Single-incision laparoscopic cholecystectomy for cholecystitis requiring percutaneous transhepatic gallbladder drainage

Clinical value of fluorescent cholangiography for the infraportal type of right posterior bile duct

BACKGROUND

The infraportal type of the right posterior bile duct (infraportal RPBD) is a well-known anatomical variation that increases the potential risk of intraoperative biliary injury. The aim of this study is to clarify the clinical value of fluorescent cholangiography during single-incision laparoscopic cholecystectomy (SILC) for patients with infraportal RPBD.

MATERIAL AND METHODS

Our procedure for SILC utilized the SILS-Port, and another 5-mm forceps was inserted via an umbilical incision. A laparoscopic fluorescence imaging system developed by Karl Storz Endoskope was utilized for fluorescent cholangiography. Between July 2010 and March 2022, 41 patients with infraportal RPBD underwent SILC. We conducted retrospective reviews of patient data, focusing on the clinical value of fluorescent cholangiography.

RESULTS

Thirty-one patients underwent fluorescent cholangiography during SILC, but the remaining ten did not. Only one patient who did not undergo fluorescent cholangiography developed an intraoperative biliary injury. The detectability of infraportal RPBD before and during the dissection of Calot's triangle was 16.1% and 45.2%, respectively. These visible infraportal RPBDs were characterized as connections to the common bile duct. The confluence pattern of infraportal RPBD significantly influenced its detectability during the dissection of Calot's triangle (p < 0.001).

CONCLUSIONS

The application of fluorescent cholangiography can lead to safe SILC, even for patients with infraportal RPBD. Its benefit is emphasized when infraportal RPBD is connected to the common bile duct.

Laparoscopic surgery and robotic surgery for single-incision cholecystectomy: an updated systematic review

The role of single-incision laparoscopic cholecystectomy (SILC) and single-incision robotic cholecystectomy (SIRC) is still unclear. We update the summarization of the feasibility and safety of SILC and SIRC. A comprehensive search of SILC and SIRC of English literature published on PubMed database between January 2015 and November 2020 was performed. A total of 70 articles were included: 41 covering SILC alone, 21 showing SIRC alone, 7 reporting both, and 1 study not specified. In total, 7828 cases were recorded (SILC/SIRC/not specified, 6234/1544/50); and the gender of 7423 cases was definitively reported: the female rate was 64.0% (SILC/SIRC/not specified, 62.1%/71.5%/74.0%). The weighted mean for body mass index (BMI), operative time, blood loss and post-operative hospital stay was 25.5 kg/m2 (SILC/SIRC, 25.0/27.0 kg/m2), 73.8 min (SILC/SIRC, 68.2/88.8 min), 12.6 mL (SILC/SIRC, 12.1/14.8 mL) and 2.5 days (SILC/SIRC, 2.8/1.9 days), respectively. The pooled prevalence of an additional port, conversion to open surgery, post-operative complications, intraoperative biliary injury, and incisional hernia was 4.1% (SILC/SIRC, 4.7%/1.9%), 0.9% (SILC/SIRC, 0.7%/1.5%), 5.9% (SILC/SIRC, 6.2%/4.1%), 0.1% (SILC/SIRC, 0.2%/0.09%), and 2.1% (SILC/SIRC, 1.4%/4.8%), respectively. Compared with conventional laparoscopic cholecystectomy, SIRC has experienced more postoperative incisional hernias (risk difference = 0.05, 95% confidence interval 0.02-0.07; P < 0.0001). By far, SILC and SIRC have not been considered a standard procedure. With the innovation of medical devices and gradual accumulation of surgical experience, feasibility and safety of performing SILC and SIRC will improve.

Comparison of outcomes of single-incision and conventional laparoscopic cholecystectomy for cholecystitis requiring percutaneous transhepatic gallbladder drainage

INTRODUCTION

Single-incision laparoscopic cholecystectomy (SILC) has been accepted as a less invasive alternative to conventional laparoscopic cholecystectomy (CLC). However, the feasibility and safety of SILC for acute cholecystitis, especially in cases with percutaneous transhepatic gallbladder drainage (PTGBD), are still limited because of the technical difficulty of SILC. The aim of this study was to retrospectively evaluate the safety and feasibility of SILC compared to CLC for cholecystitis requiring PTGBD.

