Prospective analysis of 101 consecutive cases of laparoscopic cholecystectomy for acute cholecystitis operated with harmonic scalpel

Clip-stone and T clip-sinus: A clinical analysis of six cases on migration of clips and literature review from 1997 to 2017

Introduction:

With the development of laparoscopic skills, the laparoscopic common bile duct exploration (LCBDE) and laparoscopic cholecystectomy (LC) has become the standard surgical procedure for choledocholithiasis. We usually use Hem-o-lok clips to control cystic duct and vessels, which is safe on most occasions and has few perioperative complications such as major bleeding, wound infection, bile leakage, and biliary and bowel injury. However, a rare complication of post-cholecystectomy clip migration (PCCM) increases year by year due to the advancement and development of LC, CBD exploration as well as the wide use of surgical ligation clips.

Materials and Methods:

Six patients whose clips are found dropping into CBD or forming T-tube sinus after laparoscopic surgery in our department.

Results:

Six patients whose clips are found dropping into CBD (clip-stone) (3/6) or forming T-tube sinus (T clip-sinus) (3/6) after LCBDE or LC.

Conclusions:

PCCM is a rare but severe complication of LCBDE. A pre-operative understanding of bile duct anatomy, the use of the minimum number of clips and the harmonic scalpel during the surgeries is necessary. Considering clip-stone or clip-sinus in the differential diagnosis of patients with biliary colics or cholangitis after LCBDE even years after surgery, the detailed medical history and pre-operative examination are inevitable, especially for these patients who had undergone LCBDE.

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

BACKGROUND

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

SUBJECTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

The HAC trial (harmonic for acute cholecystitis): a randomized, double-blind, controlled trial comparing the use of harmonic scalpel to monopolar diathermy for laparoscopic cholecystectomy in cases of acute cholecystitis

BACKGROUND

The HARMONIC SCALPEL (H) is an advanced ultrasonic cutting and coagulating surgical device with important clinical advantages, such as: reduced ligature demand; greater precision due to minimal lateral thermal tissue damage; minimal smoke production; absence of electric corrents running through the patient. However, there are no prospective RCTs demonstrating the advantages of H compared to the conventional monopolar diathermy (MD) during laparoscopic cholecystectomy (LC) in cases of acute cholecystitis (AC).

METHODS

This study was a prospective, single-center, randomized trial (Trial Registration Number: NCT00746850) designed to investigate whether the use of H can reduce the incidence of intra-operative conversion during LC in cases of AC, compared to the use of MD. Patients were divided into two groups: both groups underwent early LC, within 72 hours of diagnosis, using H and MD respectively (H = experimental/study group, MD = control group). The study was designed and conducted in accordance with the regulations of Good Clinical Practice.

RESULTS

42 patients were randomly assigned the use of H (21 patients) or MD (21 patients) during LC. The two groups were comparable in terms of basic patient characteristics. Mean operating time in the H group was 101.3 minutes compared to 106.4 minutes in the control group (p=ns); overall blood loss was significantly lower in the H group. Conversion rate was 4.7% for the H group, which was significantly lower than the 33% conversion rate for the control group (p<0.05). Post-operative morbidity rates differed slightly: 19% and 23% in the H and control groups, respectively (p=ns). Average post-operative hospitalization lasted 5.2 days in the H group compared to 5.4 days in the control group (p=ns).

CONCLUSIONS

The use of H appears to correlate with reduced rates of laparoscopic-open conversion. Given this evidence, H may be more suitable than MD for technically demanding cases of AC.

A meta-analysis of randomized clinical trials that compared ultrasonic energy and monopolar electrosurgical energy in laparoscopic cholecystectomy

BACKGROUND

Currently, monopolar electrical energy is still widely used as the main source of energy for laparoscopic cholecystectomy (LC). However, some studies have suggested that the use of ultrasonic energy is more advantageous. This meta-analysis pooled the currently published randomized controlled trials comparing the safety and efficacy of ultrasonic energy and monopolar electrical energy in LC.

MATERIALS AND METHODS

MEDLINE, EMBASE, Science Citation Index Expanded, and the Cochrane Central Register of Controlled Trials for relevant articles published between January 1985 to February 2012 by using the search terms "laparoscopic cholecystectomy," "electrocoagulation," "electrosurgery," "ultrasonics," "ultrasonic therapy," and "dissection." Intraoperative and postoperative measures and complications were evaluated.

