The prevention of major bile duct injures in laparoscopic cholecystectomy: the experience with 13,000 patients in a single center. Surg Laparosc Endosc Percutan Tech. 2010;20:378-383. [PMID: 21150413 DOI: 10.1097/sle.0b013e3182008efb]

Use of artificial intelligence for decision-support to avoid high-risk behaviors during laparoscopic cholecystectomy

INTRODUCTION

Bile duct injuries (BDIs) are a significant source of morbidity among patients undergoing laparoscopic cholecystectomy (LC). GoNoGoNet is an artificial intelligence (AI) algorithm that has been developed and validated to identify safe ("Go") and dangerous ("No-Go") zones of dissection during LC, with the potential to prevent BDIs through real-time intraoperative decision-support. This study evaluates GoNoGoNet's ability to predict Go/No-Go zones during LCs with BDIs.

METHODS AND PROCEDURES

Eleven LC videos with BDI (BDI group) were annotated by GoNoGoNet. All tool-tissue interactions, including the one that caused the BDI, were characterized in relation to the algorithm's predicted location of Go/No-Go zones. These were compared to another 11 LC videos with cholecystitis (control group) deemed to represent "safe cholecystectomy" by experts. The probability threshold of GoNoGoNet annotations were then modulated to determine its relationship to Go/No-Go predictions. Data is shown as % difference [99% confidence interval].

RESULTS

Compared to control, the BDI group showed significantly greater proportion of sharp dissection (+ 23.5% [20.0-27.0]), blunt dissection (+ 32.1% [27.2-37.0]), and total interactions (+ 33.6% [31.0-36.2]) outside of the Go zone. Among injury-causing interactions, 4 (36%) were in the No-Go zone, 2 (18%) were in the Go zone, and 5 (45%) were outside both zones, after maximizing the probability threshold of the Go algorithm.

CONCLUSION

AI has potential to detect unsafe dissection and prevent BDIs through real-time intraoperative decision-support. More work is needed to determine how to optimize integration of this technology into the operating room workflow and adoption by end-users.

Rouviere's Sulcus Analysis: A Critical Safety Analysis and a Guide to Safe Laparoscopic Cholecystectomy

INTRODUCTION

Laparoscopic cholecystectomy (LC) is the most frequent surgical operation in general surgery. The focus of recent research has been on improving the procedure's safety. Over 80% of healthy livers have Rouviere's sulcus (RVS), which is a natural notch in the right lobe that is present in proximity to the confluence of the bile duct. It is frequently considered an important component of safety during LC. RVS demarcates the area of the common bile duct (CBD) from the liver bed for the gall bladder. This research intends to evaluate the frequency, its relation to CBD, and the critical view of safety (CVS) during LC.

MATERIALS AND METHODS

An observational study was performed in a cohort of 50 patients listed for LC between September 2021 and September 2022. The presence of RVS was confirmed after liver retraction and dissection commenced. After the creation of CVS, its relationship with CBD was documented. Additionally, the position of the cystic lymph node was also documented during the dissection.

RESULTS

The findings of this study revealed that out of 50 patients, only 40 (80%) had RVS. However, cystic lymph nodes were present more frequently in 48 (96%) patients. CVS was achieved in all the patients, and it revealed the presence of RVS above the cystic duct-CBD junction in 37 (74%), at the level of the junction in 11 (22%), and in two (4%) where the junction could not be demarcated.

CONCLUSION

RVS is a reliable marker to dissect laterally to CBD while doing LC, which does not require any dissection and can be appreciated early during the procedure. However, its presence along with the cystic lymph node gives a better anatomical understanding of the area of CBD, thereby assisting in conducting the procedure safely.

A new operation for gallstones: Choledochoscopic gallbladder-preserving cholecystolithotomy, a retrospective study of 3,511 cases

BACKGROUND

Due to the influence of traditional Chinese culture, many cholelithiasis patients refuse to undergo cholecystectomy. This has prompted surgeons to consider a new treatment option for gallstones, which preserves the gallbladder, termed as choledochoscopic gallbladder-preserving cholecystolithotomy. In this study, we reviewed the clinical outcomes of 23 years of single-center application of choledochoscopic gallbladder-preserving cholecystolithotomy.

