Laparoscopic versus open surgery for the management of post-cholecystectomy benign biliary strictures

Enhancing laparoscopic surgery training: a comparative study of traditional models and automated error detection system

BACKGROUND

Although beneficial for patients through its minimally invasive nature, laparoscopic surgery creates unique training challenges due to limited instrument maneuverability, absence of stereovision, and inadequate real-time feedback. Traditional training models rely on subjective instructor evaluations, which are time-consuming and lack objective error detection. This study evaluates the efficacy of an Automated Error Detection System (AEDS), designed to provide real-time feedback on mistouch error counts, in improving laparoscopic skill acquisition compared to conventional methods.

METHODS

Forty novice participants were recruited and randomized into Group A (AEDS-enhanced training) and Group B (traditional training). Group A underwent a crossover design: 10 min of baseline training without AEDS followed by 10 min with AEDS. Group B completed 20 min of traditional training. The training program encompassed standardized laparoscopic tasks designed to simulate real surgical procedures. Performance metrics, including task completion time and the number of errors made, were recorded for each participant through AEDS. Confidence levels were assessed through self-reported questionnaires. Furthermore, statistical analysis was performed to evaluate the effectiveness of AEDS. A paired t-test was utilized to assess error reductions within the AEDS group, and Bland-Altman analysis was used to analyze the self-estimate error bias. Also, a Wilcoxon signed-rank test evaluated improvements in confidence levels attributable to the system, while a Mann-Whitney U test was conducted to compare performance metrics between the AEDS and traditional training groups.

RESULTS

Group A demonstrated a 24% reduction in errors post-AEDS (mean: 78.1 to 59.4, p < 0.001), outperforming Group B (mean: 67.4, p < 0.001). Participants significantly underestimated errors without AEDS (mean bias: +9.9 errors). Confidence levels in Group A increased from 2.4 to 3.6, significantly surpassing Group B's improvement (median: 3) (p < 0.001). Real-time feedback bridged perceptual gaps, enhancing both technical precision and self-assessment accuracy.

CONCLUSION

The integration of AEDS into laparoscopic training significantly reduces operational errors, accelerates skill acquisition, and boosts trainee confidence by providing objective feedback. These findings advocate for adopting AEDS in surgical education to standardize training outcomes, mitigate overconfidence, and improve patient safety. Future studies should explore AEDS scalability across advanced procedural modules and diverse trainee cohorts.

CLINICAL TRIAL NUMBER

Not applicable.

Open versus laparoscopic completion cholecystectomy in patients with previous open partial cholecystectomy: a retrospective comparative study

Background

Some patients report recurrence or persistence of their manifestations after cholecystectomy, and retained gallstones may be a relevant etiology for their complaint. Completion cholecystectomy is advised for these cases to alleviate their manifestations. No previous studies have compared the outcomes of open versus laparoscopic outcomes in these patients, especially in patients who had initial open partial procedures. That is why we performed this study to report the perioperative outcomes of the two approaches in such patients.

Methodology

This is a retrospective analysis of 80 patients who had a completion cholecystectomy in the authors' center (40 open and 40 laparoscopic cases) after initial open partial cholecystectomy.

Results

The duration elapsed since the primary procedure had an average of 18 months in the open group and 21 months in the laparoscopic group. Abdominal pain and dyspepsia were the most common presentations. Some patients had stump cholecystitis or jaundice. The intraoperative assessment revealed either the residual gallbladder or a long cystic duct stump. Laparoscopy yielded shorter operative time, earlier oral intake, and shorter hospitalization periods compared to the open approach (P<0.05). The latter was associated with a 20% wound infection rate that was never encountered after laparoscopy (P =0.003).

Conclusion

Previous open partial cholecystectomy does not hinder subsequent laparoscopic completion cholecystectomy. Additionally, laparoscopy is associated with better perioperative outcomes than the open approach.

Simulation training of laparoscopic biliary-enteric anastomosis with a three-dimensional-printed model leads to better skill transfer: a randomized controlled trial

AIM

A new simulation model and training curriculum for laparoscopic bilioenteric anastomosis has been developed. Currently, this concept lacks evidence for the transfer of skills from simulation to clinical settings. This study was conducted to determine whether training with a three-dimensional (3D) bilioenteric anastomosis model result in greater transfer of skills than traditional training methods involving video observation and a general suture model.

