Mechanisms of major biliary injury during laparoscopic cholecystectomy

The difficult laparoscopic cholecystectomy: a narrative review

BACKGROUND/PURPOSE

Laparoscopic cholecystectomy is one of the most commonly performed general surgical procedures. Difficult laparoscopic cholecystectomy is associated with increased operative time, hospital stay, complication rates, open conversion, treatment costs, and mortality. This study aimed to provide a comprehensive literature review on difficult laparoscopic cholecystectomy.

METHODS

A literature search was conducted for articles published in English up to June 2024 using common databases including PubMed/MIDLINE, Web of Science, Google Scholar, and ScienceDirect. Keywords included "safe laparoscopic cholecystectomy", "difficult laparoscopic cholecystectomy", "acute cholecystitis", "prevention of bile duct injuries", "intraoperative cholangiography," "bailout procedure," and "subtotal cholecystectomy". Only clinical trials, systematic reviews/meta-analyses, and review articles were included. Studies involving children, robotic cholecystectomy, single incision laparoscopic cholecystectomy, open cholecystectomy, and cholecystectomy for indications other than gallstone disease were excluded.

RESULTS/DISCUSSION

Emergency laparoscopic cholecystectomy for acute cholecystitis is ideally performed within 72 h of symptom onset, with a maximum window of 7-10 days. Intraoperative cholangiography can help clarify unclear biliary anatomy and detect bile duct injuries. In the "impossible gallbladder", laparoscopic cholecystostomy or gallbladder aspiration may be considered. When dissection of Calot's triangle is deemed hazardous or impossible, the fundus-first approach allows for completion of the procedure with either total cholecystectomy or subtotal cholecystectomy. Subtotal cholecystectomy is effective in preventing bile duct injuries, can be performed laparoscopically, and is currently the best available bailout approach for difficult laparoscopic cholecystectomy.

CONCLUSION

Difficult laparoscopic cholecystectomy is a common clinical scenario that requires a judicious approach by experienced surgeons in appropriate settings. When difficult laparoscopic cholecystectomy is encountered, various bailout strategies are available. Currently, subtotal cholecystectomy is likely the most effective bailout approach.

Artificial Intelligence in Minimally Invasive Surgery: Current State and Future Challenges

Recent advancements in artificial intelligence (AI) have markedly affected various fields, with notable progress in surgery. This study explores the integration of AI in surgery, particularly focusing on minimally invasive surgery (MIS), where high-quality surgical videos provide fertile ground for computer vision (CV) technology applications. CV plays an important role in enhancing intraoperative decision-making through real-time image recognition. This study considers the challenges in clinical applications and future perspectives by reviewing the current state of AI in navigation during surgery, postoperative analysis, and automated surgical skill assessment.

Magnetic compression anastomosis for the treatment of complete biliary obstruction after cholecystectomy

BACKGROUND AND AIMS

Post-cholecystectomy biliary strictures can be treated surgically or nonsurgically. Although endoscopic or percutaneous treatments are the preferred approaches, these methods are not feasible in cases in which complete stricture occlusion prevents the successful passage of a guidewire. The utility of magnetic compression anastomosis (MCA) in patients with post-cholecystectomy complete biliary obstruction that cannot be treated conventionally was evaluated.

METHODS

MCA was performed in 10 patients with post-cholecystectomy biliary strictures that did not resolve with conventional endoscopic or percutaneous treatment. One magnet was delivered through the percutaneous transhepatic biliary drainage tract, and another was advanced via ERCP of the common bile duct. After magnet approximation and recanalization, a fully covered self-expandable metal stent (FCSEMS) was placed for 3 months and then replaced for an additional 3 months. Stricture resolution was evaluated after FCSEMS removal.

RESULTS

Among the 10 patients who underwent MCA for post-cholecystectomy biliary stricture, the biliary injury was Strasberg type B in 2, type C in 3, and type E in 5. Recanalization was successful in all patients (technical success rate, 100%). The mean follow-up period after recanalization was 50.2 months (range, 13.2-116.8 months). Partial restenosis after MCA occurred in 2 patients at 24.1 and 1.6 months after stent removal. ERCP with FCSEMS placement resolved the recurrent stenosis in both patients.

CONCLUSIONS

MCA is a useful nonsurgical alternative treatment for complete biliary obstruction after cholecystectomy that cannot be resolved by use of conventional methods.

Bile Duct Injuries During Urgent Cholecystectomy at a Safety Net Teaching Hospital: Attending Experience and Time of Day May Matter

Background: Bile duct injury (BDI) is one of the most severe complications during cholecystectomy. Early identification of risk factors for BDI may permit risk reduction strategies and inform patient consent.Objective: This study aimed to define patient, provider, and systemic factors associated with BDI; BDI incidence; and short-term outcomes of BDI after urgent cholecystectomy.Methods: Patients who underwent urgent cholecystectomy for acute cholecystitis were retrospectively screened (2020-2022). All patients who sustained BDI were included without exclusions. Demographics, clinical data, and outcomes were collected and compared with descriptive statistics.Results: During the study period, BDI occurred in 4 (0.5%) of 728 patients who underwent urgent cholecystectomy for acute cholecystitis. Most BDI cases (75%) took place overnight or during the weekend. The attending surgeon was almost exclusively (75%) in their first year of practice. BDI was recognized during index operation in 2 cases (50%). Hepatobiliary surgery performed the bile duct repair in all 4 cases. Two complications occurred (50%). All patients were followed by hepatobiliary surgery in the outpatient setting and returned to their baseline level of function within 2 months of hospital discharge.Conclusion: Most BDI occurred in procedures attended by first-year faculty during after hours cholecystectomies, suggesting a role for increased proctorship in early career attendings in addition to in-hours cholecystectomy for acute cholecystitis. The timely return to baseline function experienced by these patients emphasizes the favorable outcomes associated with early recognition of BDI and involvement of hepatobiliary surgery. Further examination with multicenter evaluation would be beneficial to validate these study findings.

