The "hidden cystic duct" syndrome and the infundibular technique of laparoscopic cholecystectomy--the danger of the false infundibulum

Critical view of safety approach vs. infundibular technique in laparoscopic cholecystectomy, which one is safer? A systematic review and meta-analysis

Laparoscopic cholecystectomy (LC) remains the gold standard procedure for the management of benign gallbladder disease. Recognizing the need to mitigate complications, mainly bile duct injury (BDI), various techniques for ductal identification during LC have emerged, including the "Critical View of Safety" (CVS) and the infundibular technique (IT). In this systematic review and meta-analysis, we assess and compare the outcomes of both techniques, with a primary focus on evaluating their impact on BDIs. A comprehensive search was conducted using PubMed and Scopus databases. The search focused on the surgical technique, incidences of minor and major BDIs, operative time, conversion rate, and length of stay, among patients undergoing LC for benign gallbladder disease. Our initial search retrieved 264 studies. After screening the unique studies against our predefined inclusion/exclusion criteria, only five met our criteria and were included. Additionally, a manual search identified eight more relevant studies, bringing the total number of included studies to 13. The total number of included patients was 4,837. Approximately two-thirds underwent LC using the CVS approach (61.1%), and 66.3% were female, with a mean age of 44.4 ± 11.2 years. The CVS approach was associated with a significant reduction in overall BDIs (RR = 0.36; 95% CI 0.18-0.71) and major BDIs (RR = 0.28; 95% CI 0.13-0.63). However, there were no significant differences in terms of minor BDIs, operative time, conversion rates, or length of stay. Our study demonstrated the superiority of the CVS approach in terms of reducing the incidence of overall and major BDIs compared to IT. However, our study revealed no other significant differences between the two techniques. Further research, including multicentric randomized controlled trials, will be necessary to further evaluate the efficacy of these techniques.

Replacement of the main bile duct by bioprosthesis in an experimental porcine model (24-month results)

BACKGROUND

Cholecystectomy for conditions like iatrogenic injury during cholecystectomy can lead to complications such as bile duct injuries, necessitating alternative options like bioprosthesis.

METHODS

This study evaluated a bioprosthesis's efficacy in maintaining bile duct continuity over 24 months in 16 male pigs.

RESULTS

The bioprosthesis was implanted in the common bile duct of three-month-old animals, with follow-ups at 1, 6, 12, 18, and 24 months. Liver function remained stable, and biliary permeability was assessed through various imaging techniques. Despite mild stenosis, biliary flow was unimpeded. Histological analysis confirmed biliary epithelium presence in the regenerated area.

CONCLUSION

The bioprosthesis acted as a scaffold for tissue regeneration without compromising biliary function. Remnants of the bioprosthesis were observed but did not affect biliary excretion in the 24-month porcine model. This study highlights the bioprosthesis's potential in bile duct reconstruction, offering a safe and effective option for maintaining biliary continuity.

Efficacy and outcome of indocyanine green-based intraoperative cholangiography using near-infrared fluorescence imaging: A prospective study

INTRODUCTION

The most dreaded complication during laparoscopic cholecystectomy still remains to be injury to the common bile duct. The primary cause for bile duct injury during LC is misinterpretation of the biliary anatomy. Intra-operative cholangiography was introduced as a means of reducing the chances of biliary injury, done using Fluoroscopic imaging or Near-infrared fluorescence imaging method. NIRF is one of the most popular imaging methods in biomedical sciences. Indocyanine Green is sterile and water soluble which completely binds to albumin and is excreted in bile.

PATIENTS AND METHODS

This prospective study was conducted among 70 patients between July 2020 and December 2021. Subjects were administered 5mg of ICG dye pre-operatively and procedure performed using Karl Storz HD image S1 system with a D-light P light source for NIRF imaging.

RESULTS

The average duration of surgery was 58.10 minutes. After calot's dissection, the CBD was visualized in 88.71 % patients, with a mean time to visualization at 26.33 minutes. The cystic duct was visualized in 87.3% cases with a mean time of visualization of 32.10 minutes. The hepatic duct was visualized in 28.57% and the hepatic duct-CBD confluence was visualized in 34.28% patients.

CONCLUSION

Near infrared imaging based intra-operative cholangiography, using Indocyanine Green dye, during Lap. Cholecystectomy is an easy, useful and inexpensive method of visualizing the biliary ductal anatomy.

Critical View of Safety Dissection and Rouviere's Sulcus for Safe Laparoscopic Cholecystectomy: A Descriptive Study

Objective: To determine the importance of a critical view of safety (CVS) techniques and Rouviere's sulcus (RS) in laparoscopic cholecystectomy (LC) and its relation to biliary duct injuries (BDIs) and to determine the frequency and the type of RS. Design, Setting, and Participants: A descriptive study was carried out among 76 patients presenting to the surgery department of a tertiary care center in Nepal. The study population included all patients in the age group 16-80 years undergoing LC. Outcome Measures: The main outcome of interest was to calculate the percentage of BDIs along with the frequency and the type of RS. Results: A total of 76 patients were enrolled in the study, out of which 57(75%) were female patients with a male-to-female ratio of 1:3 and a mean age of 45.87 ± 15.33 years. Seventy-one (93.4%) patients were diagnosed with symptomatic gallstone disease. The CVS was achieved in 75 (98.7%) of the cases, whereas in 1 case, the CVS could not be achieved, and in the same patient routine LC was converted into open cholecystectomy owing to the difficult laparoscopic procedure. In 56 (73.7%) cases, RS was first visible to the operating surgeons after port installation, alignment, and adequate traction of the gallbladder; in 20 (26.3%) cases, RS was not originally apparent. Conclusion: According to the findings of this study and the literature's critical assessment of safety, this method will soon become a gold standard for dissecting gall bladder components. The technique needs to be extended further, especially for training purposes. Major difficulties can be avoided by identifying RS before cutting the cystic artery or duct during LC.

Critical View of Safety in Laparoscopic Cholecystectomy: A Systematic Review of Current Evidence and Future Perspectives

BACKGROUND

The Critical View of Safety (CVS) has been increasingly recognised as the standard method for identification of the cystic structures, to prevent vasculobiliary injuries during laparoscopic cholecystectomy, however, its adoption has been anything but universal. A significant proportion of surgeons has a poor understanding of the three requirements. To bridge this gap between theory and practice, we aimed to summarise the available evidence on CVS, emphasising on current debates and future perspectives.

METHOD

We systematically reviewed the literature (1995-2021), to identify studies reporting on the CVS. Eligible articles were classified according to methodology and key idea. A quantitative analysis was performed to evaluate effectiveness of the CVS in preventing bile duct injury (BDI).

RESULTS

150 relevant articles were identified, focusing on six main points, (1) safety and effectiveness, (2) intraoperative documentation, (3) complementary imaging techniques, (4) bail-out alternatives, (5) adoption among surgeons, and (6) education and training. The quantitative analysis included 11 studies, with 10,938 cases. Overall, the CVS was achieved in 92.5%. Conversion rate was 4.8%. CVS-related BDI was 0.09% (0.05% technical errors and 0.04% misidentification errors).