METHODS

Fifteen general surgeons with no prior experience in laparoscopic biliary-enteric anastomosis were included in this study and randomised into three training groups: video observation only, practice using a general suture model, and practice using a 3D-printed biliary-enteric anastomosis model. Following five training sessions, each surgeon was asked to perform a laparoscopic biliary-enteric anastomosis procedure on an isolated swine organ model. The operative time and performance scores of the procedure were recorded and compared among the three training groups.

RESULTS

The operation time in the 3D-printed model group was significantly shorter than the suture and video observation groups ( P =0.040). Furthermore, the performance score of the 3D-printed model group was significantly higher than those of the suture and video observation groups ( P =0.001). Finally, the goal score for laparoscopic biliary-enteric anastomosis in the isolated swine organ model was significantly higher in the 3D model group than in the suture and video observation groups ( P =0.004).

CONCLUSIONS

The utilisation of a novel 3D-printed model for simulation training in laparoscopic biliary-enteric anastomosis facilitates improved skill acquisition and transferability to an animal setting compared with traditional training techniques.

Laparoscopic repair of bile duct injuries: Feasibility and outcomes

INTRODUCTION

Bile duct injuries (BDI) following laparoscopic cholecystectomy occurs in approximately 0.6% of the cases, often being more severe and complex. Roux-en-Y hepaticojejunostomy (RYHJ) is considered the optimal therapeutic option, with success rates ranging from 75% to 98%. Several series have demonstrated the advancements of the laparoscopic approach for resolving this condition. The objective of this study is to describe our experience in the laparoscopic repair of BDI.

METHODS

A retrospective, descriptive study was conducted, including patients who underwent laparoscopic repair after BDI. Demographic, clinical, surgical, and postoperative variables were analysed using descriptive statistical analyses.

RESULTS

Eight patients with BDI underwent laparoscopic repair (out of 81 surgically repaired patients). Women comprised 75% of the sample. A complete laparoscopic repair was achieved in 75% (6) of cases. The mean age was 40.8 ± 16.61 years (range 19-65). Injuries at or above the confluence (Strasberg-Bismuth ≥ E3) occurred in 25% of cases (2). Primary repair was performed in two cases. Half of the cases underwent a Hepp-Couinaud laterolateral RYHJ, while three patients received a terminolateral RYHJ, and one underwent a bi-terminolateral RYH. The mean operative time was 260 min (range 120-360). Overall morbidity was 37.5% (3 cases): two minor complications (bile leak grade A and drainage-related bleeding) and one major complication (bile leak grade C). No mortality was recorded. The maximum follow-up period reached 26 months (range 6-26).

CONCLUSIONS

Our study demonstrates the feasibility of laparoscopic RYHJ in a selected group of patients, offering the benefits of a minimally invasive approach.

Minimally invasive surgery for post cholecystectomy biliary stricture: current evidence and future perspectives

Postcholecystectomy bile duct injury (BDI) remains a devastating iatrogenic complication that adversely impacts the quality of life with high healthcare costs. Despite a decrease in the incidence of laparoscopic cholecystectomy-related BDI, the absolute number remains high as cholecystectomy is a commonly performed surgical procedure. Open Roux-en-Y hepaticojejunostomy with meticulous surgical technique remains the gold standard surgical procedure with excellent long-term results in most patients. As with many hepatobiliary disorders, a minimally invasive approach has been recently explored to minimize access-related complications and improve postoperative recovery. Since patients with gallstone disease are often admitted for a minimally invasive cholecystectomy, laparoscopic and robotic approaches for repairing postcholecystectomy biliary stricture are attractive. While recent series have shown the feasibility and safety of minimally invasive post-cholecystectomy biliary stricture management, most are retrospective analyses with small sample sizes. Also, long-term follow-up is available only in a limited number of studies. The principles and technique of minimally invasive repair resemble open repair except for the extent of adhesiolysis and the suturing technique with continuous sutures commonly used in minimally invasive approaches. The robotic approach overcomes key limitations of laparoscopic surgery and has the potential to become the preferred minimally invasive approach for the repair of postcholecystectomy biliary stricture. Despite increasing use, lack of prospective studies and selection bias with available evidence precludes definitive conclusions regarding minimally invasive surgery for managing postcholecystectomy biliary stricture. High-volume prospective studies are required to confirm the initial promising outcomes with minimally invasive surgery.

Hepaticojejunostomy for bile duct injury: state of the art

BACKGROUND

Hepaticojejunostomy (HJ) is the gold standard procedure for the reconstruction of the bile duct in many benign and malignant situations. One of the major situation is the bile duct injury (BDI) after cholecystectomy, either for early or late repair. This procedure presents some specificities associated to a debated management of BDI.

