaluating the safety and cost-effectiveness of the method. Methods - Two hundred consecutive patients who underwent elective laparoscopic cholecystectomy were retrospectively analyzed; some of them underwent additional procedures, as liver biopsies and abdominal hernias repair. Results - From a total of 200 cases, the outpatient surgery protocol could not be carried out in 22 (11%). Twenty one (95.5%) patients remained hospitalized for 1 day and 1 (4.5%) patient remained hospitalized for 2 days. From the 178 patients who underwent ambulatory laparoscopic cholecystectomy, 3 (1.7 %) patients returned to the emergency room before the review appointment. Hospital cost was on average 35% lower for the ambulatory group. Conclusion - With appropriate selection criteria, ambulatory laparoscopic cholecystectomy is feasible, safe and effective; readmission rate is low, as well as complications related to the method. Cost savings and patient satisfaction support its adoption. Other studies are necessary to recommend this procedure as standard practice in Brazil.

A randomised, single blinded trial, assessing the effect of a two week preoperative very low calorie diet on laparoscopic cholecystectomy in obese patients

BACKGROUND

Laparoscopic cholecystectomy (LC) can be technically challenging in the obese. The primary aim of the trial was to establish whether following a Very Low Calorie Diet (VLCD) for two weeks pre-operatively reduces operation time. Secondary outcomes included perceived operative difficulty and length of hospital stay.

METHODS

A single-blinded, randomized controlled trial of consecutive patients with symptomatic gallstones and BMI >30 kg/m(2) 46 patients were randomized to a VLCD or normal diet for two weeks prior to LC. Food diaries were used to document dietary intake. The primary outcome measure was operation time. Secondary outcomes were length of stay, weight change operative complications, day case rates and perceived difficulty of operation.

RESULTS

The VLCD was well tolerated and had significantly greater preoperative weight loss (3.48 kg vs. 0.98 kg; p < 0.0001). Median operative time was significantly reduced by 6 min in the VLCD group (25 vs. 31 min; p = 0.0096). There were no differences in post-operative complications, length of stay, or day case rates between the groups. Dissection of Calot's triangle was deemed significantly easier in the VLCD group.

CONCLUSION

A two week VLCD prior to elective laparoscopic cholecystectomy in obese patients is safe, well tolerated and was shown to significantly reduce pre-operative weight and operative time.

ISRCTN

61630192. http://www.isrctn.com/ISRCTN61630192 Trial registration.

Temporary Trans-jejunal Hepatic Duct Stenting in Roux-en-y Hepaticojejunostomy for Reconstruction of Iatrogenic Bile Duct Injuries

BACKGROUND

Bile Duct Injuries (BDI) during cholecystectomy are now being recognized as major health problems.

OBJECTIVES

Herein, we present our experience with handling major BDIs and report long-term outcome of hepaticojejunostomies followed by trans-jejunal hepatic duct stenting performed to reconstruct extra-hepatic biliary tracts.

MATERIALS AND METHODS

In this case series, we prospectively collected data of 22 patients, who underwent first time biliary reconstruction through Roux-en-y hepaticojejunostomy followed by hepatic duct stenting using a trans-jejunal bifurcated 6F tube drain. The long-term outcome was assessed and defined as excellent (asymptomatic, normal liver enzymes and bilirubin levels), good (asymptomatic, mild abnormality in liver enzyme and bilirubin levels), poor (symptomatic, abnormal liver enzymes and bilirubin level) and failure (requiring reoperation).

RESULTS

A total of 22 patients including four males (18.1%) and 18 females (81.8%) were evaluated. The mean age was 42.71 (range: 23 - 74) years. Twelve patients had undergone open cholecystectomy (54.5%) and the rest had a history of laparoscopic cholecystectomy. The mean interval between the primary operation and reconstruction was 92.71 days. The mean follow-up period after biliary reconstruction was 42.33 (range: 1 - 96) months. No instance of anastomotic leakage or stenosis, biliary sepsis, thromboembolic event, or respiratory infection was noted in the long-term follow-up. The outcome was excellent in all patients. No case with poor or failure of result was noticed.

CONCLUSIONS

Although a devastating complication iatrogenic major bile duct injuries can be corrected surgically with a high rate of success. Temporary trans-jejunal stenting of the hepatic ducts can help in maintaining the integrity of anastomosis without stenosis or biliary sepsis.