CONCLUSION

Routine application of the CVS reduces BDI, but does not eliminate them altogether. Besides operative notes, the CVS should be documented by an imaging modality of sufficient quality. When the CVS cannot be safely established, the threshold for bail-out alternatives or complementary imaging should be low. Adoption by the surgical community worldwide shows great variability and focus should be placed on training through structured educational modules.

Real-time fluorescent cholangiography with indocyanine green in laparoscopic cholecystectomy: a randomized controlled trial to establish the optimal indocyanine green dose within 30 min preoperatively

PURPOSE

To establish the optimal dose of indocyanine green (ICG) to administer intravenously 30 min before laparoscopic cholecystectomy (LC).

METHODS

In this randomized controlled trial (RCT), patients undergoing LC for cholecystitis, cholelithiasis, and/or cholecystic polyps were randomized into four groups given four different ICG doses (0.025, 0.1, 0.25, 2.5 mg). Using OptoMedic endoscopy combined with a near-infrared fluorescent imaging system, we evaluated the fluorescence intensity (FI) of the common bile duct and liver at three timepoints: before surgical dissection of the cystohepatic triangle, before clipping of the cystic duct, and before closure. The bile duct-to-liver ratio (BLR) of the FI was analyzed to assess the cholangiography effect.

RESULTS

Sixty-four patients were allocated to one of four groups, with 40 patients included in the final analysis. Generally, with increasing ICG doses, the levels of FI in the bile duct and liver increased gradually at each of the three timepoints. Before surgical dissection of the cystohepatic triangle, 0.1-mg ICG showed the highest BLR (F = 3.47, p = 0.0259). Before clipping the cystic duct and before closure, the 0.025- and 0.1-mg groups showed a higher BLR than the 0.25- and 2.5-mg groups (p < 0.05). When setting the ideal cholangiography at a BLR ≥ 1, ≥ 3, or ≥ 5, the 0.1-mg group showed the highest qualified case number at the three timepoints.

CONCLUSIONS

The intravenous administration of 0.1-mg ICG, 30 min before LC, is significantly better for fluorescent cholangiography of the extrahepatic biliary structures before dissection and clipping of the cystohepatic triangle.

TRIAL REGISTRATION

This study was registered in the Chinese Clinical Trial Registry (ChiCTR) (ChiCTR2200057933).

A case of mistaken identity: bile duct masquerading as gallbladder

Laparoscopic cholecystectomy is a common surgical procedure, with potential for significant morbidity. The incidence of bile duct injuries has increased with the advent of laparoscopy, occurring in up to 1% of cases. Risk of injury increases with aberrant anatomy, acute inflammation and fibrosis. Preventative strategies include obtaining the critical view of safety, using a fundus-first approach and performing a subtotal cholecystectomy in the difficult gallbladder. Although controversy exists for routine cholangiography, its use is helpful in situations of obscure anatomy. We describe the case of a chronically inflamed and unusually small 1.5 cm gallbladder with an obliterated cystic duct. The critical view of safety was not able to be achieved and intraoperative cholangiography enabled identification of aberrant anatomy, with a dilated common duct mistaken as the gallbladder infundibulum. This case highlights the need to be vigilant to structural variation and the utility of selective cholangiography to clarify anatomy.

Challenging Orthodoxy: beyond the Critical View of Safety

BACKGROUND

The critical view of safety (CVS) is the gold standard for performing safe cholecystectomies and minimizing common bile duct (CBD) injuries. It requires three criteria: complete clearance of the hepatocystic triangle, partial separation of the gallbladder from the cystic plate, and two structures alone entering the gallbladder. However, biliary anatomy varies widely, with frequent aberrant arterial supplies, which can mislead or disorient those attempting to acquire the CVS. This study was designed to examine the nature and frequency of cystic artery anatomic anomalies.

METHODS

We conducted a prospective observational study from 2018 to 2020, compiling photos of the critical view of safety of 100 consecutive elective cholecystectomies performed at our institution. Gallbladders were dissected up to the parallel portion of the cystic plate to achieve a critical view of safety. All tubular structures were preserved and clipped. Operative reports were examined for mention of posterior cystic arteries or aberrant arterial supplies. Photos were reviewed for an adequate critical view of the safety and presence of aberrant arterial supplies. The rate of aberrant arterial supply was determined and photos were reviewed for patterns of common abnormalities.

RESULTS

There were 121 patients who underwent an elective cholecystectomy; 21 lacked intraoperative pictures and were excluded from the study. Of the 100 patients included, 57 (57%) had an aberrant arterial supply with more than one cystic artery; seven had three concurrent arteries. Of those with more than one cystic artery, 21% had a recurrent cystic artery, 21% had a posterior dominant cystic artery, and 12% had a low-branching anterior cystic artery.

CONCLUSION

Even with appropriate dissection for the CVS, surgeons can expect to frequently visualize more than two structures entering the gallbladder when a posterior cystic artery is present. It is, therefore, integral to distinguish this aberrant anatomy to prevent inadvertent injury to the CBD.

Bile duct injury in laparoscopic cholecystectomy with a posterior infundibular approach

Aims: Bile duct injury (BDI) in laparoscopic cholecystectomy (LC) has a significant impact on morbidity and mortality. Although the critical view of safety (CVS) concept is the most widely supported approach to prevent BDI, alternative approaches are used as well. The aim was to evaluate the incidence, severity, and management of bile duct injury in LC, using a posterior infundibular approach. Methods: This retrospective, monocentric cohort study includes patients who underwent LC for gallstone disease. Data were collected in a prospectively maintained database. Patients with BDI were identified and were analyzed in-depth. Results: Between 1999 and 2018, 8389 consecutive patients were included (M/F 3288/5101; mean age 55 (standard deviation; SD ± 17) years). Mean length of postoperative hospital stay was two days (SD ± 4). Fourteen patients died after LC and 21 patients were identified with BDI. Seventeen BDI (81%) patients were managed minimally invasive (14 endoscopic, 3 laparoscopic), and 4 patients via laparotomy (3 hepaticojejunostomy, 1 primary suture). Severe complications (Clavien-Dindo ≥3) after BDI repair were observed in 6 patients. There was no BDI-related mortality. Median follow-up time was 113 months (range 5–238). Conclusion: A posterior infundibular approach in LC was associated with a low incidence of BDI and no BDI-related mortality.

[Modern principles of safety in laparoscopic cholecystectomy]

Laparoscopic cholecystectomy has many advantages over open surgery. Nevertheless, incidence of intraoperative bile duct injury is consistently higher for laparoscopic technique. This review is devoted to modern principles of identifying the anatomical elements in hepatoduodenal ligament and rules for safe tissue dissection in this area. The last ones mainly consist in formation of «critical view of safety» before clipping and transection of tubular structures. The key for «critical view of safety» is mobilization of fatty and fibrous tissues of hepatocystic triangle starting from the lower third of the gallbladder.

Subtotal Cholecystectomy After Failed Critical View of Safety Is an Effective and Safe Bail Out Strategy

BACKGROUND

Bile duct injury (BDI) is accompanied by significant morbidity and long-term impact in quality of life. Subtotal cholecystectomy (STC) is an alternative to prevent this outcome but is associated with other complications. The aim of this work is to demonstrate that BDI associated morbidity exceeds STC associated morbidity, underscoring STC as a reasonable bail out strategy.