PURPOSE

This article provides a state-of-the-art of the hepaticojejunostomy procedure focusing on bile duct injury including its indications and outcomes CONCLUSION: Performed at the right moment and respecting the technical rules, HJ provides a restoration of the biliary patency in the long term of 80 to 90%. It is the main surgical technique to repair BDI. Complications and failure of this procedure can be difficult to manage. That is why the primary repair requires an appropriate multidisciplinary approach associated with an expert high quality surgical technique.

A study of simulation training in laparoscopic bilioenteric anastomosis on a 3D-printed dry lab model

BACKGROUND

There are few studies on simulation training in laparoscopic bilioenteric anastomosis. There is also a lack of mature and reliable training models for bilioenteric anastomosis. In this study, we aimed to assess a feasible training model for bilioenteric anastomosis. Surgeons can improve their surgical ability by performing laparoscopic bilioenteric anastomosis on this model through repeated training.

METHOD

The original articles related to simulation training in surgical anastomosis were identified from January 2000 to November 2021 in the Clarivate Analytics Web of Science Core Collection database. We conducted a bibliometric analysis based on the country of these publications and the type of anastomosis. A 3D-printed bilioenteric anastomosis model was applied in this study. Baseline data of 15 surgeons (5 surgeons of Attendings, 5 surgeons of Fellows, and 5 surgeons of Residents) were collected. The bilioenteric anastomosis data, including the operation time and operation score, were recorded and analyzed. A study of the learning curve was also performed for further assessment.

RESULT

Surgeons at different levels of experience exhibited different levels of performance in conducting laparoscopic bilioenteric anastomosis on this model. Experienced surgeons completed their first training session in a shorter time and obtained a higher surgical score. In turn, repeated training significantly shortened the time of laparoscopic bilioenteric anastomosis for each trainer and improved the surgical score. Surgeons with different levels of experience needed different numbers of cases to reach the stable period of the learning curve. Experienced surgeons were able to reach a proficient level through fewer training cases.

CONCLUSION

A suitable biliary-enteric anastomosis model can help surgeons conduct simulation training and provide experience and skill accumulation for future real operations. Our training model performed well in this study and can effectively accomplish this goal.

Minimally invasive biliary anastomosis after iatrogenic bile duct injury: a systematic review

Major bile duct injuries (BDIs) may require complex surgical repairs that are usually performed with a conventional open approach. This study aims to analyze current evidence concerning the safety and the outcomes of the minimally invasive (MI) approach for biliary anastomosis in post-cholecystectomy BDIs. A systematic search of MEDLINE, Embase, and Web-Of-Science indexed studies involving MI (laparoscopic or robotic) biliary anastomosis in patients with iatrogenic BDIs was performed. The quality of the studies was assessed using the MINORS criteria. A total of 13 studies involving 198 patients were included. One hundred and twenty-five patients (63.1%) underwent a laparoscopic biliary anastomosis, while 73 (36.1%) received an analogue robotic procedure. All the included BDIs were types D and E (E1-E5). The mean OT varied between 190 and 330 (mean = 227) minutes. Ten studies reported the mean intraoperative blood loss that ranged between 50 and 252 (mean = 135.9) mL. No conversions occurred in the robotic series, while four patients required conversion to open surgery among the laparoscopic ones. The mean length of postoperative hospital stay was 6.3 days. The reported overall morbidity was similar among the robotic and laparoscopic series. During the follow-up period, no surgery-related mortality occurred. A growing number of referral centers are showing the safety and feasibility of the MI approach for biliary anastomosis in patients with major BDIs. Further prospective comparative studies are needed to draw more definitive conclusions.

Preperitoneal insufflation pressure of the abdominal wall in a porcine model

BACKGROUND

Most complications and adverse events during laparoscopic surgery occur during initial entry into the peritoneal cavity. Among them, preperitoneal insufflation occurs when the insufflation needle is incorrectly placed, and the abdominal wall is insufflated. The objective of this study was to find a range for static pressure which is low enough to allow placement of a Veress needle into the peritoneal space without causing preperitoneal insufflation, yet high enough to separate abdominal viscera from the parietal peritoneum.