"Laparoscopic Cholecystectomy: A Single Surgeon's Experience in some of the Teaching Hospitals of West Bengal"

Laparoscopic cholecystectomy has revolutionized the management of symptomatic gallstone disease since its introduction more than 20 years ago. It has gained widespread acceptance and is presently the gold standard for its management. This large study spanned over last 10 years and includes prospective data on 950 elective cases of laparoscopic cholecystectomy since 2002. All cases were operated personally by the author in different teaching hospitals of West Bengal. The following were looked into: profiles of the patients including major comorbidities requiring special precautions, the frequency of "difficult cholecystectomies," conversion rate, and operative and postoperative complications. The results showed that 75 % of the patients were females. The mean age of the female patients was 35 years (range15-75), while that of the male patients was 42 (range 18-68). Thirty-two patients had major comorbidities which required special precautions in the perioperative period. Twenty-six percent of the cases were categorized as "difficult," and 6 % of the cases had to be converted to open procedure. Major complications occurred in 11 patients of which five had to be converted. Fifty-five patients had port-site infection due to atypical mycobacteria species of which majority occurred in the last 1 year of the study. All of them responded to second-line antitubercular medications.

Use of floseal hemostatic matrix for control of hemostasis during laparoscopic cholecystectomy for acute cholecystitis: a multicenter historical control group comparison (the GLA study gelatin matrix for acute cholecystitis)

BACKGROUND

In patients with acute cholecystitis undergoing laparoscopic cholecystectomy, bleeding is a common complication that can reduce procedural visibility and worsen outcome. Insufficient hemostasis can also lead to postoperative bleeding that can, in rare cases, be fatal. Topical hemostatic agents are used to ensure adequate hemostasis during laparoscopic cholecystectomy.

SUBJECTS AND METHODS

This prospective, open-label, nonrandomized, historical control group study investigated the use of Floseal(®) (Baxter International, Inc., Deerfield, IL) hemostatic matrix as an adjunct to surgical techniques to achieve hemostasis of the resected areas in patients undergoing laparoscopic cholecystectomy for acute cholecystitis. The primary end point was the rate of complete hemostasis 10 minutes after laparoscopic application of Floseal to the gallbladder bed. Secondary end points included complete hemostasis rates at 2, 4, and 6 minutes, surgery time, laparoscopic procedure to open laparotomy conversion rate, postoperative bleeding rate, and mortality and safety outcomes over the entire follow-up period.

RESULTS

From April to November 2011, 101 consecutive patients were enrolled (51 men; mean age, 61.5±6.2 years). The historical control group of 100 age- and gender-matched patients with acute cholecystitis had undergone laparoscopic cholecystectomy without hemostatic agent. In the Floseal group, bleeding ceased within 10 minutes after laparoscopic application of the hemostatic agent to the gallbladder bed in all patients. The conversion rate was significantly lower in the Floseal group than in the control group (4 versus 12 patients, P<.05).

CONCLUSIONS

Floseal in acute cholecystitis is safe, is effective in controlling bleeding, and results in a lower conversion rate compared with cholecystectomy without hemostatic agents.

LigLAP: Encirclement and Ligation of Vessels in Laparoscopic Surgery: A Double-Layer Suture Sealing Approach

This article proposes a potential automatic ligation (LigLAP) method to occlude vessels and ducts in several laparoscopic surgical procedures. Currently, stapling devices are widely used for this purpose. However, there are some complications associated with stapling devices, including biliary leak and tissue damage. In this article, we examine the feasibility of an alternative method that uses a double-layer suture to encircle and occlude a vessel. A heating element melts the outer layer of the suture at the cross-point of the suture to create a seal. Several electromechanical mechanisms have been proposed to carry out this ligation process. In addition, some parts have been prototyped for experimental verification and visualization. Several double-layered sutures have been created, and their tensile strength and sealing capabilities have been measured. Moreover, a simple leakage experiment has been performed to verify experimentally the idea of using the double-layer suture. The results show that the new suture and the thermal sealing method provide the required strength to occlude balloons filled with water. Although the results suggest that the proposed method and the double-layer suture may be used in surgical ligation processes, much more rigorous testing of leakage is required.