Artificial intelligence applied to laparoscopic cholecystectomy: what is the next step? A narrative review

Artificial Intelligence (AI) is playing an increasing role in several fields of medicine. AI is also used during laparoscopic cholecystectomy (LC) surgeries. In the literature, there is no review that groups together the various fields of application of AI applied to LC. The aim of this review is to describe the use of AI in these contexts. We performed a narrative literature review by searching PubMed, Web of Science, Scopus and Embase for all studies on AI applied to LC, published from January 01, 2010, to December 30, 2023. Our focus was on randomized controlled trials (RCTs), meta-analysis, systematic reviews, and observational studies, dealing with large cohorts of patients. We then gathered further relevant studies from the reference list of the selected publications. Based on the studies reviewed, it emerges that AI could strongly improve surgical efficiency and accuracy during LC. Future prospects include speeding up, implementing, and improving the automaticity with which AI recognizes, differentiates and classifies the phases of the surgical intervention and the anatomic structures that are safe and those at risk.

Standardization of a goal-oriented approach to acute cholecystitis: easy-to-follow steps for performing subtotal cholecystectomy

BACKGROUND

A critical view of safety (CVS) is important to ensure safe laparoscopic cholecystectomy. When the CVS is not possible, subtotal cholecystectomy is performed. While considering subtotal cholecystectomy, surgeons are often concerned about preventing bile leakage from the cystic ducts. The two main types of subtotal cholecystectomy for acute cholecystitis are fenestrating and reconstituting. Previously, there were no selection criteria for these two; therefore, open conversion was performed. This study aimed to evaluate our goal-oriented approach to choose fenestrating or reconstituting subtotal cholecystectomy for acute cholecystitis.

METHODS

We introduced our goal-oriented approach in April 2019. Before introducing this approach, laparoscopic cholecystectomy for acute cholecystitis was performed without criteria for subtotal cholecystectomy. After our approach was introduced, laparoscopic cholecystectomy for acute cholecystitis was performed according to the subtotal cholecystectomy criteria. We retrospectively reviewed the medical records of patients who underwent laparoscopic cholecystectomy for acute cholecystitis between 2015 and 2021. Laparoscopic cholecystectomy for acute cholecystitis was performed by surgeons regardless of whether they were novices or veterans.

RESULTS

The period from April 2015 to March 2019 was before the introduction (BI) of our approach, the period from April 2019 to December 2021 was after the introduction (AI) of our approach. There were 177 and 186 patients with acute cholecystitis during the BI and AI periods, respectively. There were no significant differences between groups in terms of preoperative characteristics, operative time, and blood loss. No difference in the laparoscopic subtotal cholecystectomy rate between groups (10.2% [BI] vs. 13.9% [AI]; p = 0.266) was obserbed. The open conversion rate during the BI period was significantly higher than that during the AI period (7.4% vs. 1.6%; p = 0.015).

CONCLUSIONS

Our goal-oriented approach is feasible, safe, and easy for many surgeons to understand.

Implications of routine cholangiography during laparoscopic cholecystectomy on postoperative testing: Review of more than 2,300 cases in a community-based practice

BACKGROUND

We hypothesized that routine cholangiography during laparoscopic cholecystectomy may increase use of postoperative imaging and invasive testing.

METHODS

A retrospective review was performed of laparoscopic cholecystectomy cases at 6 community hospitals from 2017 through 2020. For surgeons performing routine vs selective cholangiography, we compared primary outcomes of operative time, 30-day complications, and postoperative imaging or procedures.

RESULTS

In total, 2359 laparoscopic cholecystectomy procedures were performed. Eighteen surgeons performed routine cholangiography (1125 cases), and 13 performed selective (1234 cases). Mean operative time was longer in the routine group (125.3 vs 98.7 min, P < .001). Between groups, 30-day complications were similar. Two common bile duct injuries were identified in the routine group. Postoperatively, the routine group underwent 2.5 times more imaging and invasive testing (P < .001).

CONCLUSIONS

In community hospitals, laparoscopic cholecystectomy can be performed safely by surgeons using cholangiography routinely or selectively. Routine cholangiography resulted in more postoperative imaging and invasive testing.

SAGES safe cholecystectomy modules improve practicing surgeons' judgment: results of a randomized, controlled trial

BACKGROUND

Despite the advantages of laparoscopic cholecystectomy, major bile duct injury (BDI) rates during this operation remain unacceptably high. In October 2018, SAGES released the Safe Cholecystectomy modules, which define specific strategies to minimize the risk of BDI. This study aims to investigate whether this curriculum can change the knowledge and behaviors of surgeons in practice.

METHODS

Practicing surgeons were recruited from the membership of SAGES and the American College of Surgeons Advisory Council for Rural Surgery. All participants completed a baseline assessment (pre-test) that involved interpreting cholangiograms, troubleshooting difficult cases, and managing BDI. Participants' dissection strategies during cholecystectomy were also compared to the strategies of a panel of 15 experts based on accuracy scores using the Think Like a Surgeon validated web-based platform. Participants were then randomized to complete the Safe Cholecystectomy modules (Safe Chole module group) or participate in usually scheduled CME activities (control group). Both groups completed repeat assessments (post-tests) one month after randomization.

RESULTS

Overall, 41 participants were eligible for analysis, including 18 Safe Chole module participants and 23 controls. The two groups had no significant differences in pre-test scores. However, at post-test, Safe Chole module participants made significantly fewer errors managing BDI and interpreting cholangiograms. Safe Chole module participants were less likely to convert to an open operation on the post-test than controls when facing challenging dissections. However, Safe Chole module participants displayed a similar incidence of errors when evaluating adequate critical views of safety.