METHODS

We compared 115 patients who underwent STC with 293 patients who were referred to our center with BDI type E1-E3 and underwent surgical repair. The groups were comparable because in both instances the surgeon had the opportunity to decide not to perform a total cholecystectomy once critical view of safety (CVS) was not achieved.

RESULTS

Bile leakage was found in 21% of the STC group with only one BDI (0.9%). More Accordion ≥ 4 were found in the STC group (10.4% vs 4.8%, p = 0.035); however, reoperations were more frequent in the BDI group (8.2% vs 0.9%, p = 0.006). No patient in the STC group required reintervention for completion cholecystectomy. After 3.8 years follow-up, 2.4% of patients had secondary biliary cirrhosis in the BDI group; none in the STC group.

CONCLUSIONS

Despite complications of STC, morbidity associated with BDI is much higher due to high long-term reoperation rate, in addition to secondary biliary cirrhosis. STC is a safe alternative that can prevent BDI if properly and timely performed in the context of difficult cholecystectomy.

Comparative analysis of reliability and clinical effects of the critical view of safety approach used in laparoscopic cholecystectomy in the pediatric population

PURPOSE

With the increase in indications for cholecystectomy in children, the frequency of laparoscopic cholecystectomy procedures and related problems has increased. The Critical View of Safety (CVS) is the target-specific method for identifying the cystic duct during laparoscopic cholecystectomy to prevent common bile duct injury. We hypothesize that the use of CVS is reliable in the pediatric population.

METHODS

Data of 91 patients under 18 years of age who underwent elective laparoscopic cholecystectomy were retrospectively analyzed. Patients were divided into two groups depending on whether CVS was applied. The descriptive characteristics and complications of the two groups were compared.

RESULTS

CVS was applied to 41 patients. When the groups were compared in terms of operation time, postoperative length of stay, idiopathic gallbladder perforation, dropping stone, and presence of surgical site infection, no statistical significant difference was found. However, the time to start oral feeding was shorter in CVS group (p = 0.01).

CONCLUSION

We believe CVS is a reliable method to ensure safe cystic channel identification in the pediatric population. New studies are warranted on the effectiveness of CVS for safely performing laparoscopic cholecystectomy in children, as the procedure is being performed more frequently in the pediatric population.

Posterior infundibular dissection: safety first in laparoscopic cholecystectomy

Background

Laparoscopic cholecystectomy is still fraught with bile duct injuries (BDI). A number of methods such as intra-operative cholangiography, use of indocyanine green (ICG) with infrared imaging, and the critical view of safety (CVS) have been suggested to ensure safer Laparoscopic cholecystectomy (LC).To these, we add posterior infundibular dissection as the initial operative maneuver during LC. Here, we report specific technical details of this approach developed over 30 years with no bile duct injuries and update our experience in 1402 LC.

Methods

In this manuscript, we present a detailed and illustrated description of a posterior infundibular dissection as the initial approach to laparoscopic cholecystectomy (LC). This technique developed after thirty years of experience with LC and have used it routinely over the past ten years with no bile duct injury.

Results

Between January of 2010 and December 2019, 1402 Laparoscopic cholecystectomies were performed using the posterior infundibular approach. Operations performed on elective basis constituted 80.3% (1122/1402) and 19.97% were emergent (280/1402). One intra-operative cholangiogram was performed after a posterior sectoral duct was identified. There was one conversion to open cholecystectomy due to bleeding. There were 4 bile leaks that were managed with endoscopic retrograde cholangio-pancreatography (ERCP). There were no bile duct injuries.

Conclusion

Adopting an initial posterior mobilization of the gallbladder infundibulum lessens the need for medial and cephalad dissection to the node of Lund, allowing for a safer laparoscopic cholecystectomy. In fact the safety of the technique comes from the initial dissection of the lateral border of the infundibulum. The risk of BDI can be reduced to null as was our experience. This approach does not preclude the use of other intra-operative maneuvers or methods.

Supplementary information

The online version of this article (doi:10.1007/s00464-020-08281-1) contains supplementary material, which is available to authorized users.

Obesity is not a risk factor for either mortality or complications after laparoscopic cholecystectomy for cholecystitis

Obesity is a positive predictor of surgical morbidity. There are few reports of laparoscopic cholecystectomy (LC) outcomes in obese patients. This study aimed to clarify this relationship. This retrospective study included patients who underwent LC at Showa University Northern Yokohama Hospital between January 2017 and April 2020. A total of 563 cases were examined and divided into two groups: obese (n = 142) (BMI ≥ 25 kg/m2) and non-obese (n = 241) (BMI < 25 kg/m2). The non-obese group had more female patients (54%), whereas the obese group had more male patients (59.1%). The obese group was younger (56.6 years). Preoperative laboratory data of liver function were within the normal range. The obese group had a significantly higher white blood cell (WBC) count (6420/μL), although this was within normal range. Operative time was significantly longer in the obese group (p = 0.0001). However, blood loss and conversion rate were not significantly different among the groups, neither were surgical outcomes, including postoperative hospital stay and complications. Male sex and previous abdominal surgery were risk factors for conversion, and only advanced age (≥ 79 years) was an independent predictor of postoperative complications as observed in the multivariate analysis. Although the operation time was prolonged in obese patients, operative factors and outcomes were not. Therefore, LC could be safely performed in obese patients with similar efficacy as in non-obese patients.

Safe Cholecystectomy Multi-society Practice Guideline and State of the Art Consensus Conference on Prevention of Bile Duct Injury During Cholecystectomy

BACKGROUND

BDI is the most common serious complication of laparoscopic cholecystectomy. To address this problem, a multi-society consensus conference was held to develop evidenced-based recommendations for safe cholecystectomy and prevention of BDI.

METHODS

Literature reviews were conducted for 18 key questions across 6 broad topics around cholecystectomy directed by a steering group and subject experts from 5 surgical societies (Society of Gastrointestinal and Endoscopic Surgeons, Americas Hepato-Pancreato-Biliary Association, International Hepato-Pancreato-Biliary Association, Society for Surgery of the Alimentary Tract, and European Association for Endoscopic Surgery). Evidence-based recommendations were formulated using the grading of recommendations assessment, development, and evaluation methodology. When evidence-based recommendations could not be made, expert opinion was documented. A number of recommendations for future research were also documented. Recommendations were presented at a consensus meeting in October 2018 and were voted on by an international panel of 25 experts with greater than 80% agreement considered consensus.

RESULTS

Consensus was reached on 17 of 18 questions by the guideline development group and expert panel with high concordance from audience participation. Most recommendations were conditional due to low certainty of evidence. Strong recommendations were made for (1) use of intraoperative biliary imaging for uncertainty of anatomy or suspicion of biliary injury; and (2) referral of patients with confirmed or suspected BDI to an experienced surgeon/multispecialty hepatobiliary team.

CONCLUSIONS

These consensus recommendations should provide guidance to surgeons, training programs, hospitals, and professional societies for strategies that have the potential to reduce BDIs and positively impact patient outcomes. Development of clinical and educational research initiatives based on these recommendations may drive further improvement in the quality of surgical care for patients undergoing cholecystectomy.