METHODS

From 1 July 2017 to 8 June 2019, eight patients underwent SILC with PTGBD, and nine underwent CLC with PTGBD. The patients' data, including the operative time, total blood loss, conversion rate to laparotomy, and perioperative complications, were compared.

RESULTS

In seven of eight patients, SILC was successfully performed. Only one patient required conversion to open surgery because necrosis prevented the cystic duct from being clipped. However, bile leakage occurred in this patient and was successfully treated with percutaneous drainage and antibiotics. In the CLC group, one patient required laparotomy but had no postoperative complications due to strong adhesion. One patient underwent reoperation for bile duct injury after the first operation. One other complication (ie, wound infection) was seen in the CLC group. There was no significant difference in the mean operative time and estimated blood loss between the SILC and CLC groups.

CONCLUSION

With our gallbladder retraction method, SILC may be a relatively safe and feasible alternative to CLC for cholecystitis, even in cases requiring PTGBD.

Protective efficacy of combined use of parecoxib and dexmedetomidine on postoperative hyperalgesia and early cognitive dysfunction after laparoscopic cholecystectomy for elderly patients

PURPOSE

To investigate efficacy of combined use of parecoxib and dexmedetomidine on postoperative pain and early cognitive dysfunction after laparoscopic cholecystectomy for elderly patients.

METHODS

The present prospective randomized controlled study included a total of 80 patients who underwent laparoscopic cholecystectomy surgery during January 2016 to November 2017 in our hospital. All patients were randomly divided into 4 groups, the parecoxib group, the dexmedetomidine group, the parecoxib and dexmedetomidine combined group, and the control group. Demographic data and clinical data were collected. Indexes of heart rate (HR), mean arterial pressure (MAP), levels of jugular venous oxygen saturation (SjvO2) and jugular venous oxygen pressure (PjvO2) were recorded at different time points before and during the surgery. The mini-mental state examination (MMSE) score, Ramsay score and Visual Analogue Score (VAS) were measured.

RESULTS

Levels of both SjvO2 and PjvO2 were significantly higher in parecoxib group, dexmedetomidine group and the combined group than the control group. Meanwhile, levels of both SjvO2 and PjvO2 in the combined group were the highest. VAS scores were significantly lower in the combined group than all other groups, and total patient controlled intravenous analgesia (PCIA) pressing times within 48 h after surgery were the lowest in the combined group. Both Ramsay and MMSE scores were the highest in the combined group compared with other groups, while were the lowest in the control group.

CONCLUSION

The combined use of parecoxib and dexmedetomidine could reduce the postoperative pain and improve the postoperative sedation and cognitive conditions of patients after laparoscopic cholecystectomy.

Application of fluorescent cholangiography during single-incision laparoscopic cholecystectomy for cholecystitis with a right-sided round ligament: Preliminary experience

An 82-year-old woman was diagnosed with cholecystitis with a right-sided round ligament. We planned a single-incision laparoscopic cholecystectomy. Based on the findings of fluorescent cholangiography, the running course of the common bile duct was confirmed before dissection of Calot's triangle, and the confluence between the cystic duct and the common bile duct was exposed after the dissection of Calot's triangle. The planned surgery was successful. The operative time and intraoperative blood loss were 157 min and 2 mL, respectively. The patient was discharged from our hospital 3 days after surgery. Application of fluorescent cholangiography during a laparoscopic cholecystectomy for the patients with a right-sided round ligament should be widely accepted.

Application of Fluorescent Cholangiography for Determination of the Resection Line During a Single-Incision Laparoscopic Cholecystectomy for a Benign Lesion of the Cystic Duct: Preliminary Experience

BACKGROUND

To avoid bile leakage from the stump of a cystic duct that is closed at edematous and/or involved areas, the decision regarding the location of the resection line during a laparoscopic cholecystectomy for benign lesions extending into the cystic duct is important and requires technical ingenuity. For these situations, we used fluorescent cholangiography.

METHODS

Our procedure for single-incision laparoscopic cholecystectomy utilized the SILS-Port, and an additional pair of 5-mm forceps was inserted via an umbilical incision. As a fluorescence source, 1 mL of indocyanine green was intravenously injected after endotracheal intubation of patients in the operating room. A laparoscopic fluorescence imaging system developed by Karl Storz Endoskope was utilized for fluorescent cholangiography.

RESULTS

Fluorescent cholangiography could be used to identify the border of the lesion in the cystic duct. According to the fluorescent cholangiography results, a location for the resection line of the cystic duct could be identified; therefore, the planned resection was successful and produced a histologically negative margin.