CONCLUSIONS

In this randomized-controlled trial, the SAGES Safe Cholecystectomy modules improved surgeons' abilities to interpret cholangiograms and safely manage BDI. Additionally, surgeons who studied the modules were less likely to convert to open during difficult dissections. These data show the power of the Safe Cholecystectomy modules to affect practicing surgeons' behaviors in a measurable and meaningful way.

Surgical reconstruction of major bile duct injuries: Long-term results and risk factors for restenosis

BACKGROUND

A single-institution retrospective analysis was undertaken to assess long-term results of definitive surgical reconstruction for major bile duct injuries and risk factors for restenosis.

METHODS

Patients treated between January 1995 and October 2020 were reviewed retrospectively. The primary outcome measure was patency.

RESULTS

Of 417 patients referred to a tertiary center, 290 (69.5%) underwent surgical reconstruction; mostly in the form of a hepaticojejunostomy (n = 281, 96.8%). Major liver resection was undertaken in 18 patients (6.2%). There were 7 postoperative deaths (2.4%). Patency was achieved in 97.4% of primary repairs and 88.8% of re-repairs. Primary patency at three months (including postoperative deaths and stents removed afterwards) in primary repairs was significantly higher than secondary patency attained during the same period in re-repairs (89.3% vs 76.5%, p < 0.01). The actuarial primary patency was also significantly higher compared to the actuarial secondary patency 10 years after reconstruction (86.7% vs 70.4%, p = 0.001). Vascular disruption was the only independent predictor of loss of patency after reconstruction (OR 7.09, 95% CI 3.45-14.49, p < 0.001), showing interaction with injuries at or above the biliary bifurcation (OR 9.52, 95% CI 2.56-33.33, p < 0.001).

CONCLUSIONS

Long-term outcome of surgical reconstruction for major bile duct injuries was superior in primary repairs compared to re-repairs. Concomitant vascular injury was independently associated with loss of patency requiring revision.

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.

Timing of surgical repair of bile duct injuries after laparoscopic cholecystectomy: A systematic review

BACKGROUND

The surgical management of bile duct injuries (BDIs) after laparoscopic cholecystectomy (LC) is challenging and the optimal timing of surgery remains unclear. The primary aim of this study was to systematically evaluate the evidence behind the timing of BDI repair after LC in the literature.

AIM

To assess timing of surgical repair of BDI and postoperative complications.

METHODS

The MEDLINE, EMBASE, and The Cochrane Library databases were systematically screened up to August 2021. Risk of bias was assessed via the Newcastle Ottawa scale. The primary outcomes of this review included the timing of BDI repair and postoperative complications.

RESULTS

A total of 439 abstracts were screened, and 24 studies were included with 15609 patients included in this review. Of the 5229 BDIs reported, 4934 (94%) were classified as major injury. Timing of bile duct repair was immediate (14%, n = 705), early (28%, n = 1367), delayed (28%, n = 1367), or late (26%, n = 1286). Standardization of definition for timing of repair was remarkably poor among studies. Definitions for immediate repair ranged from < 24 h to 6 wk after LC while early repair ranged from < 24 h to 12 wk. Likewise, delayed (> 24 h to > 12 wk after LC) and late repair (> 6 wk after LC) showed a broad overlap.

CONCLUSION

The lack of standardization among studies precludes any conclusive recommendation on optimal timing of BDI repair after LC. This finding indicates an urgent need for a standardized reporting system of BDI repair.

Repeat Laparoscopic Cholecystectomy for Duplicated Gallbladder After 16-Year Interval

BACKGROUND

Gallbladder duplication can present a diagnostic challenge, particularly in patients who have had prior cholecystectomy with a missed duplicated gallbladder.

CASE PRESENTATION

Presented is the case of a man with 16 years of recurrent, persistent right upper quadrant pain after cholecystectomy who was found to have a duplicated gallbladder.

CONCLUSIONS

Gallbladder duplication can be difficult to diagnose and frequently evades preoperative visualization. In particular, patients who have had prior operations or infections that may lead to epigastric adhesions are at higher risk for a missed gallbladder duplication at time of operation. An intraoperative cholangiogram should be routinely performed when the inferior liver margin is poorly visualized due to scarring or patient habitus. Gallbladder anomalies should be considered in the differential preoperatively for all patients undergoing hepatobiliary procedures and for postoperative patients with persistent biliary symptoms.

[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.

Injuries during Laparoscopic Cholecystectomy: A Scoping Review of the Claims and Civil Action Judgements

BACKGROUND

To define what type of injuries are more frequently related to medicolegal claims and civil action judgments.

METHODS

We performed a scoping review on 14 studies and 2406 patients, analyzing medicolegal claims related to laparoscopic cholecystectomy injuries. We have focalized on three phases associated with claims: phase of care, location of injuries, type of injuries.

RESULTS

The most common phase of care associated with litigation was the improper intraoperative surgical performance (47.6% ± 28.3%), related to a "poor" visualization, and the improper post-operative management (29.3% ± 31.6%). The highest rate of defense verdicts was reported for the improper post-operative management of the injury (69.3% ± 23%). A lower rate was reported in the incorrect presurgical assessment (39.7% ± 24.4%) and in the improper intraoperative surgical performance (21.39% ± 21.09%). A defense verdict was more common in cystic duct injuries (100%), lower in hepatic bile duct (42.9%) and common bile duct (10%) injuries.

CONCLUSIONS

During laparoscopic cholecystectomy, the most common cause of claims, associated with lower rate of defense verdict, was the improper intraoperative surgical performance. The decision to take legal action was determined often for poor communication after the original incident.