A practical new strategy to prevent bile duct injury during laparoscopic cholecystectomy. A single-center experience with 5539 cases

Purpose

Bile duct injury (BDI) is a catastrophic complication of cholecystectomy, and misidentification of the cystic anatomy is considered to be the main cause. Although several techniques have been developed to prevent BDI, such as the “critical view of safety”, the infundibular technique, the rates remain higher during laparoscopic cholecystectomy (LC) than during open surgery. We, here, propose a practical new strategy for ductal identification, that can help to prevent laparoscopic bile duct injury.

Methods

A retrospective study of 5539 patients who underwent LC from March 2007 to February 2019 at a single institution was conducted. The gallbladder infundibulum was classified by its position located on an imaginary clock with the gallbladder neck as the center point of the dial, 3-o’clock position as cranial, 6-o’clock as dorsal, 9-o’clock as caudal, and 12-o’clock as ventral, as well as the axial position. Patient demographics, pathologic variables and infundibulum classification were evaluated. Detailed analysis of ductal identification based on gallbladder infundibulum position was performed in this study. All infundibulum positions were recorded by intraoperative laparoscopic video or photographic images.

Results

All the patients successfully underwent LC during the study period. No conversion or serious complications such as biliary injury occurred. Gallbladders with infundibulum of 3-o’clock position, 6-o’clock position, 9-o’clock position, 12-o’clock position, axial position were 12.3%, 23.4%, 28.0%, 4.2%, and 32.1%, respectively. The 3-o’clock and 12-o’clock position were pitfalls that might cause biliary injury.

Conclusion

The gallbladder infundibulum as a navigator is useful for ductal identification to reduce BDI and improve the safety of LC.

Bile duct injuries after cholecystectomy, analysis of constant risk

Backgrounds/Aims

The bile duct injuries are the most severe complications that occur after the surgical manipulation of the bile duct. The hepaticojejunostomy remained as the best treatment. Several factors identified that affect the result. This study aimed to analyze and identify risk factors that affected the evolution of these patients.

Methods

A retrospective, observational study was conducted from February 1998 to June 2017. We included all patients with bile duct injuries who required surgical treatment.

Results

We found 79 patients. The majority had a Bismuth type III in 35.4% (n=28). The morbidity of the Hepaticojejunostomy was 19% (n=15). In short-term follow-up, the main complications were cholangitis 11.4% (n=9) and bile leak 10% (n=8). In the long-term follow-up, in 2.5% (n=2) stricture was presented. On the comparison between postoperative and preoperative parameters, biliary peritonitis after a cholecystectomy (p=0.02) was an independent predictor of postoperative morbidity (p<0.05).

Conclusions

In the treatment of bile duct injuries, different factors affect their outcomes. Our results show that infectious complications continue to affect the results of the treatment of bile duct lesions.

Safe cholecystectomy multi-society practice guideline and state-of-the-art consensus conference on prevention of bile duct injury during cholecystectomy

BACKGROUND

Bile duct injury (BDI) is the most common serious complication of laparoscopic cholecystectomy. To address this problem, a multi-society consensus conference was held to develop evidenced-based recommendations for safe cholecystectomy and prevention of BDI.

METHODS

Literature reviews were conducted for 18 key questions across six broad topics around cholecystectomy directed by a steering group and subject experts from five surgical societies (SAGES, AHPBA IHPBA, SSAT, and EAES). Evidence-based recommendations were formulated using the GRADE methodology. When evidence-based recommendations could not be made, expert opinion was documented. A number of recommendations for future research were also documented. Recommendations were presented at a consensus meeting in October 2018 and were voted on by an international panel of 25 experts with greater than 80% agreement considered consensus.

RESULTS

Consensus was reached on 17 of 18 questions by the Guideline Development Group (GDG) and expert panel with high concordance from audience participation. Most recommendations were conditional due to low certainty of evidence. Strong recommendations were made for (1) use of intraoperative biliary imaging for uncertainty of anatomy or suspicion of biliary injury; and (2) referral of patients with confirmed or suspected BDI to an experienced surgeon/multispecialty hepatobiliary team.

CONCLUSION

These consensus recommendations should provide guidance to surgeons, training programs, hospitals, and professional societies for strategies that have the potential to reduce BDIs and positively impact patient outcomes. Development of clinical and educational research initiatives based on these recommendations may drive further improvement in the quality of surgical care for patients undergoing cholecystectomy.

Recommendation for cholecystectomy protocol based on intraoperative ultrasound - a single-centre retrospective case-control study

Introduction

There is a strong need to make laparoscopic cholecystectomy as safe as possible, but sometimes complications in the form of bile duct and/or vascular injury occur. The safe plane of dissection can be precisely identified with intraoperative ultrasound, ensuring reduction of the complication rate to a minimum.

Aim

To evaluate the advantages of the cholecystectomy protocol based on the use of intraoperative ultrasound during laparoscopic and open cholecystectomy.

Material and methods

The study group consisted of 700 patients with symptomatic cholecystolithiasis, which was divided into two subgroups: with the critical view of safety only (312 patients) and with the critical view of safety + laparoscopic/open cholecystectomy ultrasound (388 patients). Laparoscopic cholecystectomy and conversion in patients from the second subgroup were performed under the control of intraoperative ultrasound.

Results

We did not observe any biliary complications, and the visualization of the common bile duct, the proper hepatic artery and the portal vein was obtained in every patient from the critical view of safety + laparoscopic/open cholecystectomy ultrasound group. The mean time of the operation was significantly shorter and the conversion, biliary injury and intraoperative bleeding rates were significantly lower in this group of patients.

Conclusions

Intraoperative ultrasound is a very efficient and safe method of guidance, and its use should be standard along with the critical view of safety during cholecystectomy.

Evolution of bile duct repair in a low and middle-income country (LMIC): a comparison of diagnosis, referral, management and outcomes in repair of bile duct injury after laparoscopic cholecystectomy from 1991 to 2004 and 2005-2017

BACKGROUND

There is a paucity of data from the developing world regarding laparoscopic cholecystectomy (LC) bile duct injuries (BDIs), despite the fact that most of the world's population live in a developing country. We assessed how referral patterns, management and outcomes after LC-BDI repair have evolved over time in patients treated at a tertiary referral center in a low and middle-income country (LMIC).

METHODS

Patients with LC-BDIs requiring hepaticojejunostomy were identified from a prospective database. Clinical characteristics, geographic distance from referral hospital, timing of referral and repair, and post-operative outcomes were compared in two cohorts treated during 1991-2004 and 2005-2017.

RESULTS

Of 125 patients, 32 underwent repair in the early period, 93 in the latter. There was no difference in demographic or clinical characteristics, but a 45.6% increase in geographically distant referrals in the 2005-2017 period. Time from diagnosis to referral and referral to repair increased significantly (p = 0.031, p < 0.001), necessitating more intermediate repairs. Despite this, the number of severe complications decreased (p = 0.022) while long-term outcomes remained unchanged.

CONCLUSION

In this study from an LMIC, geographic and logistic constraints necessitated deviation from accepted algorithms devised for well-resourced countries. When appropriately adapted, results comparable to those reported from developed countries are achievable.