Laparoscopic cholecystectomy: consensus conference-based guidelines

INTRODUCTION

Laparoscopic cholecystectomy (LC) is the gold standard technique for gallbladder diseases in both acute and elective surgery. Nevertheless, reports from national surveys still seem to represent some doubts regarding its diffusion. There is neither a wide consensus on its indications nor on its possible related morbidity. On the other hand, more than 25 years have passed since the introduction of LC, and we have all witnessed the exponential growth of knowledge, skill and technology that has followed it. In 1995, the EAES published its consensus statement on laparoscopic cholecystectomy in which seven main questions were answered, according to the available evidence. During the following 20 years, there have been several additional guidelines on LC, mainly focused on some particular aspect, such as emergency or concomitant biliary tract surgery.

METHODS

In 2012, several Italian surgical societies decided to revisit the clinical recommendations for the role of laparoscopy in the treatment of gallbladder diseases in adults, to update and supplement the existing guidelines with recommendations that reflect what is known and what constitutes good practice concerning LC.

An option of conservative management of a duodenal injury following laparoscopic cholecystectomy

Duodenal injury following laparoscopic cholecystectomy is rare complications with catastrophic sequelae. Most injuries are attributed to thermal burns with electrocautery following adhesiolysis and have a delayed presentation requiring surgical intervention. We present a case of a 47-year-old gentleman operated on for laparoscopic cholecystectomy with a bilious drain postoperatively; for which an ERC was done showing choledocholithiasis with cystic duct stump blow-out and a drain in the duodenum suggestive of an iatrogenic duodenal injury. He was managed conservatively like a duodenal fistula and recovered without undergoing any intervention.

Retraction-Related Acute Liver Failure after Urological Laparoscopic Surgery

Liver retraction is necessary for optimal exposure during laparoscopic right renal surgery. We described a patient who developed fulminant liver failure as a result of liver retractor-induced excessive ischemic changes in the right lobe of the liver. A 37-year-old male underwent a right side laparoscopic pyeloplasty for ureteropelvic junction obstruction. At the beginning of the operation, a small snake retractor was placed through a 5-mm port under direct vision. The liver was lifted in the appropriate direction to optimize exposure by using the laparoscope holder. The operation was prolonged. However, we achieved significant improvements in the efficiency of liver retraction using the holder. On the first postoperative day, the patient's serum levels of GOT, GPT and LDH had remarkably increased. A computerized tomogram confirmed the presence of excessive ischemic changes of the right lobe of the liver. Our method which used a laparoscope holder device for liver retraction maintained a better surgical field. However, neglecting to make minor adjustments to the positioning of the retractor can cause significant pressure on the liver parenchyma in a single area. As surgical procedures increase in complexity, the surgeon should keep these potential side effects in mind and shift the retraction point at regular intervals. In this report, we discussed various types of retractor-related liver injuries and their management, and highlighted the importance of intermittent release of retraction during prolonged surgery.

Imaging in laparoscopic cholecystectomy--what a radiologist needs to know

Laparoscopic cholecystectomy is the gold standard treatment option for cholelithiasis. In order to properly assess for the complications related to the procedure, an understanding of the normal biliary anatomy, its variants and the normal postoperative imaging is essential. Radiologist must be aware of benefits and limitations of multiple imaging modalities in characterizing the complications of this procedure as each of these modalities have a critical role in evaluating a symptomatic post-cholecystectomy patient. The purpose of this article is describe the multi-modality imaging of normal biliary anatomy and its variants, as well as to illustrate the imaging features of biliary, vascular, cystic duct, infectious as well as miscellaneous complications of laparoscopic cholecystectomy. We focus on the information that the radiologist needs to know about the radiographic manifestations of potential complications of this procedure.

Day-surgery versus overnight stay surgery for laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy is used to manage symptomatic gallstones. There is considerable controversy regarding whether it should be done as day-surgery or as an overnight stay surgery with regards to patient safety.

OBJECTIVES

To assess the impact of day-surgery versus overnight stay laparoscopic cholecystectomy on patient-oriented outcomes such as mortality, severe adverse events, and quality of life.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, and mRCT until September 2012.

SELECTION CRITERIA

We included randomised clinical trials comparing day-surgery versus overnight stay surgery for laparoscopic cholecystectomy, irrespective of language or publication status.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trials for inclusion and independently extracted the data. We analysed the data with both the fixed-effect and the random-effects models using Review Manager 5 analysis. We calculated the risk ratio (RR), mean difference (MD), or standardised mean difference (SMD) with 95% confidence intervals (CI) based on intention-to-treat or available case analysis.