METHODS

A total of 5,451 patients with chronic cholelithiasis were selected from 1992 to 2011 as per the inclusion criteria for the choledochoscopic gallbladder-preserving cholecystolithotomy study, and clinicopathological and follow-up data were collected from 4,340 patients who underwent successful choledochoscopic gallbladder-preserving cholecystolithotomy. The endpoints of the follow-up were recurrence of stones, loss to follow-up, patient death, removal of the gallbladder for other reasons, or end of follow-up in December 2015.

RESULTS

All 4,340 cases underwent choledochoscopic gallbladder-preserving cholecystolithotomy with a mean procedure time of 79.6 ± 35.4 minutes, among which 3,511 (80.9%) received at least 1 follow-up. The recurrence rate of gallstones gradually increased with increasing follow-up duration, with a recurrence rate of 0.83% within 1 year after surgery and a maximal cumulative recurrence rate of 7.94% at 23 years. The 5-year cumulative recurrence rate of gallstones in the age group ≤20 years was 16.80%, which was significantly higher than those of other age groups, and the 5-year recurrence rate in the single gallstone group was 2.87%, which was significantly lower than that in the multiple gallstone group. Age and number of gallstones were independent risk factors for gallstone recurrence after choledochoscopic gallbladder-preserving cholecystolithotomy.

CONCLUSION

The recurrence rate of gallstones after choledochoscopic gallbladder-preserving cholecystolithotomy is low, and most patients with recurrence are asymptomatic or have only mild symptoms. Age and number of gallstones were independent risk factors. Choledochoscopic gallbladder-preserving cholecystolithotomy is a safe and effective surgical option for gallstone removal in patients who do not wish to undergo cholecystectomy.

Are laparoscopic cholecystectomy and natural orifice transluminal endoscopic surgery gallbladder preserving cholecystolithotomy truly comparable? A propensity matched study

BACKGROUND

Cholecystectomy is the preferred treatment option for symptomatic gallstones. However, another option is gallbladder-preserving cholecystolithotomy which preserves the normal physiological functions of the gallbladder in patients desiring to avoid surgical resection.

AIM

To compare the feasibility, safety and effectiveness of pure natural orifice transluminal endoscopic surgery (NOTES) gallbladder-preserving cholecystolithotomy vs laparoscopic cholecystectomy (LC) for symptomatic gallstones.

METHODS

We adopted propensity score matching (1:1) to compare trans-rectal NOTES cholecystolithotomy and LC patients with symptomatic gallstones. We reviewed 2511 patients with symptomatic gallstones from December 2017 to December 2020; 517 patients met the matching criteria (NOTES, 110; LC, 407), yielding 86 pairs.

RESULTS

The technical success rate for the NOTES group was 98.9% vs 100% for the LC group. The median procedure time was 119 min [interquartile ranges (IQRs), 95-175] with NOTES vs 60 min (IQRs, 48-90) with LC (P < 0.001). The frequency of post-operative pain was similar between NOTES and LC: 4.7% (4/85) vs 5.8% (5/95) (P = 0.740). The median duration of post-procedure fasting with NOTES was 1 d (IQRs, 1-2) vs 2 d with LC (IQRs, 1-3) (P < 0.001). The median post-operative hospital stay for NOTES was 4 d (IQRs, 3-6) vs 4 d for LC (IQRs, 3-5), (P = 0.092). During follow-up, diarrhea was significantly less with NOTES (5.8%) compared to LC (18.6%) (P = 0.011). Gallstones and cholecystitis recurrence within a median of 12 mo (range: 6-40 mo) following NOTES was 10.5% and 3.5%, respectively. Concerns regarding the presence of abdominal wall scars were present in 17.4% (n = 15/86) of patients following LC (mainly women).

CONCLUSION

NOTES provides a feasible new alternative scar-free treatment for patients who are unwilling or unable to undergo cholecystectomy. This minimally invasive organ-sparing procedure both removes the gallstones and preserves the physiological function of the gallbladder. Reducing gallstone recurrence is essential to achieving widespread clinical adoption of NOTES.

Laparoscopic cholecystectomy for gangrenous cholecystitis in around nineties: Two case reports

BACKGROUND

Gangrenous cholecystitis is a form of acute cholecystitis which involves gangrenous alterations in the gallbladder wall and it often follows an acute and serious course. We herein report on two cases of very elderly people diagnosed early with gangrenous cholecystitis, who safely underwent laparoscopic cholecystectomy (LC) and both demonstrated a good outcome.