Management of Postcholecystectomy Complications

Cholecystectomy is one of the most common general surgery procedures performed worldwide. Complications include bile duct injury, strictures, bleeding, infection/abscess, retained gallstones, hernias, and postcholecystectomy syndrome. Obtaining a critical view of safety and following the other tenets of the Safe Cholecystectomy Task Force will aid in the prevention of bile duct injury and other morbidity associated with cholecystectomy.

Laparoscopic cholecystectomy in a swine model using a novel near-infrared fluorescent IV dye (BL-760)

BACKGROUND AND OBJECTIVES

Bile duct injury during laparoscopic cholecystectomy has an incidence rate of 1%-2% and commonly appears under conditions of severe inflammation, adhesion, or unexpected anatomical variations. Despite the difficulties and rising concerns of identifying bile duct during surgeries, surgeons do not have a specific modality to identify bile duct except intraoperative cholangiography. While no biliary-specific fluorescent dye exists for clinical use, our team has previously described the development of a preclinical biliary-specific dye, BL-760. Here, we present our study of laparoscopic cholecystectomy using the fluorescent dye in a swine model.

STUDY DESIGN/MATERIALS AND METHODS

With an approval from Institutional Animal Care and Use Committee, two 20-25 kg swine underwent laparoscopic abdominal surgery using a Food and Drug Administration-cleared fluorescent laparoscopic system. Images of the liver and gallbladder were taken both before and after intravenous injection of the novel fluorescent dye. The dye was dosed at 60 μg/kg and injected via the ear vein. The amount of time taken to visualize fluorescence in the biliary tract was measured. Fluorescent signal was observed after injection, and target-to-background ratio (TBR) of the biliary tract to surrounding cystic artery and liver parenchyma was measured.

RESULTS

Biliary tract visualization under fluorescent laparoscopy was achieved within 5 min after the dye injection without any adverse effects. Cystic duct and extrahepatic duct were clearly visualized and identified with TBR values of 2.19 and 2.32, respectively, whereas no fluorescent signal was detected in liver. Cystic duct and artery were successfully ligated by an endoscopic clip applier with the visual assistance of highlighted biliary tract images. Laparoscopic cholecystectomy was completed within 30 min in each case without any complications.

CONCLUSIONS

BL-760 is a novel preclinical fluorescent dye useful for intraoperative identification and visualization of biliary tract. Such fluorescent dye that is exclusively metabolized by liver and rapidly excreted into biliary tract would be beneficial for all types of hepato-biliary surgeries. With the validation of additional preclinical data, this novel dye has potential to be a valuable tool to prevent any iatrogenic biliary injuries and/or bile leaks during laparoscopic abdominal and liver surgeries.

Gallbladder adhesion degree as predictor of conversion surgery, common bile duct injury and resurgery in laparoscopic cholecystectomy: A cross-sectional study

Background

The gold-standard treatment for cholecystectomy, laparoscopic cholecystectomy, has remarkably variable outcomes and conversion rates. We investigated the gallbladder adhesion degree as a predictor of conversion surgery, common bile duct injury, and resurgery.

Methods

We reviewed 157 medical records and video recordings of laparoscopic cholecystectomy on patients with cholelithiasis with or without cholecystitis at three hospitals in Yogyakarta, Indonesia from January 2016 to December 2018. The degree of gallbladder adhesion is classified into 4 categories: no adhesion, <50% adhesion, 50%-buried GB, and completely buried GB.

Results

One hundred fifty seven patients were involved in this study, of whom 58 were males and 99 females with average age 49.2. Eighty-one patients out of 157 patients (51.6%) had gallbladder adhesion comprising of 61/157 (38.9%) with <50% adhesion and 20/157 (12.7%) 50%-buried GB. There is one incidence each of conversion surgery, CBD injury, and resurgery. The degree of GB adhesion has low degree of correlation with conversion surgery, CBD injury, and resurgery wirh r value of 0.156, 0.041, and 0.156 respectively. There is significant correlation between the degree of GB adhesion and conversion surgery and resurgery with p value of 0.032, and 0.032 respectively. There is no significant correlation between degree of GB adhesion and CBD injury with p value of 0.453.

Conclusion

The degree of GB adhesion has low degree of correlation with conversion, CBD injury and resurgery. This study also showed that patients with high degree of gallbladder adhesion are still eligible for laparoscopic procedure performed by an experienced surgeon.

Review of imaging in post-laparoscopy cholecystectomy complications

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

Learning curve for laparoscopic cholecystectomy has not been defined: A systematic review

Background

Laparoscopic cholecystectomy is one of the most performed surgeries worldwide but its learning curve is still unclear.

Methods

A systematic review was conducted according to the 2009 Preferred Reporting Items for Systematic Reviews and Meta‐analyses guidelines. Two independent reviewers searched the literature in a systematic manner through online databases, including Medline, Scopus, Embase, and Google Scholar. Human studies investigating the learning curve of laparoscopic cholecystectomy were included. The Newcastle–Ottawa scale for cohort studies and the GRADE scale were used for the quality assessment of the selected articles.

Results

Nine cohort studies published between 1991 and 2020 were included. All studies showed a great heterogeneity among the considered variables. Seven articles (77.7%) assessed intraoperative variables only, without considering patient's characteristics, operator's experience, and grade of gallbladder inflammation. Only five articles (55%) provided a precise cut‐off value to see proficiency in the learning curve, ranging from 13 to 200 laparoscopic cholecystectomies.

Conclusions

The lack of clear guidelines when evaluating the learning curve in surgery, probably contributed to the divergent data and heterogeneous results among the studies. The development of guidelines for the investigation and reporting of a surgical learning curve would be helpful to obtain more objective and reliable data especially for common operation such as laparoscopic cholecystectomy.