MAIN RESULTS

We identified a total of six trials at high risk of bias involving 492 participants undergoing day-case laparoscopic cholecystectomy (n = 239) versus overnight stay laparoscopic cholecystectomy (n = 253) for symptomatic gallstones. The number of participants in each trial ranged from 28 to 150. The proportion of women in the trials varied between 74% and 84%. The mean or median age in the trials varied between 40 and 47 years.With regards to primary outcomes, only one trial reported short-term mortality. However, the trial stated that there were no deaths in either of the groups. We inferred from the other outcomes that there was no short-term mortality in the remaining trials. Long-term mortality was not reported in any of the trials. There was no significant difference in the rate of serious adverse events between the two groups (4 trials; 391 participants; 7/191 (weighted rate 1.6%) in the day-surgery group versus 1/200 (0.5%) in the overnight stay surgery group; rate ratio 3.24; 95% CI 0.74 to 14.09). There was no significant difference in quality of life between the two groups (4 trials; 333 participants; SMD -0.11; 95% CI -0.33 to 0.10).There was no significant difference between the two groups regarding the secondary outcomes of our review: pain (3 trials; 175 participants; MD 0.02 cm visual analogue scale score; 95% CI -0.69 to 0.73); time to return to activity (2 trials, 217 participants; MD -0.55 days; 95% CI -2.18 to 1.08); and return to work (1 trial, 74 participants; MD -2.00 days; 95% CI -10.34 to 6.34). No significant difference was seen in hospital readmission rate (5 trials; 464 participants; 6/225 (weighted rate 0.5%) in the day-surgery group versus 5/239 (2.1%) in the overnight stay surgery group (rate ratio 1.25; 95% CI 0.43 to 3.63) or in the proportion of people requiring hospital readmissions (3 trials; 290 participants; 5/136 (weighted proportion 3.5%) in the day-surgery group versus 5/154 (3.2%) in the overnight stay surgery group; RR 1.09; 95% CI 0.33 to 3.60). No significant difference was seen in the proportion of failed discharge (failure to be discharged as planned) between the two groups (5 trials; 419 participants; 42/205 (weighted proportion 19.3%) in the day-surgery group versus 43/214 (20.1%) in the overnight stay surgery group; RR 0.96; 95% CI 0.65 to 1.41). For all outcomes except pain, the accrued information was far less than the diversity-adjusted required information size to exclude random errors.

AUTHORS' CONCLUSIONS

Day-surgery appears just as safe as overnight stay surgery in laparoscopic cholecystectomy. Day-surgery does not seem to result in improvement in any patient-oriented outcomes such as return to normal activity or earlier return to work. The randomised clinical trials backing these statements are weakened by risks of systematic errors (bias) and risks of random errors (play of chance). More randomised clinical trials are needed to assess the impact of day-surgery laparoscopic cholecystectomy on the quality of life as well as other outcomes of patients.

[Not Available]

OBJECTIVE

To deteremine the incidence, nature and management of extra-biliary complications of laparoscopic cholecystectomy.

MATERIALS AND METHODS

This study presents a retrospective analysis of extra-biliary complications occuring during 1046 laparoscopic cholecystectomies performed from August 2003 to December 2006. The study population included all the patients with symptomatic gallstone disease in whom laparoscopic cholecystectomy was performed. The extra-biliary complications were divided into two distinct categories: (i) Procedure related and (ii) Access related.

RESULTS

The incidence of access-related complications was 3.77% and that of procedure-related complications was 6.02%. Port-site bleeding was troublesome at times and demanded a re-do laparoscopy or conversion. Small bowel laceration occurred in two patients where access was achieved by closed technique. Five cases of duodenal and two of colonic perforations were the major complications encountered during dissection in the area of Calot's triangle. In 21 (2%) patients the procedure was converted to open surgery due to different complications. Biliary complications occurred in 2.6% patients in the current series.

CONCLUSION

Major extra-biliary complications are as frequent as the biliary complications and can be life-threatening. An early diagnosis is critical to their management.

Is routine intraoperative cholangiogram necessary in the twenty-first century? A national view

INTRODUCTION

Intraoperative cholangiogram (IOC) can define biliary ductal anatomy. Routine IOC has been proposed previously. However, current surgeon IOC utilization practice patterns and outcomes are unclear.

METHODS

Nationwide Inpatient Sample 2004-2009 was queried for patients with acute biliary disease undergoing cholecystectomy (CCY). Analyses only included surgeons performing ≥10 CCY/year. We dichotomized surgeons into a routine IOC group vs. selective. Outcomes included bile duct injury, complications, mortality, length of stay, and cost.