CASE SUMMARY

Case 1: An 89-year-old female. She underwent abdominal contrast-enhanced computed tomography (CECT) due to abdominal pain and diarrhea. Her gallbladder wall indicated the absence of contrast enhancement, thus leading to diagnosis of gangrenous cholecystitis and she therefore underwent LC. Although her gallbladder demonstrated diffuse necrosis and it was also partly perforated, she was able to be discharged without any serious complications. Case 2: A 91-year-old female. She made an emergency visit with a chief complaint of abdominal pain. Abdominal CECT revealed swelling of the gallbladder and an ambiguous continuity of the gallbladder wall. She was diagnosed with gangrenous cholecystitis and underwent LC. Her gallbladder had swelling and diffuse necrosis. Although her preoperative blood culture was positive, she showed a good outcome following surgery.

CONCLUSION

Although a definite diagnosis of gangrenous cholecystitis is difficult to make prior to surgery, if an early diagnosis can be made and appropriate treatment can be carried out, then even very elderly individuals may be discharged without major complications.

The Role of Endoscopic Retrograde Cholangiopancreatography in the Management of Biliary Complication Post-Laparoscopic Cholecystectomy

BACKGROUND: Laparoscopic cholecystectomy considers a golden surgery for gallbladder removal nowadays, and it carries some complications like biliary injuries, which can manage successfully by endoscopic retrograde cholangiopancreatography. AIM: To estimate the role of endoscopic management of bile duct injury (BDI) following laparoscopic cholecystectomy. PATIENT AND METHODS: A prospective study conducted at Al-Sader Medical City, Najaf City, Iraq, during the period between September 2018 and December 2020, included 44 patients complicated by the biliary injury resulting in a persistent biliary leak and/or jaundice after laparoscopic cholecystectomy and evaluated by endoscopic retrograde cholangiopancreatography (ERCP). RESULTS: Findings revealed that 25% of cases had complete BDI, only one managed by plastic stent placement, the other 10 referred for open surgical constructions, 61% had partial injury associated with the biliary leak, all managed by sphincterotomy and plastic stent placement through ERCP, almost 7% had a partial clipping of bile duct all managed with sphincterotomy, balloon dilatation/stone extraction, and plastic stent placement, 5% had slipped clips of cystic duct stump, are managed with sphincterotomy and plastic stent placement. Moreover, only one patient, 2%, had distal common bile duct stone with bile leak, managed by sphincterotomy and stone extraction. CONCLUSIONS: Laparoscopic cholecystectomy, a gold standard therapeutic option for symptomatic cholecystolithiasis, is associated with an increased risk of biliary injury due to many factors. ERCP is a safe means of diagnosing the cause of bile leakage after laparoscopic cholecystectomy. It also offers definitive treatment in most cases by endoscopic sphincterotomy and plastic stent placement.

Importance of Rouviere's sulcus in laparoscopic cholecystectomy

Background:

Rouviere's sulcus is a 2–5 cm fissure on the liver between the right lobe and caudate process. The benefit of finding the Rouviere's sulcus during laparoscopic cholecystectomy is supported by the fact that the cystic duct and artery lay anterosuperior to the sulcus, and the common bile duct (CBD) lays below the level of the Rouviere's sulcus. Hence, it can serve as an extrabiliary anatomical reference point during laparoscopic cholecystectomy to identify the location of CBD.

Materials and Methods:

This prospective observational study was carried out on 99 patients during a period of 1 year. During laparoscopic cholecystectomy, Rouviere's sulcus was identified after retracting the fundus of the gallbladder toward the right shoulder. Its morphology in terms of open type, close type, or scar-like shapes was recorded, and if the CBD outline could be visualized, then its relation with the Rouviere's sulcus was noted.

Results:

Among all 99 study patients, Rouviere's sulcus could be identified in 63 cases (63.63%), whereas it could not be seen in 36 cases (36.36%) (P < 0.007). It was of open type in 68.25% (43 cases), close type in 25.39% (16 cases), and scar like in 6.35% (4 cases) (P < 0.0001). The Rouviere's sulcus was found to be above the level of CBD line in 50 patients (79.36%) and at the same level in 11 patients (17.46%), and in two patients, (5.97%) CBD line could not be visualized.