METHODS

A pressure test was performed on twelve fresh porcine carcasses to determine the minimum preperitoneal insufflation pressure and the minimum initial peritoneal cavity insufflation pressure. Each porcine model had five needle placement categories. One category tested the initial peritoneal cavity insufflation pressure beneath the umbilicus. The four remaining categories tested the preperitoneal insufflation pressure at four different anatomical locations on the abdomen that can be used for initial entry. The minimum initial insufflation pressures from each carcass were then compared to the preperitoneal insufflation pressures to obtain an optimal range for initial insufflation.

RESULTS

Increasing the insufflation pressure increased the probability of preperitoneal insufflation. Also, there was a statistically significant difference (p < 0.05) between the initial peritoneal cavity insufflation pressures (8.83 ± 4.19 mmHg) and the lowest preperitoneal pressures (32.54 ± 7.84 mmHg) (mean ± SD).

CONCLUSION

Pressures greater than 10 mmHg resulted in initial cavity insufflation and pressures greater than 20 mmHg resulted in preperitoneal insufflation in porcine models. By knowing the minimum pressure required to separate the layers of the abdominal wall, the risk of preperitoneal insufflation can be mitigated while obtaining safe and efficient entry into the peritoneal cavity. The findings in this research are not a guideline for trocar or Veress needle placement, but instead reveal preliminary data which may lead to more studies, technology, etc.

Bile duct injury during laparoscopic cholecystectomy: An Indian e-survey

Backgrounds/Aims

In the absence of national registry of laparoscopic cholecystectomy (LC) or its complications, it is impossible to determine incidence of bile duct injury (BDI) in India. We conducted an e-survey among practicing surgeons to determine prevalence and management patterns of BDI in India. Our hypothesis was that majority of surgeons would have experienced a BDI during LC despite large experience and that most surgeons who have a BDI tend to manage it themselves.

Methods

An 18-question e-survey of practicing laparoscopic surgeons in India was done.

Results

278/727 (38%) surgeons responded. 240/278 (86%) respondents admitted to a BDI during LC and 179/230 (78%) affirmed to more than one BDI. A total of 728 BDIs were reported. 36/230 (15%) respondents experienced their first BDI even after >10 years of practice and 40% had their first BDI even after having performed >100 LCs. 161/201 (80%) of the respondents decided to manage the BDI themselves, including 56/99 (57%) non-biliary surgeons and 44/82 (54%) surgeons working in non-biliary center. 37/201 (18%) respondents admitted to having a mortality arising out of a BDI; the mortality rate of BDI was 37/728 (5%) in this survey. Only 13/201 (6%) respondents have experienced a medico-legal case related to a BDI during LC.

Conclusions

Prevalence of BDI is high in India and occurs despite adequate experience and volume. Even inexperienced non-biliary surgeons working in non-biliary centers attempt to repair the BDI themselves. BDI is associated with significant mortality but litigation rates are fortunately low in India.

Treatment of complex complications after choledochal cyst resection by multiple minimal invasive therapies: A case report

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Complications after choledochal cyst resection are common, mainly anastomotic stricture, bowel obstruction, biliary fistula and pancreatic cyst remnant.

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Reoperation is the optimal method for patients with pancreatic cyst remnant and hepaticojeju-nal anastomotic stricture.

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ERCP, balloon dilation should be considered as a supporting tools to reduce the risk and mor-bidity of surgery.

Introduction

Choledochal cyst is a rare benign congenital dilation of the bile duct, which causes recurring disturbing symptoms without totally resection. Nonetheless, postoperative complications are still a common issue. A step up management for patients with complex complications is required to address the problem.

Case presentation

We report a 10-year-old child who suffered complex postoperative complications after choledochal cyst resection at the age of 5, including cholangitis, bilioenteric stenosis and cystolithiasis in remnant intrapancreatic duct cyst. She occasionally endured episodes of epigastric pain, fever and jaundice afterwards. As the symptoms and recurrent rate were worsen over time, the patient was admitted multiple times and various approaches (balloon dilation, percutaneous transhepatic biliary drainage, endoscopic retrograde cholangiopancreatography and laparoscopic surgery) were applied. Afterwards, patient recovered and discharged without any complications.

Conclusion

Our case presented sophisticated complications relating to choledochal cyst that were successfully treated by a combination of modern minimal invasive techniques. Despite operated by experienced surgeons, the post-op complications are still a concerned problem due to difficult laparoscopic techniques, injuries of hepatic artery, infection and risk of malignancy. We suggested that minimal-invasive procedures should be considered first with the aim of relieving symptoms, biliary drainage and preparing for the reoperation.