The segment IV approach: a useful method for achieving the critical view of safety during laparoscopic cholecystectomy in patients with anomalous bile duct

BACKGROUND

The critical view of safety (CVS) method can be achieved by avoiding vasculo-biliary injury resulting from misidentification during laparoscopic cholecystectomy (LC). Although achieving the CVS has become popular worldwide, there is no established standardized technique to achieve the CVS in patients with an anomalous bile duct (ABD). We recently reported our original approach for securing the CVS using a new landmark, the diagonal line of the segment IV of the liver (D-line). The D-line is an imaginary line that lies on the right border of the hilar plate. The cystic structure can be securely isolated along the D-line without any misidentification, regardless of the existence of an ABD. We named this approach the segment IV approach in LC.

METHODS

In this study, we adopted the segment IV approach in patients with an ABD.

RESULTS

From October 2015 to June 2020, 209 patients underwent LC using the segment IV approach. Among them, three (1.4%) were preoperatively diagnosed with an ABD. The branching point of the cystic duct was the posterior sectional duct, anterior sectional duct, or left hepatic duct in each patient. The CVS was achieved in all cases without any complications.

CONCLUSION

It is a promising technique, especially even for patients with an ABD during LC.

Recommendation for Photographic Documentation of Safe Laparoscopic Cholecystectomy

Background

Bile duct injury and vasculobiliary injury are possible complications during laparoscopic cholecystectomy which can lead to increased morbidity, mortality, costs of hospitalization and litigation. Proper documentation of the critical view of safety and safe plane of dissection may play a crucial role for archivization, teaching and medicolegal purposes.

Methods

The study group consisted of 100 patients with symptomatic cholecystolithiasis qualified for laparoscopic cholecystectomy. The critical view of safety was documented on two photographs and safe plain of dissection obtained with laparoscopic ultrasound was documented on one photograph as well as the whole procedure was recorded. The photographs were printed in the operating theatre and videos were stored on an external hard drive.

Results

The mean time to obtain and analyse photographs was significantly shorter than video, and the size of the stored data was significantly smaller for photographs than videos. The cost of one documentation procedure was significantly lower for video than photographs. Critical view of safety was obtained in 91 patients, and laparoscopic ultrasound was successful in 99 patients. The conversion rate was 2%, and fundus-first cholecystectomies were performed in 6% of patients. We did not observe any biliary and vascular complications.

Conclusions

Photographic documentation of the critical view of safety and safe plane of dissection should be an inherent part of laparoscopic cholecystectomy. Our proposal of documentation prepared in the operating theatre and stored in the patient’s documentation is an example of an easy, fast and cheap method of data archivization.

Factors influencing the occurrence of biliary stricture above the confluence in major bile ducts injuries: Analysis of a case series

Background

bile duct injury is a complication that occurs mainly after cholecystectomy. Outcomes of biliary repair surgery are worse when the stricture level is above the biliary confluence.

Method

A single centred retrospective study was carried out on patients operated in our department for biliary stricture after a major bile duct injury over the period from January 2010 to May 2018. Only patients operated for biliary stricture were included. This study aimed to determine the independent factors influencing the occurrence of a stricture above de biliary confluence. Univariate and multivariate binary regression was used for data analysis.

Results

Fifty-three patients were included, they were 43 women and 10 men, sex-ratio was 0.23. Thirty-one patients had Grade E3-E4-E5 stricture (58,5%), and patients who had a failure of a previous repair surgery accounted for 36% (n = 19) of our patients.After univariate and multivariate analysis, only laparoscopic cholecystectomy (OR = 7.58, CI = [1.47-38, 91], P = 0.015) and failure of anterior biliary repair surgery (OR = 7, 12, CI = [1.29-39.42], P = 0.025) were independent factors associated with more frequent occurrence of biliary strictures above the confluence.

Conclusion

Failure of biliary repair surgery makes the pre-existing biliary stricture progress and compromises subsequent surgery's outcomes. It is important to refer all cases of bile duct injury to specialized centers to increase the chances of success of the first biliary repair surgery.

Bile Duct Injury—Classification and Prevention

Iatrogenic bile duct injuries (BDI) are commonly encountered after laparoscopic cholecystectomy. Timely recognition of these injuries is important as the outcome depends on the optimal management and there is significant impact on the patient’s quality of life. Therapeutic management is guided by the type and extent of the bile duct injury and availability of expertise, and includes involvement of endoscopic, surgical, and radiological approaches.

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.

The prevalence of the Rouviere's sulcus: A meta-analysis with implications for laparoscopic cholecystectomy

Rouvière's sulcus (RS) is increasingly being recognized as an important extra-biliary landmark during laparoscopic cholecystectomy (LC). The aim of this study was to conduct a systematic analysis of the prevalence and morphological types of RS. A systematic search was conducted through the major databases PubMed, ScienceDirect, Google Scholar, China National Knowledge Infrastructure (CNKI), SciELO, and the Cochrane Library to identify studies eligible for inclusion. The data were extracted and pooled into a random-effects meta-analysis using STATA software. The primary and secondary outcomes of the study were the pooled prevalence of RS and its morphological types, respectively. A total of 23 studies (n = 4,495 patients) were included. The overall pooled prevalence of RS was 83% (95% confidence interval [CI] [78, 87]). There were no significant differences in prevalence between cadaveric studies (82%, 95% CI [76, 87]) and laparoscopic studies (83%, 95% CI [77, 88]). The open RS constituted 66% (95% CI [61, 71]) of all cases, while the closed type was present in 34% (95% CI [29, 39]). RS is a relatively constant anatomical structure that can be reliably identified in most patients undergoing cholecystectomy. It can therefore be used as a fixed extra-biliary landmark for the appropriate site at which to start dissecting during LC to help prevent iatrogenic bile duct injury.