Retrograde tracing along "cystic duct" method to prevent biliary misidentification injury in laparoscopic cholecystectomy

Bile duct injury remains the most serious complication of laparoscopic cholecystectomy (LC), the main cause was misidentification of cystic duct (CD). The aim of this study was to evaluate the effectiveness and security of retrograde tracing along "cystic duct" (RTACD) method for the prevention of biliary misidentification injury in LC. The conception of RTACD method was first described and then illustrated by simulation dissection with extrahepatic biliary structure charts. A total of 840 patients undergoing LC were selected. After the "CD" was separated during operation, its authenticity was identified by RTACD method according to its course and origin. The "CD" can be clipped/divided only when it was identified to be true CD. Among 840 patients, the initially separated "CD" was identified as actual CD in 831 cases, common hepatic (bile) duct in six cases, accessory right posterior sectoral duct in two cases, and right haptic duct in one case. LCs were successfully finished in 837 patients, and converted to open cholecystectomy in three cases. The average operation time was 64.23 min (range 25-225 min), and the average blood loss was 8.07 ml (range 2-200 ml). No biliary misidentification injury was found. All patients recovered smoothly. No jaundice or abdominal pain was noted in the patients during 1-19 months follow-up. RTACD method is a safe and effective new technique of preventing biliary misidentification injury.

Fundus first as the standard technique for laparoscopic cholecystectomy

In previous studies the fundus first technique (FF) has been a cost-effective way to simplify the laparoscopic cholecystectomy (LC) and facilitate patient rehabilitation. The feasibility and safety profile when introducing FF as the standard technique were aimed in this study. Between 2004–2014, 29 surgeons performed 1425 LC with FF and 320 with a conventional technique. During the first year 56% were with FF and 98% during the last four years. More females, ultrasonic shears, urgent operations, daycare operations and a shorter operation time were found with FF. 63 (3.6%) complications occurred: 10 (0.6%) bleedings, 33 (1.9%) infections and 12 (0.7%) bile leakages. Leakage from cystic duct occurred in 4/112 (3.6%) when closed with ultrasonic shears and in 4/1633 (0.2%) with clips (p 0.008). A common bile duct lesion occurred in 1/1425 (0.07%) with FF and in 3/320 (0.9%) with the conventional approach (p 0.003). In a multivariate regression model, the conventional technique was a risk factor for bile duct injury with an odds ratio of 20.8 (95% CI 1.6–259.2). In conclusion FF was effectively established as the standard procedure and associated with lower rates of bile duct injuries. Clipless closure of the cystic duct increased the rate of leakage.

Live Quality Assurance: Using a Multimedia Messaging Service Group Chat to Instantly Grade Intraoperative Images

BACKGROUND

The technique for attaining photographic evidence of the critical view of safety (CVS) in laparoscopic cholecystectomy (LC) has previously been defined; however, the consistency, accuracy, and feasibility of CVS in practice is unknown. The aim of this study was to use an already established image sharing and grading system to determine the feasibility of timely feedback after sharing intraoperative images of the CVS and to evaluate if and how cholecystitis affects the ability to attain a CVS.

STUDY DESIGN

We studied 193 laparoscopic cholecystectomies performed by 14 surgeons between August 2017 and January 2019. Anterior and posterior intraoperative CVS images were shared using a standard multimedia messaging system (MMS). Images were graded remotely by members of the group using an established scoring system, and their times to response and scores were recorded. Response data were analyzed for the ability to attain timely and consistent CVS scores.

RESULTS

There were 74 urgent laparoscopic cholecystectomies for acute cholecystitis and 119 nonurgent cholecystectomies performed during the study period. Scoring of shared images occurred in less than 5 minutes, and peer review (mean 3 responses) showed agreement that was not significantly different. In patients with acute cholecystitis, a small but significant difference was observed between anterior and posterior image scoring agreement.

CONCLUSIONS

An established image sharing and grading system for CVS can be used for real-time intraoperative feedback without increasing operative time or compromising private health information. The CVS is almost always attainable; however, decreases in CVS quality and grading agreement are observed in patients with acute cholecystitis.

Improving attainment of the critical view of safety during laparoscopic cholecystectomy

INTRODUCTION

We hypothesized that practicing surgeons would successfully achieve a better and more frequent Critical View of Safety (CVS) during laparoscopic cholecystectomy (LC) after participation in a structured Safe CVS Curriculum.

METHODS

All surgeons performing LC at a regional health system had four LC cases recorded: twice before and twice after a curriculum focused on the CVS, which was led by a member of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Safe LC Task Force. Videos were then de-identified and randomly ordered for grading on a 6-point CVS assessment tool by two expert surgeons, who were blinded to the operator and whether the surgeries were performed before or after the curriculum. Confidence surveys and performance on a CVS identification video quiz were also compared pre- and post-curriculum.

RESULTS

Twelve surgeons (five general, four acute care, and three minimally invasive) with an average experience of 17.9 ± 6.3 years participated in the study. After the curriculum, surgeons achieved all three CVS criteria in more cases (1/24 (4%) versus 10/24 (42%), p < 0.004). There was also significant improvement in correctly identifying whether the CVS was achieved in 10 video clips from the Internet (7.9 ± 1.5 vs. 9.3 ± 0.8, p = 0.006) and increased confidence on a 5-point Likert scale in accurately identifying the CVS (4.5 ± 0.5 vs. 4.9 ± 0.3, p = 0.017).

CONCLUSION

A structured curriculum on achieving a quality CVS for practicing, experienced surgeons improved their confidence and frequency of obtaining the Critical View of Safety during LC. We recommend that the Safe CVS Curriculum be considered for widespread use in order to increase the quality and frequency of attaining the Critical View of Safety.

Comprehensive and innovative techniques for laparoscopic choledocholithotomy: A surgical guide to successfully accomplish this advanced manipulation

Surgeries for benign diseases of the extrahepatic bile duct (EHBD) are classified as lithotomy (i.e., choledocholithotomy) or diversion (i.e., choledochojejunostomy). Because of technical challenges, laparoscopic approaches for these surgeries have not gained worldwide popularity. The right upper quadrant of the abdomen is advantageous for laparoscopic procedures, and laparoscopic choledochojejunostomy is safe and feasible. Herein, we summarize tips and pitfalls in the actual procedures of choledocholithotomy. Laparoscopic choledocholithotomy with primary closure of the transductal incision and transcystic C-tube drainage has excellent clinical outcomes; however, emergent biliary drainage without endoscopic sphincterotomy and preoperative removal of anesthetic risk factors are required. Elastic suture should never be ligated directly on the cystic duct. Interrupted suture placement is the first choice for hemostasis near the EHBD. To prevent progressive laceration of the EHBD, full-layer interrupted sutures are placed at the upper and lower edges of the transductal incision. Cholangioscopy has only two-way operation; using dedicated forceps to atraumatically grasp the cholangioscope is important for smart maneuvering. The duration of intraoperative stone clearance accounts for most of the operative time. Moreover, dedicated forceps are an important instrument for atraumatic grasping of the cholangioscope. Damage to the cholangioscope requires expensive repair. Laparoscopic approach for choledocholithotomy involves technical difficulties. I hope this document with the visual explanation and literature review will be informative for skillful surgeons.