RESULTS

Eight high-quality randomized controlled trials with 1056 patients were included. Differences in mean operation time, mean blood loss, mean hospital stay, gallbladder perforation, and postoperative abdominal pain score at 24 hours were statistically significant between the two groups, in favor of the use of ultrasonic energy. However, there were no differences in operation conversion, bile leakage, intra-abdominal collections, and postoperative nausea at 24 hours.

CONCLUSIONS

Ultrasonic energy is as safe and effective as electrosurgical energy and potentially might be safer in LC. However, the financial implications of this technical modality need to be established in cost-effectiveness analysis.

Laparoscopic approach to acute abdomen from the Consensus Development Conference of the Società Italiana di Chirurgia Endoscopica e nuove tecnologie (SICE), Associazione Chirurghi Ospedalieri Italiani (ACOI), Società Italiana di Chirurgia (SIC), Società Italiana di Chirurgia d'Urgenza e del Trauma (SICUT), Società Italiana di Chirurgia nell'Ospedalità Privata (SICOP), and the European Association for Endoscopic Surgery (EAES)

BACKGROUND

In January 2010, the SICE (Italian Society of Endoscopic Surgery), under the auspices of the EAES, decided to revisit the clinical recommendations for the role of laparoscopy in abdominal emergencies in adults, with the primary intent being to update the 2006 EAES indications and supplement the existing guidelines on specific diseases.

METHODS

Other Italian surgical societies were invited into the Consensus to form a panel of 12 expert surgeons. In order to get a multidisciplinary panel, other stakeholders involved in abdominal emergencies were invited along with a patient's association. In November 2010, the panel met in Rome to discuss each chapter according to the Delphi method, producing key statements with a grade of recommendations followed by commentary to explain the rationale and the level of evidence behind the statements. Thereafter, the statements were presented to the Annual Congress of the EAES in June 2011.

RESULTS

A thorough literature review was necessary to assess whether the recommendations issued in 2006 are still current. In many cases new studies allowed us to better clarify some issues (such as for diverticulitis, small bowel obstruction, pancreatitis, hernias, trauma), to confirm the key role of laparoscopy (such as for cholecystitis, gynecological disorders, nonspecific abdominal pain, appendicitis), but occasionally previous strong recommendations have to be challenged after review of recent research (such as for perforated peptic ulcer).

CONCLUSIONS

Every surgeon has to develop his or her own approach, taking into account the clinical situation, her/his proficiency (and the experience of the team) with the various techniques, and the specific organizational setting in which she/he is working. This guideline has been developed bearing in mind that every surgeon could use the data reported to support her/his judgment.

Biliary complications secondary to post-cholecystectomy clip migration: a review of 69 cases

INTRODUCTION

Post-cholecystectomy clip migration (PCCM) is rare and can lead to complications which include clip-related biliary stones. Most have been reported as case reports. This study reviews cases of clip migration reported in the literatures.

METHOD

Searches and reviews of the literatures from "PubMed," "EMBASE," and "Google Scholar" search engines using the keywords "clip migration" and "bile duct stones" were carried out. Eighty cases from 69 publications were identified but details for only 69 cases were available for the study.

RESULTS

The median age at presentations of PCCM was 60 years old (range, 31 to 88 years; female, 61.8%) and the median time from the initial cholecystectomy to clinical presentations was 26 months (range, 11 days to 20 years). Of primary surgeries, 23.2% was for complicated gallstones disease. The median number of clips placed during surgery was six (range, two to more than ten clips). Common diagnoses at presentations of PCCM were obstructive jaundice (37.7%), cholangitis (27.5%), biliary colic (18.8%), and acute pancreatitis (8.7%). The median number of migrated clip was one (range, one to six). Biliary dilatation and strictures were encountered in 74.1% and 28.6%, respectively. Of the 69 cases of PCCM-associated complications, 53 (77%) were successfully treated with endoscopic retrograde cholangiopancreatography (ERCP), 14 (20.2%) with surgery, and one (1.4%) with successful percutaneous transhepatic cholangiography treatment. One patient had spontaneous clearance of PCCM. There was no reported mortality related to PCCM.

CONCLUSION

PCCM can occur at any time but typically occur at a median of 2 years after cholecystectomy. Clinical presentations are similar to those with primary or secondary choledocholithiasis. Most can be managed successfully with ERCP.