Conclusion:

Identification of Rouviere's sulcus during laparoscopic cholecystectomy can serve as an additional reference point to avoid major bile duct injury. In the era of laparoscopy, it can be better visualized after creating the pneumoperitoneum and retracting the fundus of the gallbladder.

Reconsideration of indications for choledochoscopic gallbladder-preserving surgery and preventive measures for postoperative recurrence of gallstones

Introduction

The recurrence of cholecystolithiasis after choledochoscopic gallbladder-preserving surgery is a major problem. It is unclear whether the recurrence of cholecystolithiasis is due to the limitations of the operation itself or to the selection of inappropriate candidates.

Aim

To analyze the recurrence of cholecystolithiasis after choledochoscopic gallbladder-preserving surgery and to provide guidance for the treatment of cholecystolithiasis by choledochoscopic gallbladder-preserving surgery.

Material and methods

A total of 145 patients who had undergone choledochoscopic gallbladder-preserving surgery were studied from January 2012 to January 2018. The recurrence rate, recurrence time, and risk factors were evaluated.

Results

Of these 145 patients, 14 (9.66%) experienced recurrence with a mean follow-up time of 39.72 ±24.44 months. The mean time to recurrence was 30.07 ±21.21 months. Univariate analysis showed that pregnancy history (p = 0.008), the uniformity of gallstones (p = 0.002), preoperative inflammation (p = 0.022), postoperative oral drugs (p = 0.022) and the regularity of diet (p = 0.001) were significantly related to recurrence. The uniformity of gallstones (odds ratio (OR) = 0.079; 95% confidence interval (CI): 0.010–0.590; p = 0.013) and the regularity of diet (OR = 0.074; 95% CI: 0.010–0.528; p = 0.009) were independent prognostic factors for recurrence according to multivariate analysis.

Conclusions

Nonuniform gallstones combined with an irregular diet are significant risk factors that predict cholecystolithiasis recurrence.

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.

Laparoscopic ultrasonography as an alternative to intraoperative cholangiography during laparoscopic cholecystectomy

AIM

To assess the role of laparoscopic ultrasound (LUS) as a substitute for intraoperative cholangiography (IOC) during cholecystectomy.

METHODS

We present a MEDLINE and PubMed literature search, having used the key-words “laparoscopic intraoperative ultrasound” and “laparoscopic cholecystectomy”. All relevant English language publications from 2000 to 2016 were identified, with data extracted for the role of LUS in the anatomical delineation of the biliary tract, detection of common bile duct stones (CBDS), prevention or early detection of biliary duct injury (BDI), and incidental findings during laparoscopic cholecystectomy. Data for the role of LUS vs IOC in complex situations (i.e., inflammatory disease/fibrosis) were specifically analyzed.

RESULTS

We report data from eighteen reports, 13 prospective non-randomized trials, 5 retrospective trials, and two meta-analyses assessing diagnostic accuracy, with one analysis also assessing costs, duration of the examination, and anatomical mapping. Overall, LUS was shown to provide highly sensitive mapping of the extra-pancreatic biliary anatomy in 92%-100% of patients, with more difficulty encountered in delineation of the intra-pancreatic segment of the biliary tract (73.8%-98%). Identification of vascular and biliary variations has been documented in two studies. Although inflammatory disease hampered accuracy, LUS was still advantageous vs IOC in patients with obscured anatomy. LUS can be performed before any dissection and repeated at will to guide the surgeon especially when hilar mapping is difficult due to fibrosis and inflammation. In two studies LUS prevented conversion in 91% of patients with difficult scenarios. Considering CBDS detection, LUS sensitivity and specificity were 76%-100% and 96.2%-100%, respectively. LUS allowed the diagnosis/treatment of incidental findings of adjacent organs. No valuable data for BDI prevention or detection could be retrieved, even if no BDI was documented in the reports analyzed. Literature analysis proved LUS as a safe, quick, non-irradiating, cost-effective technique, which is comparatively well known although largely under-utilized, probably due to the perception of a difficult learning curve.

CONCLUSION

We highlight the advantages and limitations of laparoscopic ultrasound during cholecystectomy, and underline its value in difficult scenarios when the anatomy is obscured.