How to perform laparoscopic cholecystectomy safely?

Laparoscopic cholecystectomy (LC) is a successful paradigm for modern minimally invasive surgery. Currently, there are few doctors and even patients who are willing to undergo open cholecystectomy. At the scientific level, LC is safe enough; however, given that the number of patients undergoing LC is large, even a lower incidence of complications can cause an amazing absolute number of patients with complications. The risk factors of LC are numerous, and laparoscopic-related risk factors are the key to deciding surgical indications for LC. In different types of cholecystitis, LC has shown minimally invasive advantages compared with open cholecystectomy. To carry out LC safely, we should emphasize the principle of adherence, attention to details, and timely adjustment. It is necessary to consider the "delayed strategy", which means repeated identification before the key points of surgery, such as vessel or tract identification and disconnection. In the process of tissue dissociation, we must wait for the assistant to adjust in time to avoid misjudgment under the fixed thinking and overlapping vision.

Successful Laparoscopic Cholecystectomy in Moderate to Severe Acute Cholecystitis: Visual Explanation with Video File

BACKGROUND Experience alone is insufficient to ensure successful laparoscopic cholecystectomy (LC), although LC has become widespread worldwide. Iatrogenic biliary injuries occur beyond the learning curve. CASE REPORT Biliary injury during laparoscopic cholecystectomy results from anatomical misidentification. The use of a critical view of safety has been established, to identify the cystic artery and the cystic duct, as the cystic duct can be hidden by inflammation (infundibular cystic duct). Seven patients who underwent emergency laparoscopic cholecystectomy due to acute cholecystitis are presented who underwent a critical view of safety protocol during surgery. Five men and two women (mean age, 63.0±13.0 years) included five cases of acute severe cholecystitis and two cases of acute moderate cholecystitis. The mean operative time to complete the critical view of safety exposure was 54.0±17.4 minutes. No cases underwent conversion to open surgery. The mean postoperative duration to ambulation and normal diet was 0.7±0.5 days and 1.0±0.6 days, respectively. The mean time to postoperative patient discharge was 3.9±0.9 days. In all seven cases, the postoperative course was uneventful. The protocol for this surgical procedure is presented, with schematic figures and videos. CONCLUSIONS A case series of seven patients who presented with moderate-to-severe acute cholecystitis and who underwent laparoscopic cholecystectomy, showed good postoperative outcome without surgical complications, using a using a critical view of safety protocol.

Lacunar implementation of the critical view of safety technique for laparoscopic cholecystectomy: Results of a nationwide survey

BACKGROUND

Bile duct injury remains a dilemma in laparoscopic cholecystectomy, with an incidence still higher than in conventional cholecystectomy. The Critical View of Safety technique is used as one of the important operating technique to reduce bile duct injury incidence. The objective of this study was to determine current practices in laparoscopic cholecystectomy and the use of the Critical View of Safety technique among surgeons and residents in surgical training.

METHODS

We conducted an electronic survey among all affiliated members of the Association of Surgeons of the Netherlands containing questions regarding the current practice of laparoscopic cholecystectomy, essential steps of the Critical View of Safety technique, reasons for conversion to open cholecystectomy, and the use of other safety techniques.

RESULTS

The response rate was 37% (766/2,055). In the study, 610 completed surveys were analyzed. Of the respondents, 410 (67.2%) were surgeons and 200 (32.8%) were residents in surgical training. Furthermore, 98.2% of the respondents indicated incorporating the Critical View of Safety technique into current practice. However, only 72% of respondents performed the essential steps of the Critical View of Safety technique frequently. Subsequently, half of respondents were able to identify the corresponding steps of the Critical View of Safety technique, and only 16.9% were able to distinguish these adequately from possible harmful steps. Furthermore, 74.9% selected ≥1 possible harmful steps as part of this technique. Residents significantly performed and selected the essential steps of the Critical View of Safety technique more often than surgeons. Intraoperative cholangiography, intraoperative ultrasound, and fluorescence cholangiography are seldom used. Bail-out techniques such as subtotal cholecystectomy, fundus first dissection, and leaving the gallbladder in situ are familiar to the majority of respondents.

CONCLUSION

Responses indicate that practically all Dutch surgeons and residents claim to use the Critical View of Safety technique. The majority of surgeons and residents are unable to discern correctly the essential steps of the Critical View of Safety technique from actions not part of the technique and even potentially harmful. Residents' current knowledge regarding the Critical View of Safety technique is superior to those of surgeons.

Quality of Life and Medico-Legal Implications Following Iatrogenic Bile Duct Injuries

In this review we aimed to evaluate quality of life after bile duct injury and the consequent medico-legal implications. A comprehensive English language literature search was performed on MEDLINE, Embase, Science Citation Index and Google™ Scholar databases for articles published between January 2000 and April 2016. The last date of search was 11 April 2016. Key search words included bile duct injury, iatrogenic, cholecystectomy, prevention, risks, outcomes, quality of life, litigation and were used in combination with the Boolean operators AND, OR and NOT. Long-term survival after bile duct injury is significantly impaired (all-cause long-term mortality approximately 21 %) along with the quality of life (especially psychological/mental state remains affected). Bile duct injury is associated with high rates of litigation. Monetary compensation varied from £2500 to £216,000 in the UK, €9826-€55,301 in the Netherlands and $628,138-$2,891,421 in the USA. Bile duct injuries have profound implications for patients, medical personnel and healthcare providers as they cause significant morbidity and mortality, high rates of litigation and raised healthcare expenditure.

Measuring Decision-Making During Thyroidectomy: Validity Evidence for a Web-Based Assessment Tool

BACKGROUND

Errors in judgment during thyroidectomy can lead to recurrent laryngeal nerve injury and other complications. Despite the strong link between patient outcomes and intraoperative decision-making, methods to evaluate these complex skills are lacking. The purpose of this study was to develop objective metrics to evaluate advanced cognitive skills during thyroidectomy and to obtain validity evidence for them.

METHODS

An interactive online learning platform was developed ( www.thinklikeasurgeon.com ). Trainees and surgeons from four institutions completed a 33-item assessment, developed based on a cognitive task analysis and expert Delphi consensus. Sixteen items required subjects to make annotations on still frames of thyroidectomy videos, and accuracy scores were calculated based on an algorithm derived from experts' responses ("visual concordance test," VCT). Seven items were short answer (SA), requiring users to type their answers, and scores were automatically calculated based on their similarity to a pre-populated repertoire of correct responses. Test-retest reliability, internal consistency, and correlation of scores with self-reported experience and training level (novice, intermediate, expert) were calculated.

RESULTS

Twenty-eight subjects (10 endocrine surgeons and otolaryngologists, 18 trainees) participated. There was high test-retest reliability (intraclass correlation coefficient = 0.96; n = 10) and internal consistency (Cronbach's α = 0.93). The assessment demonstrated significant differences between novices, intermediates, and experts in total score (p < 0.01), VCT score (p < 0.01) and SA score (p < 0.01). There was high correlation between total case number and total score (ρ = 0.95, p < 0.01), between total case number and VCT score (ρ = 0.93, p < 0.01), and between total case number and SA score (ρ = 0.83, p < 0.01).