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.

Development of an artificial intelligence system using deep learning to indicate anatomical landmarks during laparoscopic cholecystectomy

BACKGROUND

The occurrence of bile duct injury (BDI) during laparoscopic cholecystectomy (LC) is an important medical issue. Expert surgeons prevent intraoperative BDI by identifying four landmarks. The present study aimed to develop a system that outlines these landmarks on endoscopic images in real time.

METHODS

An intraoperative landmark indication system was constructed using YOLOv3, which is an algorithm for object detection based on deep learning. The training datasets comprised approximately 2000 endoscopic images of the region of Calot's triangle in the gallbladder neck obtained from 76 videos of LC. The YOLOv3 learning model with the training datasets was applied to 23 videos of LC that were not used in training, to evaluate the estimation accuracy of the system to identify four landmarks: the cystic duct, common bile duct, lower edge of the left medial liver segment, and Rouviere's sulcus. Additionally, we constructed a prototype and used it in a verification experiment in an operation for a patient with cholelithiasis.

RESULTS

The YOLOv3 learning model was quantitatively and subjectively evaluated in this study. The average precision values for each landmark were as follows: common bile duct: 0.320, cystic duct: 0.074, lower edge of the left medial liver segment: 0.314, and Rouviere's sulcus: 0.101. The two expert surgeons involved in the annotation confirmed consensus regarding valid indications for each landmark in 22 of the 23 LC videos. In the verification experiment, the use of the intraoperative landmark indication system made the surgical team more aware of the landmarks.

CONCLUSIONS

Intraoperative landmark indication successfully identified four landmarks during LC, which may help to reduce the incidence of BDI, and thus, increase the safety of LC. The novel system proposed in the present study may prevent BDI during LC in clinical practice.

Segment IV approach for difficult laparoscopic cholecystectomy

Although achieving the critical view of safety (CVS) is useful for avoiding vasculobiliary injury during laparoscopic cholecystectomy (LC), the CVS cannot always be achieved in cases of severe cholecystitis because of technical difficulties. Herein, we focused on segment IV of the liver and its diagonal line (D-line) as a feasible landmark for carrying out difficult LC. The D-line connects the right dorsal and left ventral corners of segment IV and is used as the vectoral landmark, which is where the gallbladder is first dissected to achieve CVS without misidentification. Conversion to subtotal cholecystectomy along the D-line is also feasible when gallbladder wall scarring is severe. We named this procedure the segment IV approach for LC. Sixty-two consecutive difficult LC (including 27 scheduled LC after percutaneous transhepatic gallbladder drainage [PTGBD] and 35 conservatively treated cases of Tokyo Guidelines [TG] grade II cholecystitis) were managed by the segment IV approach. Successful gallbladder extraction along the D-line was achieved in 44 (71%) cases; all of these cases also achieved CVS following total cholecystectomy. The other 18 (29%) cases were converted to subtotal cholecystectomy because gallbladder extraction along the D-line failed as a result of severe cholecystitis with inflammatory adhesion with surrounding structures. Median operative time and intraoperative blood loss were 135 (range, 54-290) min and 10 (range, 0-100) mL, respectively. No intra- or postoperative complications were observed. The segment IV approach is feasible for achieving CVS and for considering subtotal cholecystectomy in difficult LC cases where scarring of the gallbladder wall is present.

[The Critical View of Safety to Avoid Biliary Complications in Laparoscopic Cholecystectomy]

Laparoscopic cholecystectomy is one of the most frequently performed procedures worldwide. Therefore, iatrogenic injury to the choledochal duct, although rare, remains a surgical risk that should not be underestimated. Over the years, various methods have been described to avoid this serious complication, with its high morbidity and even mortality. One of the safest methods to avoid bile duct lesions is to establish the so called "critical view of safety" before cutting any structures. This method shall be demonstrated in this instructional video.

Complete laparoscopic cholecystectomy for a duplicated gallbladder: A case report

INTRODUCTION

Duplication of the gallbladder (GB) is a rare congenital abnormality occurring in 1 in 4000 to 5000 births. Three types have been reported: type I (split primordial GB), type II (2 separate GBs with their own cystic ducts), and type III (triple GBs drained by 1 to 3 separate cystic ducts). Patients with a duplicated GB are usually asymptomatic and are sometimes not diagnosed on preoperative imaging, which might increase the difficulty and risk of cholecystectomy. The key to successful treatment is total removal of the duplicated GB to avoid the recurrence of disease. Intraoperative cholangiography is recommended for identifying and resecting duplicated GBs. The final diagnosis depends on the histopathology.

PATIENT CONCERNS

A 62-year-old woman had recurrent upper abdominal pain and nausea for 1 year, with no fever, jaundice, or other symptoms. An ultrasound of the abdomen indicated polyps in the GB. Computed tomography (CT) revealed moderate dense structures attached to the wall of the GB and an unusual 47 × 21 mm elliptical structure with an extra tubule located above the main GB.

DIAGNOSIS

A diagnosis of duplicated GB was made based on the histopathology.

INTERVENTIONS

The patient underwent a laparoscopic cholecystectomy with total removal of the duplicated GB.

OUTCOMES

The patient's postoperative course was uneventful and she was discharged from the hospital on the second postoperative day. She had no upper abdominal pain at the 6-month follow-up.

CONCLUSION

Duplicated gallbladder is a rare congenital biliary anatomy, which is usually asymptomatic and sometimes cannot be diagnosed on preoperative imaging. With gallbladder disease, the duplicated GBs should be removed totally; a laparoscopic approach should be attempted first and cholangiography is recommended to aid in identifying and resecting the duplicated GBs. The final diagnosis depends on the histopathology. There is still insufficient evidence on the need to remove duplicated GBs found incidentally.