RESULTS

Of the nonweighted patients, 111,815 underwent CCY. A total of 4,740 actual surgeon yearly volumes were examined. On average, each surgeon performed 23.6 CCYs and 7.9 IOCs annually, using IOC in 33 % of cases. The routine IOC group used IOC for 96 % of cases, whereas selective IOC group used IOC ∼25 % of the time. Routine IOC surgeons had no difference in mortality (0.4 %) or rate of bile duct injury (0.25 vs. 0.26 %), but higher overall complications (7.3 vs. 6.8 %, p = 0.04). Patients of routine IOC surgeons received more additional procedures and incurred higher costs.

CONCLUSION

Routine IOC does not decrease the rate of bile duct injury, but is associated with significant added cost. Surgeons' routine use of IOC is correlated with increased rates of postsurgical procedures, and is associated with increased overall complications. These data suggest routine IOC may not improve outcomes.

Ambulatory laparoscopic cholecystectomy: An audit of day case vs overnight surgery at a community hospital in Japan

AIM: To evaluate the applicability and safety of ambulatory laparoscopic cholecystectomy (LC) and to compare day case and overnight stay LC.

METHODS: Data were collected retrospectively and consecutively for day case and overnight stay LC patients from July 1, 2009 to April 30, 2011. Outcomes were analyzed for patient demographics, operation time, blood loss during operation and frequency and reasons for unexpected or prolonged hospitalization in each group.

RESULTS: There was no hospital mortality and no patient was readmitted with serious morbidity after discharge. 50 patients received a day case LC and 19 had an overnight stay LC. There was a significant difference in age between both groups (P < 0.02). There were no significant differences between the day case LC performed (n = 41) and failed (n = 9) groups and between the day case LC performed and the one night stay LC (n = 12) groups. There was a significant difference in age between the one night stay and more nights stay LC groups (P < 0.05). Thus, elderly patients showed a tendency to like to stay in hospital rather than being a day case. The proportion of unexpected or prolonged hospitalization was not significantly different between the day case and overnight stay LC groups, when the patient’s request was excluded.

CONCLUSION: Day case LC can be performed with a low rate of complications. In overnight stay patients, there are many who could be performed safely as a day case. Moreover, we need to take special care to treat elderly patients.

[Typical intraoperative complications in laparoscopic surgery]

For all common laparoscopic procedures (e. g. cholecystectomy, appendectomy, inguinal hernia repair, fundoplication and colorectal resection) it has been possible to demonstrate in systematic reviews and meta-analyses that they produce better results in terms of perioperative outcome than open surgery. Accordingly, there are very few publications that report on intraoperative complications and their management. In this respect a distinction must be made between positioning complications, access complications and complications related to the pneumoperitoneum, which can manifest in all laparoscopic procedures, as well as the specific complications associated with individual procedures.The main focus of any consideration of intraoperative complications must of course be on strategies to prevent the occurrence. If intraoperative complications have occurred, the most important aspect is the diagnosis and control with prime importance accorded to which complications can still be controlled using a laparoscopic approach and when an open procedure must be used. In general a switch to open surgery should be made in the event of serious complications. Only a highly experienced laparoscopic surgeon will be able to safely manage complications once they have occurred without putting the patient at further risk. In doubtful situations the approach that poses least risk is open surgery for complications that have already occurred.

Laparoscopic cholecystectomy without handling the cystic artery: a new approach to minimize complications

INTRODUCTION

Although laparoscopy has now become the procedure of choice for removal of gallbladder, complications especially injury to cystic artery and ducts are thought to be higher. We describe a technique that avoids handling and injury of cystic artery and resultant duct injuries. The video length is 2 minutes 13 seconds.

MATERIALS AND METHODS

From October 7, 2005, to December 31, 2010, 17 patients were successfully operated by the cystic artery sparing technique. In this technique, dissection begins distal to cystic lymph node on the gallbladder wall using hook cautery, thereby clears the Calot's triangle without even touching the cystic artery. This maneuver eliminates the risk of injuring thus causing bleeding and any subsequent complications. Age, sex, and operative outcomes including follow-ups were evaluated.