CONCLUSION

This study describes the development of novel metrics and provides validity evidence for an interactive Web-based platform to objectively assess decision-making during thyroidectomy.

Depicting surgical anatomy of the porta hepatis in living donor liver transplantation

Visualizing the complex anatomy of vascular and biliary structures of the liver on a case-by-case basis has been challenging. A living donor liver transplant (LDLT) right hepatectomy case, with focus on the porta hepatis, was used to demonstrate an innovative method to visualize anatomy with the purpose of refining preoperative planning and teaching of complex surgical procedures. The production of an animation-enhanced video consisted of many stages including the integration of pre-surgical planning; case-specific footage and 3D models of the liver and associated vasculature, reconstructed from contrast-enhanced CTs. Reconstructions of the biliary system were modeled from intraoperative cholangiograms. The distribution of the donor portal veins, hepatic arteries and bile ducts was defined from the porta hepatis intrahepatically to the point of surgical division. Each step of the surgery was enhanced with 3D animation to provide sequential and seamless visualization from pre-surgical planning to outcome. Use of visualization techniques such as transparency and overlays allows viewers not only to see the operative field, but also the origin and course of segmental branches and their spatial relationships. This novel educational approach enables integrating case-based operative footage with advanced editing techniques for visualizing not only the surgical procedure, but also complex anatomy such as vascular and biliary structures. The surgical team has found this approach to be beneficial for preoperative planning and clinical teaching, especially for complex cases. Each animation-enhanced video case is posted to the open-access Toronto Video Atlas of Surgery (TVASurg), an education resource with a global clinical and patient user base. The novel educational system described in this paper enables integrating operative footage with 3D animation and cinematic editing techniques for seamless sequential organization from pre-surgical planning to outcome.

IRCAD recommendation on safe laparoscopic cholecystectomy

An expert recommendation conference was conducted to identify factors associated with adverse events during laparoscopic cholecystectomy (LC) with the goal of deriving expert recommendations for the reduction of biliary and vascular injury. Nineteen hepato-pancreato-biliary (HPB) surgeons from high-volume surgery centers in six countries comprised the Research Institute Against Cancer of the Digestive System (IRCAD) Recommendations Group. Systematic search of PubMed, Cochrane, and Embase was conducted. Using nominal group technique, structured group meetings were held to identify key items for safer LC. Consensus was achieved when 80% of respondents ranked an item as 1 or 2 (Likert scale 1-4). Seventy-one IRCAD HPB course participants assessed the expert recommendations which were compared to responses of 37 general surgery course participants. The IRCAD recommendations were structured in seven statements. The key topics included exposure of the operative field, appropriate use of energy device and establishment of the critical view of safety (CVS), systematic preoperative imaging, cholangiogram and alternative techniques, role of partial and dome-down (fundus-first) cholecystectomy. Highest consensus was achieved on the importance of the CVS as well as dome-down technique and partial cholecystectomy as alternative techniques. The put forward IRCAD recommendations may help to promote safe surgical practice of LC and initiate specific training to avoid adverse events.

Preoperative predictors of conversion as indicators of local inflammation in acute cholecystitis: strategies for future studies to develop quantitative predictors

BACKGROUND

Observational studies have identified risk factors for conversion from laparoscopic to open cholecystectomy in acute cholecystitis. The aim of this study is to evaluate the reliability of these predictors and to identify sources of heterogeneity in the studies.

METHODS

OVID was searched for papers published from 1995 to 2016. Studies with more than 100 patients were included. Risk factors for conversion were abstracted and categorized by statistical significance.

RESULTS

Eleven studies were evaluated. Inflammation with difficulty in anatomic identification was the most common reason of conversion. Because of heterogeneity among studies a quantitative approach was not possible. Therefore, qualitative analysis using a heat map was performed along with investigation into sources of heterogeneity with the aim of creating a framework for future quantitative studies. Age, maleness, and white blood cell count were most commonly identified predictors of conversion. Sources of heterogeneity were criteria for diagnosis of acute cholecystitis, selection of patients for laparoscopic cholecystectomy, selection of variables and variations in their thresholds.

CONCLUSIONS

In acute cholecystitis, inflammation is the most common reason for conversion. Age, maleness and white blood cell count are common predictors of conversion. Large scale prospective studies with minimal heterogeneity are needed to establish validity of these and other predictors.

What Are the Principles That Guide Behaviors in the Operating Room?: Creating a Framework to Define and Measure Performance

OBJECTIVE

To identify the core principles that guide expert intraoperative behaviors and to use these principles to develop a universal framework that defines intraoperative performance.

BACKGROUND

Surgical outcomes are associated with intraoperative cognitive skills. Yet, our understanding of factors that control intraoperative judgment and decision-making are limited. As a result, current methods for training and measuring performance are somewhat subjective-more task rather than procedure-oriented-and usually not standardized. They thus provide minimal insight into complex cognitive processes that are fundamental to patient safety.

METHODS

Cognitive task analyses for 6 diverse surgical procedures were performed using semistructured interviews and field observations to describe the thoughts, behaviors, and actions that characterize and guide expert performance. Verbal data were transcribed, supplemented with content from published literature, coded, thematically analyzed using grounded-theory by 4 independent reviewers, and synthesized into a list of items.

RESULTS

A conceptual framework was developed based on 42 semistructured interviews lasting 45 to 120 minutes, 5 expert panels and 51 field observations involving 35 experts, and 135 sources from the literature. Five domains of intraoperative performance were identified: psychomotor skills, declarative knowledge, advanced cognitive skills, interpersonal skills, and personal resourcefulness. Within the advanced cognitive skills domain, 21 themes were perceived to guide the behaviors of surgeons: 18 for surgical planning and error prevention, and 3 for error/injury recognition, rescue, and recovery. The application of these thought patterns was highly case-specific and variable amongst subspecialties, environments, and individuals.

CONCLUSIONS

This study provides a comprehensive definition of intraoperative expertise, with greater insight into the complex cognitive processes that seem to underlie optimal performance. This framework provides trainees and other nonexperts with the necessary information to use in deliberate practice and the creation of effective thought habits that characterize expert performance. It may help to identify gaps in performance, and to isolate root causes of surgical errors with the ultimate goal of improving patient safety.

The Difficult Gallbladder: A Safe Approach to a Dangerous Problem

Laparoscopic cholecystectomy is a common surgical procedure, and remains the gold standard for the management of benign gallbladder and biliary disease. While this procedure can be technically straightforward, it can also represent one of the most challenging operations facing surgeons. This dichotomy of a routine operation performed so commonly that poses such a hidden risk of severe complications, such as bile duct injury, must keep surgeons steadfast in the pursuit of safety. The "difficult gallbladder" requires strict adherence to the Culture of Safety in Cholecystectomy, which promotes safety first and assists surgeons in managing or avoiding difficult operative situations. This review will discuss the management of the difficult gallbladder and propose the use of subtotal fenestrating cholecystectomy as a definitive option during this dangerous situation.