Endoscopic-Laparoscopic Cholecystolithotomy in Treatment of Cholecystolithiasis Compared With Traditional Laparoscopic Cholecystectomy

The study aimed to compare the application values of endoscopic-laparoscopic cholecystolithotomy (ELC) and laparoscopic cholecystectomy (LC) for patients with cholecystolithiasis. It did a retrospective analysis of 107 patients with cholecystolithiasis who underwent ELC and 144 patients with cholecystolithiasis who underwent LC. There is no significant difference in operating time and expenses when comparing ELC with LC (P>0.05). ELC showed significantly less blood loss during operation compared with LC (P<0.01). Shortened exhaust time (P<0.05) and hospital stay (P<0.01) were present in patients who underwent ELC. Moreover, ELC showed decreased occurrence rate of dyspepsia and diarrhea in comparison with LC (P<0.01). The stone recurrence rate of ELC was 16.67%. ELC decreased the recurrence of stone in common bile duct in comparison with LC. The contractile function of gallbladder was close to normal (P<0.05), and the thickness of gallbladder wall significantly decreased (P<0.001). Patients who underwent ELC showed less digestive symptom, good recovery, and low stone recurrence compared with those who underwent LC.

Evidence-based clinical practice guidelines for cholelithiasis 2016

Cholelithiasis is one of the commonest diseases in gastroenterology. Remarkable improvements in therapeutic modalities for cholelithiasis and its complications are evident. The Japanese Society of Gastroenterology has revised the evidence-based clinical practice guidelines for cholelithiasis. Forty-three clinical questions, for four categories-epidemiology and pathogenesis, diagnosis, treatments, and prognosis and complications-were selected, and a literature search was performed for the clinical questions with use of the MEDLINE, Cochrane, and Igaku Chuo Zasshi databases for the period between 1983 and June 2012. The guidelines were developed with use of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. This article preferentially describes the clinical management of cholelithiasis and its complications. Following description of the diagnosis performed stepwise through imaging modalities, treatments of cholecystolithiasis, choledocholithiasis, and hepatolithiasis are introduced along with a flowchart. Since there have been remarkable improvements in endoscopic treatments and surgical techniques, the guidelines ensure flexibility in choices according to the actual clinical environment. The revised clinical practice guidelines are appropriate for use by clinicians in their daily practice.

Blunt Dissection: A Solution to Prevent Bile Duct Injury in Laparoscopic Cholecystectomy

Background:

Laparoscopic cholecystectomy (LC) has been a standard operation and replaced the open cholecystectomy (OC) rapidly because the technique resulted in less pain, smaller incision, and faster recovery. This study was to evaluate the value of blunt dissection in preventing bile duct injury (BDI) in laparoscopic cholecystectomy (LC).

Methods:

From 2003 to 2015, LC was performed on 21,497 patients, 7470 males and 14,027 females, age 50.3 years (14–84 years). The Calot's triangle was bluntly dissected and each duct in Calot's triangle was identified before transecting the cystic duct.

Results:

Two hundred and thirty-nine patients (1.1%) were converted to open procedures. The postoperative hospital stay was 2.1 (0–158) days, and cases (46%) had hospitalization days of 1 day or less, and 92.8% had hospitalization days of 3 days or less; BDI was occurred in 20 cases (0.09%) including 6 cases of common BDI, 2 cases of common hepatic duct injury, 1 case of right hepatic duct injury, 1 case of accessory right hepatic duct, 1 case of aberrant BDI 1 case of biliary stricture, 1 case of biliary duct perforation, 3 cases of hemobilia, and 4 cases of bile leakage.

Conclusion:

Exposing Calot's triangle by blunt dissection in laparoscopic cholecystectomy could prevent intraoperative BDI.

Laparoscopic antegrade cholecystectomy: a standard procedure?

Retrograde approach ("fundus first") is often used in open surgery, while in laparoscopic cholecystectomy (LC) is less frequent. LC, with antegrade access, is done by putting in traction the infundibulum and going up to the fundus before to clip the cystic. Our study analyzes a number of surgical procedures performed by experienced surgeons in laparoscopy. From 2002 to 2015, 1740 laparoscopic cholecystectomies were performed at our Institution. The operative procedure performed since 2002 consists of the incision of the visceral peritoneum from the infundibulum away from Calot's triangle along the gallbladder bed up to the fundus. Then it continues from the fundus up to the infundibulum.