RESULTS

Age of the patients ranged from 3.4 years to 16 years with an average of 10.12 years. Males were predominant (10:7). Average operative time was 40 minutes. There were no intraoperative or immediate postoperative complications. Patients were allowed feeding 4-6 hours after operation and discharged the following morning. Patients were asked to come for follow-up at 1 week, 1 month, 3 months, 6 months, and 1 year and thereafter yearly. Follow-up period ranged from 6 months to 5 years. There were no operation-related complications other than minor abdominal pain in 3 patients and port-site pain in 2 patients which resolved on conservative treatments.

CONCLUSION

During laparoscopic cholecystectomy, if handling of the main cystic artery is avoided then complications of hemorrhage and bile duct injuries can be minimized.

Bleeding complications in laparoscopic cholecystectomy: Incidence, mechanisms, prevention and management

BACKGROUND

Laparoscopic cholecystectomy (LC) has established itself firmly as the 'gold standard' for the treatment of gallstone disease, but it can, at times, be associated with significant morbidity and mortality. Existing literature has focused almost exclusively on the biliary complications of this procedure, but other complications such as significant haemorrhage can also be encountered, with an immediate mortality if not recognized and treated in a timely manner.

MATERIALS AND METHODS

Publications in English language literature that have reported the complication of bleeding during or after the performance of LC were identified and accessed. The results thus obtained were tabulated and analyzed to get a true picture of this complication, its mechanism and preventive measures.

RESULTS

Bleeding has been reported to occur with an incidence of up to nearly 10% in various series, and can occur at any time during LC (during trocar insertion, dissection technique or slippage of clips/ ligatures) or in the postoperative period. It can range from minor haematomas to life-threatening injuries to major intra-abdominal vessels (such as aorta, vena cava and iliacs).

CONCLUSION

Good surgical technique, awareness and early recognition and management of such cases are keys to success when dealing with this problem.

Biliary complications postlaparoscopic cholecystectomy: mechanism, preventive measures, and approach to management: a review

Laparoscopic cholecystectomy has emerged as a gold standard therapeutic option for the management of symptomatic cholelithiasis. However, adaptation of LC is associated with increased risk of complications, particularly bile duct injury ranging from 0.3 to 0.6%. Occurrence of BDI results in difficult reconstruction, prolonged hospitalization, and high risk of long-term complications. Therefore, more emphasis is placed on preventing these complications. In addition to adequate training, several techniques have been proposed to prevent bile duct injury including use of 30° scope, adequate delineation of structures in Calot's triangle (critical view), avoidance of diathermy close to common hepatic duct, and intraoperative cholangiogram, and to maintain a low threshold to conversion to open approach when uncertain. Management of Bile duct injury depends on the nature of injury, time of detection, and the expertise available, and would range from simple subhepatic drainage to Roux-en-Y hepaticojejunostomy particularly performed at specialised centers. This article based on the literature review aims to review the biliary complications following laparoscopic cholecystectomy with reference to its mechanism , preventive measures to be taken, and the management approach.

Single-incision laparoscopic cholecystectomy: a comparison with the gold standard

BACKGROUND

Single-incision laparoscopic cholecystectomy (SILC) may be a comparable alternative to conventional multiport laparoscopic cholecystectomy (LC). This study compared procedural outcomes and costs between SILC and LC.

METHODS

A retrospective review of patients undergoing SILC over an 8-month period was performed. A cohort of LC patients from the same surgeons over the preceding 8 months was used as historic controls. Demographics, comorbidities, diagnosis, operative data, pain control in the recovery room, complications, length of hospital stay, and cost were compared between the two groups.

RESULTS

Of the 285 patients, 177 underwent LC and 108 underwent SILC. The mean age was 49.7 years for the LC patients and 48.2 years for the SILC patients (p = 0.44). Two of the LC patients underwent conversion to open surgery. None of SILC patients were converted to open procedure, although nine had additional ports placed. After multivariate adjustment, SILC was associated with a 15% longer operative time (p = 0.053) and a 66% shorter hospital stay (p = 006) than LC. Biliary dyskinesia and biliary colic were independently associated with shorter operative times and a reduced hospital stay. No significant differences were noted in pain score, narcotics used in the postanesthesia care unit (PACU), 30-day complication rates (1.7 vs 1.9%; p = 1), hospital charges, or cost between the two groups.

CONCLUSIONS

Single-incision LC is safe, significantly reduces the hospital stay, and is an acceptable alternative to traditional LC. Although further study is warranted, initial results indicate that SILC may offer the most benefit for outpatient procedures.