CONCLUSIONS

Application of fluorescent cholangiography in the determination of the location of the resection line location during a laparoscopic cholecystectomy for benign lesions of the cystic duct should be widely accepted.

Successful laparoscopic cholecystectomy for acute cholecystitis with kyphoscoliosis by the devised placement of trocar ports: A case report

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Kyphoscoliosis has various surgical difficulties for laparoscopic cholecystectomy.

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Low-lying costal arches prevents surgeons from accessing the gall bladder.

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A transumbilical multi-port and left abdominal port is useful for patients with kyphoscoliosis.

Introduction

Kyphoscoliosis, which is a deformity of the spine caused by aging and osteoporosis, results in various surgical difficulties for laparoscopic cholecystectomy (LC) due to low-lying costal arches, such as a small abdominal working space, disturbance of the surgical view and decreased controllability of the surgical instrument.

Presentation of case

We herein report the case of a 92-year old woman with severe kyphoscoliosis who was diagnosed with Grade II acute cholecystitis. Taking her general status into consideration, emergency percutaneous transhepatic gallbladder drainage (PTGBD) was initially performed. After PTGBD, the patient’s physical status and systemic inflammation markedly improved. She then underwent interval LC. The surgical view of the upper abdomen including the gallbladder was entirely interrupted by bilateral low-lying costal arches with adhesion to the greater omentum. To access the gallbladder without interruption by the low-lying costal arch, the first umbilical port was changed to a multi-port with surgical glove and an additional port was added in the left abdomen. Consequently, LC was safely accomplished with the creation of the critical view.

Discussion

A low-lying costal arch due to kyphoscoliosis can prevent surgeons from accessing the gallbladder. LC with the standard 4-port method could not be accomplished because of insufficient lifting of the low-lying costal arch. Devised placement of the ports is needed to access the gallbladder between bilateral low-lying costal arches.

Conclusion

A transumbilical multi-port and left abdominal port may be effective for successful LC of acute cholecystitis with kyphoscoliosis.

Clinical value and pitfalls of fluorescent cholangiography during single-incision laparoscopic cholecystectomy

PURPOSE

To clarify the clinical value and pitfalls of fluorescent cholangiography (FC) during single-incision laparoscopic cholecystectomy (SILC).

METHODS

Our SILC procedure utilized the SILS-Port with additional 5-mm forceps through an umbilical incision. A laparoscopic fluorescent imaging system developed by Karl Storz Endoskope was utilized for fluorescent cholangiography.

RESULTS

We performed fluorescent cholangiography during SILC in 21 patients. All procedures were completed successfully without biliary injury. The detectability of the running course of the cystic duct, the confluence between the cystic duct and the common hepatic duct, and the common hepatic duct before the dissection in Calot's triangle was 47.6, 71.4, and 81.0 %, respectively. The detectability of biliary structures was worse in 9 obese patients (body mass index ≥ 25.0 kg/m²) than in 12 non-obese patients. The mean operative time for the patients in whom fluorescent cholangiography could identify the running course of the cystic duct before dissection in Calot's triangle (68 ± 16 min) was shorter than that for the other patients (91 ± 35 min; p = 0.037).

CONCLUSIONS

Fluorescent cholangiography can prevent biliary injury during SILC and facilitate SILC. Obesity is the most important factor that can prevent identification of biliary structures under fluorescent cholangiography.

Single-Incision Laparoscopic Cholecystectomy after Endoscopic Nasogallbladder Drainage: A Case Report

OBJECTIVE

To report a single-incision laparoscopic cholecystectomy (SILC) for a patient with cholecystitis that required endoscopic nasogallbladder drainage (ENGBD).

CLINICAL PRESENTATION AND INTERVENTION

A 75-year-old man was diagnosed with moderate acute cholecystitis and underwent antiplatelet therapy for a history of brain infarction. An ENGBD was performed as an initial treatment for his cholecystitis. After recovery from the cholecystitis, a SILC was performed using a SILS Port with an additional forceps. Because neither Rouviere's sulcus nor Calot's triangle could be identified with a favorable laparoscopic view, the fundus-first procedure was selected. The patient's postoperative course was uneventful, and he was discharged from the hospital on day 3 after surgery.

CONCLUSION

In this case of a patient who had cholecystitis that required ENGBD, a SILC was successful performed using a combination of SILS Port with additional forceps and fundus-first procedure.