Post cholecystectomy bile duct injury: early, intermediate or late repair with hepaticojejunostomy - an E-AHPBA multi-center study

BACKGROUND

Treatment of bile duct injuries (BDI) during cholecystectomy depends on the severity of injury and the timing of diagnosis. Standard of care for severe BDIs is hepaticojejunostomy. The aim of this retrospective multi-center study was to assess the optimal timing for repair of BDI with hepaticojejunostomy.

METHODS

Members of the European-African HepatoPancreatoBiliary Association were invited to report all consecutive patients with hepaticojejunostomy after BDI from January 2000 to June 2016. Patients were stratified according to the timing of biliary reconstruction with hepaticojejunostomy: early (day 0-7), intermediate (1-6 weeks) and late (6 weeks-6 months). Primary endpoint was re-intervention >90 days after the hepaticojejunostomy and secondary endpoints were severe 90-day complications and liver-related mortality.

RESULTS

In total 913 patients from 48 centers were included in the analysis. In 401 patients (44%) the bile duct injury was diagnosed intraoperatively, and 126 patients (14%) suffered from concomitant vascular injury. In multivariable analysis the timing of hepaticojejunostomy had no impact on postoperative complications, the need for re-intervention after 90 days nor liver-related mortality. The rate of re-intervention more than 90 days after the hepaticojejunostomy was significantly increased in male patients but decreased in older patients. Severe co-morbidity increased the risk for liver-related mortality (HR 3.439; CI 1.37-8.65; p = 0.009).

CONCLUSION

After BDI occurring during cholecystectomy, the timing of biliary reconstruction with hepaticojejunostomy did not have any impact on severe postoperative complications, the need for re-intervention or liver-related mortality. Individualised treatment after iatrogenic bile duct injury is still advisable.

Clinical investigation of the cystic duct variation based on the anatomy of the hepatic vasculature

PURPOSE

Anatomical variation of the cystic duct (CD) is rare but can result in misunderstanding of the CD anatomy during laparoscopic cholecystectomy, potentially leading to bile duct injury. Therefore, the precise preoperative identification of CD variation is important. However, preoperative imaging analyses of the biliary system are not always possible or sufficient. We therefore investigated CD variations based on the anatomy of the hepatic vasculature.

METHODS

This study enrolled 480 patients who underwent imaging before hepatobiliary pancreatic surgery. We assessed the variation of the CD and hepatic vasculature and evaluated the correlations among these variations.

RESULTS

A variant CD anatomy was identified in 12 cases (2.5%) as CD draining into the right hepatic bile duct (BD) in 4 cases and into the right posterior BD in 8 cases. CD variation was significantly more common in cases with portal vein (PV) and BD variation than in those without the variation. We developed a scoring system based on the presence of PV and BD variations that showed good discriminatory power for identification of CD variants.

CONCLUSION

Cases with a variant CD anatomy were more likely to exhibit variant PV and BD anatomies than cases with a normal CD anatomy. These findings will be useful for the preoperative identification of CD variants.

A three-step conceptual roadmap for avoiding bile duct injury in laparoscopic cholecystectomy: an invited perspective review

Bile duct injuries are the most common serious complication of cholecystectomy. Avoidance of bile duct injury is a key aim of biliary surgery. The purpose of this paper is to describe laparoscopic cholecystectomy from the viewpoint of three conceptual goals. Three conceptual goals of cholecystectomy are: (1) getting secure anatomical identification of key structures; (2) making the right decision not to perform a total cholecystectomy when conditions are too dangerous to get secure identification - the "inflection point"; and (3) finishing the operation safely when secure anatomical identification of cystic structures is not possible. The Critical View of Safety (CVS) has been shown to be a good way of getting secure anatomical identification. Conceptually, CVS is a method of target identification, the targets being the two cystic structures. Sometimes, anatomic identification is not possible because the risk of biliary injury is judged to be too great. Then a decision is made to abandon the attempt to do a complete cholecystectomy - and instead to "bail-out". This "inflection point" is defined as the moment at which the decision is made to halt the attempt to perform a total cholecystectomy laparoscopically and to finish the operation by a different method. Currently the best bail-out procedure seems to be subtotal fenestrating cholecystectomy. Application of conceptual goals of cholecystectomy can help the surgeon to avoid biliary injury.

Excision of a part of the bile duct as an iatrogenic injury typical for laparoscopic cholecystectomy - characteristics, treatment and long-term results, based on own material

Introduction

Cholecystectomy is associated with the risk of bile duct injury (BDI). The nature of the injury in laparoscopic cholecystectomy (LC) cases seems to be more serious.

Aim

We present an analysis of long-term results of the treatment of patients who underwent operations at our department due to iatrogenic excision of a part of the bile duct (EPBD).

Material and methods

Out of all 120 patients treated for BDI in our department we selected a group of 40 with EPBD. In all cases the corrective operation was hepaticojejunostomy. The median follow-up time was 157 (56–249) months. We evaluated risk factors for EPBD during LC compared to open cholecystectomy (OC).

Results

Among bile duct injuries referred to our centre, EPBD occurred more frequently during LC (46.7%) compared to OC (11%), p < 0.001. Injuries located in the hepatic hilum occurred more often in the case of LC (68.6%) than OC (20%), p = 0.056. We did not find a difference in the frequency of EPBD between LC and OC groups depending on the presence of acute or chronic cholecystitis. The narrow common hepatic duct was reported more frequently in the LC (68.6%) vs. OC (20%) group, p = 0.056. Satisfactory long-term reconstructive treatment results were observed in 36 (90%) of 40 patients.