RESULTS

There were no bile duct injuries. Average operative time was 40 min. 22 conversions to an open procedure (1.3%) occurred, in cases of acute cholecystitis and cirrhotic patient. Postoperative stay was mean 2 days with no delayed sequelae on follow up.

CONCLUSIONS

gallbladder antegrade dissection for laparoscopic cholecystectomy can reduce the time of surgery and is an easier technique to perform. Therefore, it can be proposed as the standard procedure and not only be used for difficult cholecystectomies.

Effect of institutional volume on laparoscopic cholecystectomy outcomes: Systematic review and meta-analysis

AIM: To determine whether institutional laparoscopy cholecystectomy (LC) volume affects rates of mortality, conversion to open surgery, bile leakage and bile duct injury (BDI).

METHODS: Eligible studies were prospective or retrospective cohort studies that provided data on outcomes from consecutive LC procedures in single institutions. Relevant outcomes were mortality, conversion to open surgery, bile leakage and BDI. We performed a Medline search and extracted data. A regression analysis using generalized estimating equations were used to determine the influence of annual institutional LC caseload on outcomes. A sensitivity analysis was performed including only those studies that were published after 1995.

RESULTS: Seventy-three cohorts (127404 LC procedures) were included. Average complication rates were 0.06% for mortality, 3.23% for conversion, 0.44% for bile leakage and 0.28% for bile duct injury. Annual institutional caseload did not influence rates of mortality (P = 0.142), bile leakage (P = 0.111) or bile duct injury (P = 0.198) although increasing caseload was associated with reduced incidence of conversion (P = 0.019). Results from the sensitivity analyses were similar.

CONCLUSION: Institutional volume is a determinant of LC complications. It is unclear whether volume is directly linked to complication rates or whether it is an index for protocolised care.

Cholecystectomy for biliary dyskinesia: how did we get there?

BACKGROUND

The focus of biliary dyskinesia (BD) shifted within the last 30 years, moving from symptoms after cholecystectomy (CCY) to symptoms with morphological normal gallbladder, but low gallbladder ejection fraction.

METHODS

We searched the pubmed database to systematically review studies focusing on the diagnosis and treatment of gallbladder dysfunction.

RESULTS

Impaired gallbladder contraction can be found in about 20% of healthy controls and an even higher number of patients with various other disorders. Surgery for BD increased after introduction of laparoscopic CCY, with BD now accounting for >20% of CCY in adults and up to 60% in pediatric patients. The majority of cases reported were operated in the USA, which differs from surgical series for cholelithiasis. Postoperative outcomes do not differ between groups with abnormal or normal gallbladder function.

CONCLUSION

Functional gallbladder testing should not be seen as an indicator of relevant biliary tract disease or prognostic marker to identify patients who may benefit from operative intervention. Instead biliary dyskinesia should be considered as a part of a spectrum of functional disorders, which are generally managed conservatively. Small proof of concept studies have demonstrated effects of medical therapy on biliary dysfunction and should thus be never tested in appropriately designed trials.

Postcholecystectomy bile duct injury and its sequelae: pathogenesis, classification, and management

A bile duct injury sustained during cholecystectomy can change the life of patients who submit themselves to a seemingly innocuous surgery. It has far-reaching medical, socioeconomic, and legal ramifications. Attention to detail, proper interpretation of variant anatomy, use of intraoperative cholangiography, and conversion to an open procedure in cases of difficulty can avoid/lessen the impact of some of these injuries. Once suspected, the aims of investigation are to establish the type and extent of injury and to plan the timing and mode of intervention. The principles of treatment are to control sepsis and to establish drainage of all liver segments with minimum chances of restricturing. Availability of expertise, morbidity, mortality, and quality of life issues dictate the modality of treatment chosen. Endoscopic intervention is the treatment of choice for minor leaks and provides outcomes comparable to surgery in selected patients with lateral injuries and partial strictures. A Roux-en-Y hepaticojejunostomy (HJ) by a specialist surgeon is the gold standard for high strictures, complete bile duct transection and has been shown to provide excellent long-term outcomes. Percutaneous intervention is invaluable in draining bile collections and is useful in treating post-HJ strictures. Combined biliovascular injuries, segmental atrophy, and secondary biliary cirrhosis with portal hypertension are special circumstances which are best managed by a multidisciplinary team at an experienced center for optimal outcomes.