Measuring intra-operative decision-making during laparoscopic cholecystectomy: validity evidence for a novel interactive Web-based assessment tool

BACKGROUND

Errors in judgment during laparoscopic cholecystectomy can lead to bile duct injuries and other complications. Despite correlations between outcomes, expertise and advanced cognitive skills, current methods to evaluate these skills remain subjective, rater- and situation-dependent and non-systematic. The purpose of this study was to develop objective metrics using a Web-based platform and to obtain validity evidence for their assessment of decision-making during laparoscopic cholecystectomy.

METHODS

An interactive online learning platform was developed ( www.thinklikeasurgeon.com ). Trainees and surgeons from six institutions completed a 12-item assessment, developed based on a cognitive task analysis. Five items required subjects to draw their answer on the surgical field, and accuracy scores were calculated based on an algorithm derived from experts' responses ("visual concordance test", VCT). Test-retest reliability, internal consistency, and correlation with self-reported experience, Global Operative Assessment of Laparoscopic Skills (GOALS) score and Objective Performance Rating Scale (OPRS) score were calculated. Questionnaires were administered to evaluate the platform's usability, feasibility and educational value.

RESULTS

Thirty-nine subjects (17 surgeons, 22 trainees) participated. There was high test-retest reliability (intraclass correlation coefficient = 0.95; n = 10) and internal consistency (Cronbach's α = 0.87). The assessment demonstrated significant differences between novices, intermediates and experts in total score (p < 0.01) and VCT score (p < 0.01). There was high correlation between total case number and total score (ρ = 0.83, p < 0.01) and between total case number and VCT (ρ = 0.82, p < 0.01), and moderate to high correlations between total score and GOALS (ρ = 0.66, p = 0.05), VCT and GOALS (ρ = 0.83, p < 0.01), total score and OPRS (ρ = 0.67, p = 0.04), and VCT and OPRS (ρ = 0.78, p = 0.01). Most subjects agreed or strongly agreed that the platform and assessment was easy to use [n = 29 (78 %)], facilitates learning intra-operative decision-making [n = 28 (81 %)], and should be integrated into surgical training [n = 28 (76 %)].

CONCLUSION

This study provides preliminary validity evidence for a novel interactive platform to objectively assess decision-making during laparoscopic cholecystectomy.

Open-access technique and "critical view of safety" as the safest way to perform laparoscopic cholecystectomy

BACKGROUND

The 2 main challenges of laparoscopic cholecystectomy are primary peritoneal access and safe identification, ligation, and division of the cystic duct and cystic artery.

PATIENTS AND METHODS

This is a 13-year period retrospective study from January 2000 to December 2012. All the operations were performed by 1 surgeon and all the data were collected from the hospitals archive. A total of 929 laparoscopic cholecystectomies were performed for symptomatic cholelithiasis. The first author was involved in all the operations either by performing or assisting in them. The open access (OA) technique was used in all cases for the creation of pneumoperitoneum. After establishing the pneumoperitoneum, the "critical view of safety" (CVS) technique was used to ligate and divide the cystic duct and cystic artery. When the OA was not possible or CVS was not feasible, the operation was converted to open.

RESULTS

Successful establishment of pneumoperitoneum with OA was possible in 911 of 929 (98.06%) patients and CVS was achieved in 873 patients (95.82%). In 18 patients the operation was converted to open because of dense adhesions not permitting the establishment of the pneumoperitoneum. No intraoperative or postoperative complications occurred in these patients. No bile duct injury occurred in this series. Postoperative complications were recorded in 19 patients (2.04%). Five patients had bleeding from port sites, 12 patients had wound infection at the umbilical incision, and 2 patients developed subhepatic collections, which were drained percutaneously under computed tomographic guidance.

CONCLUSIONS

In this series of laparoscopic cholecystectomies, we used the "open access" technique to create pneumoperitoneum and we obtained the "critical view of safety" for the identification of the cystic duct. Our results show that this approach is the safest way to perform and teach laparoscopic cholecystectomy.

Subtotal Cholecystectomy-"Fenestrating" vs "Reconstituting" Subtypes and the Prevention of Bile Duct Injury: Definition of the Optimal Procedure in Difficult Operative Conditions

Less than complete cholecystectomy has been advocated for difficult operative conditions for more than 100 years. These operations are called partial or subtotal cholecystectomy, but the terms are poorly defined and do not stipulate whether a remnant gallbladder is created. This article briefly reviews the history and development of the procedures and introduces new terms to clarify the field. The term partial is discarded, and subtotal cholecystectomies are divided into "fenestrating" and "reconstituting" types. Subtotal reconstituting cholecystectomy closes off the lower end of the gallbladder, reducing the incidence of postoperative fistula, but creates a remnant gallbladder, which may result in recurrence of symptomatic cholecystolithiasis. Subtotal fenestrating cholecystectomy does not occlude the gallbladder, but may suture the cystic duct internally. It has a higher incidence of postoperative biliary fistula, but does not appear to be associated with recurrent cholecystolithiasis. Laparoscopic subtotal cholecystectomy has advantages but may require advanced laparoscopic skills.

Absorbable bioprosthesis for the treatment of bile duct injury in an experimental model

INTRODUCTION

Cholecystectomy is a common surgical procedure in which complications may occur, such as injury to the biliary tract, which are associated with high morbidity. The aim of this study was to demonstrate the efficacy of a polymer-based absorbable bioprosthesis with bone scaffold for the treatment of bile duct injury in an animal model.

MATERIALS AND METHODS

An absorbable bioprosthesis was used to replace the common bile duct in 15 pigs which were divided into 3 groups with different follow-ups at 1, 3 and 6 months. The animals were anesthetized at these time points and laboratory tests, Magnetic Resonance Cholangiopancreatogram [MRCP], Choledochoscopy using Spyglass and Endoscopic retrograde Cholangiopancreatogram [ERCP] were performed. After radiological evaluation was complete, the animals were euthanized and histological and immunohistochemical analyses were performed.

RESULTS

Liver function tests at different time points demonstrated no significant changes. No mortality or postoperative complications were found in any of the experimental models. Imaging studies ([MRCP], [ERCP] and Choledochoscopy with SpyGlass(™)) showed absence of stenosis or obstruction in all the experimental models.

DISCUSSION

Histological and immunohistochemical staining (CK19 and MUC5+) revealed the presence of biliary epithelium with intramural biliary glands in all the experimental models. There was no stenosis or obstruction in the bile duct.

CONCLUSIONS

The bioprosthesis served as scaffolding for tissue regeneration. There was no postoperative complication at 6 months follow-up. This bioprosthesis could be used to replace the bile duct in cancer or bile duct injury. The bioprosthesis may allow different modeling depending on the type of bile duct injury.

A gallbladder with the "hidden cystic duct": A brief overview of various surgical techniques of the Calot's triangle dissection

We present a case of a middle-aged female who attended for a routine laparoscopic cholecystectomy as a day case surgery. At operation, she was found to have a distended gallbladder with an unusually prominent distal portion. This has made the dissection of the Calot's triangle challenging. As a result, the "critical view of safety" technique was applied. This allowed for the clear Calot's triangle visualization and identification of the cystic duct and artery. This case highlights that the knowledge of various ways of the cystic duct dissection is essential to every surgeon. Furthermore, this helps to adjust the dissection approach on an individual case bases ensuring avoidance of the common bile duct injuries.