Conclusions

Excision of a part of the bile duct occurs more often during LC than OC. It is often located in the hepatic hilum. Presence of a narrow common hepatic duct is a risk factor for EPBD during LC. Large diameter hepaticojejunostomy is a reconstructive procedure that promises good long-term results.

Practical Management of Indeterminate Biliary Strictures

Indeterminate biliary strictures pose a diagnostic and therapeutic challenge. Although underlying malignancy is a primary concern, biliary strictures may result from benign processes. An accurate diagnosis is paramount to define the treatment strategy and minimize morbidity. The limitations of traditional endoscopic retrograde cholangiopancreatography-based tissue acquisition with cytology brushings are well-documented. Endoscopic retrograde cholangiopancreatography is generally unable to determine a stricture's etiology. Complementary advanced endoscopic imaging and multimodal tissue acquisition have evolved. Careful consideration of the clinical presentation, location of the stricture, and interpretation of imaging constitute the most optimal approach for diagnosis and management.

An Update on Technical Aspects of Cholecystectomy

Laparoscopic cholecystectomy has revolutionized the field of surgery, and is currently the gold standard in the treatment for symptomatic cholelithiasis. The goal of every laparoscopic cholecystectomy should be attainment of the critical view of safety before cutting the cystic duct and artery to reduce the risk of bile duct injury. Open cholecystectomy is most commonly performed when laparoscopic cholecystectomy is converted to open or when laparoscopic cholecystectomy is contraindicated. Robotic cholecystectomy is a safe alternative to conventional laparoscopic cholecystectomy, and follows the same basic operative principles.

Percutaneous endobiliary radiofrequency ablation for refractory benign hepaticojejunostomy and biliary strictures

PURPOSE

The objective of this study was to determine the safety and efficacy of percutaneous endobiliary radiofrequency ablation (ERFA) and balloon dilation for the treatment of hepaticojejunostomy (HJ) strictures resistant to surgery and/or other interventions.

MATERIALS AND METHODS

Eighteen patients who underwent percutaneous ERFA for HJ stricture were included. There were 10 men and 8 women with a mean age of 48.3±10.8 (SD) years (range: 33-69 years). The 18 patients had a total of 29 benign HJ strictures secondary to cholecystectomy (14 patients; 78.0%), Whipple procedure (3 patients; 16.6%) or blunt abdominal trauma (1 patient; 5.4%). The different end-points were technical success, clinical success, recurrence, procedure-related mortality, and morbidity.

RESULTS

Technical and clinical success rates were 100% and 83.3%, respectively. No mortality and major procedure-related complications were observed. One patient experienced minor complication (self-limited pleural effusion). Two patients did not show favorable response to ERFA whereas 10 patients had no stricture recurrence during a mean follow-up period of 7.3 months±1.0 (SD) (range: 4-10 months).

CONCLUSION

ERFA is a safe and effective treatment for benign HJ and biliary strictures. However, more studies involving more patients with a long-term follow-up period should be made to fully determine the long-term results of ERFA.

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.

Delphi consensus on bile duct injuries during laparoscopic cholecystectomy: an evolutionary cul-de-sac or the birth pangs of a new technical framework?

Bile duct injury (BDI) during laparoscopic cholecystectomy remains a serious iatrogenic surgical complication. BDI most often occurs as a result of misidentification of the anatomy; however, clinical evidence on its precise mechanism and surgeons' perceptions is scarce. Surgeons from Japan, Korea, Taiwan, and the USA, etc. (n = 614) participated in a questionnaire regarding their BDI experience and near-misses; and perceptions on landmarks, intraoperative findings, and surgical techniques. Respondents voted for a Delphi process and graded each item on a five-point scale. The consensus was built when ≥80% of overall responses were 4 or 5. Response rates for the first- and second-round Delphi were 60.6% and 74.9%, respectively. Misidentification of local anatomy accounted for 76.2% of BDI. Final consensus was reached on: (1) Effective retraction of the gallbladder, (2) Always obtaining critical view of safety, and (3) Avoiding excessive use of electrocautery/clipping as vital procedures; and (4) Calot's triangle area and (5) Critical view of safety as important landmarks. For (6) Impacted gallstone and (7) Severe fibrosis/scarring in Calot's triangle, bail-out procedures may be indicated. A consensus was reached among expert surgeons on relevant landmarks and intraoperative findings and appropriate surgical techniques to avoid BDI.

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.

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.

Fluorescent Imaging With Indocyanine Green During Laparoscopic Cholecystectomy in Patients at Increased Risk of Bile Duct Injury

BACKGROUND

Although rare, injury to the common bile duct (CBD) during laparoscopic cholecystectomy (LC) can be reduced by better intraoperative visualization of the cystic duct (CD) and CBD. The aim of this study was to establish the efficacy of early visualization of the CD and the added value of CBD identification, using near-infrared (NIR) light and the fluorescent agent indocyanine green (ICG), in patients at increased risk of bile duct injury.

MATERIALS AND METHODS

Patients diagnosed with complicated cholecystitis and scheduled for LC were included. The CBD and CD were visualized with NIR light before and during dissection of the liver hilus and at critical view of safety (CVS).

RESULTS

Of the 20 patients originally included, 2 were later excluded due to conversion. In 6 of 18 patients, the CD was visualized early during dissection and prior to imaging with conventional white light. The CBD was additionally visualized with ICG-NIR in 7 of 18 patients. In 1 patient, conversion was prevented due to detection of the CD and CBD with ICG-NIR.

CONCLUSIONS

Early visualization of the CD or additional identification of the CBD using ICG-NIR in patients with complicated cholecystolithiasis can be helpful in preventing CBD injury. Future studies should attempt to establish the optimal dosage and time frame for ICG administration and bile duct visualization with respect to different gallbladder pathologies.