Gallbladder-preserving cholelithotomy in laparoscopic and flexible choledochoscopic era: a report of 316 cases

BACKGROUND

The gallbladder is an organ with accurate functions of concentrating and storing bile and regulating the bile flow. Cholecystectomy is associated with some severe complications in some patients. This study was to investigate the safety and effectiveness of gallbladder-preserving cholelithotomy (GPC) for patients with gallstones in laparoscopic and flexible choledochoscopic era.

METHODS

From January 2006 to January 2007, a total of 316 patients with gallstone were assigned to GPC according to our inclusion criteria at Yunna Lithiasis Hospital. The procedures were performed by 1 surgical team under laparoscopic and flexible choledochoscopic guidance. The short-term clinical outcome and long-term gallstone recurrence rate were evaluated.

RESULTS

The success rate of GPC was 95.25%. No severe postoperative complications such as bile leakage and hemorrhage occurred. Conversion to cholecystectomy was required in 15 patients. During 25 to 72 months of follow-up, the gallstone recurrence rate at 12, 36, and 60 months were 0%, 3.32%, and 5.64%, respectively.

CONCLUSION

GPC using laparoscopy and flexible choledochoscopy is safe and effective in selected patients, the stone recurrence rate is acceptable.

Direct puncture cholangiography for clarifying difficult anatomy

Direct puncture cholangiography is a simple technique that may be of help in clarifying difficult anatomy.

Laparoscopic cholecystectomy is a very frequently performed procedure. Its most dreadful complication is bile duct injury. Difficulty in appreciating the biliary anatomy plays an important role in its causation. Here we describe our technique in clarifying the difficult anatomy by directly injecting the radiologic contrast in the ambiguous area, and thus avoiding a potential injury.

Is routine intraoperative cholangiogram necessary in the twenty-first century? A national view

INTRODUCTION

Intraoperative cholangiogram (IOC) can define biliary ductal anatomy. Routine IOC has been proposed previously. However, current surgeon IOC utilization practice patterns and outcomes are unclear.

METHODS

Nationwide Inpatient Sample 2004-2009 was queried for patients with acute biliary disease undergoing cholecystectomy (CCY). Analyses only included surgeons performing ≥10 CCY/year. We dichotomized surgeons into a routine IOC group vs. selective. Outcomes included bile duct injury, complications, mortality, length of stay, and cost.

RESULTS

Of the nonweighted patients, 111,815 underwent CCY. A total of 4,740 actual surgeon yearly volumes were examined. On average, each surgeon performed 23.6 CCYs and 7.9 IOCs annually, using IOC in 33 % of cases. The routine IOC group used IOC for 96 % of cases, whereas selective IOC group used IOC ∼25 % of the time. Routine IOC surgeons had no difference in mortality (0.4 %) or rate of bile duct injury (0.25 vs. 0.26 %), but higher overall complications (7.3 vs. 6.8 %, p = 0.04). Patients of routine IOC surgeons received more additional procedures and incurred higher costs.

CONCLUSION

Routine IOC does not decrease the rate of bile duct injury, but is associated with significant added cost. Surgeons' routine use of IOC is correlated with increased rates of postsurgical procedures, and is associated with increased overall complications. These data suggest routine IOC may not improve outcomes.

Biliary complications postlaparoscopic cholecystectomy: mechanism, preventive measures, and approach to management: a review

Laparoscopic cholecystectomy has emerged as a gold standard therapeutic option for the management of symptomatic cholelithiasis. However, adaptation of LC is associated with increased risk of complications, particularly bile duct injury ranging from 0.3 to 0.6%. Occurrence of BDI results in difficult reconstruction, prolonged hospitalization, and high risk of long-term complications. Therefore, more emphasis is placed on preventing these complications. In addition to adequate training, several techniques have been proposed to prevent bile duct injury including use of 30° scope, adequate delineation of structures in Calot's triangle (critical view), avoidance of diathermy close to common hepatic duct, and intraoperative cholangiogram, and to maintain a low threshold to conversion to open approach when uncertain. Management of Bile duct injury depends on the nature of injury, time of detection, and the expertise available, and would range from simple subhepatic drainage to Roux-en-Y hepaticojejunostomy particularly performed at specialised centers. This article based on the literature review aims to review the biliary complications following laparoscopic cholecystectomy with reference to its mechanism , preventive measures to be taken, and the management approach.