'Extreme' vasculobiliary injuries: association with fundus-down cholecystectomy in severely inflamed gallbladders

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.

Portal vein reconstruction in iatrogenic portal vein ligation

Laparoscopic cholecystectomy for acute cholecystitis is one of the most performed surgeries and is generally regarded as a safe procedure with a low risk of complications. Vascular and biliary injuries are rare but have severe consequences. No systematic studies have been performed to delineate optimal treatment strategies in these scenarios, which are typically managed on a case-by-case basis. The present report describes a patient who underwent a laparoscopic cholecystectomy, complicated by common bile duct and main portal vein ligation, resulting in hepatic infarcts, perihepatic abscess, and portal hypertension with ascites and portomesenteric congestive enteropathy. This case focuses on management of this patient's vascular injury, which was successfully treated by endovascular portal venous reconstruction using trans-splenic and right internal jugular vein access.

Acute cholecystitis treated with urgent cholecystectomy achieves higher rate of critical view of safety when compared to interval cholecystectomy after tube cholecystostomy

BACKGROUND

There are few reported outcomes of treatment of acute cholecystitis incorporating current guidelines for gallbladder dissection techniques and use of percutaneous tube cholecystostomy (PCT). The authors hypothesize PCT allows regression of peritoneal inflammation, but infundibular inflammation is increased at interval cholecystectomy, resulting in greater requirement for advanced dissection techniques.

METHODS

Between December 2009 and July 2023, 1222 patients were admitted with acute cholecystitis and ultimately underwent cholecystectomy. Of these 1222 patients, there were 876 patients that underwent urgent (within 10 days) cholecystectomy (UrgSurg), 170 patients underwent interval cholecystectomy (10 or more days) after antibiotic therapy (IntMed), and 175 patients that underwent PCT and interval cholecystectomy (IntTube). Minimally invasive operation was attempted in all patients. Patient demographics, comorbidities, surgical techniques (Critical View of Safety (CVS), infundibulum down, fundus-down, subtotal fenestrating, subtotal reconstituting, and conversion to open operation), and surgical outcomes were reviewed retrospectively. Multivariate logistic regression was performed to identify if interval cholecystectomy was independently associated with more advanced dissection techniques or reinterventions.

RESULTS

Compared to the UrgSurg and IntMed patients, IntTube patients were significantly older (Median: 60 vs 66 vs 68, P < 0.001) and more often male (41.7% vs 47.6% vs 72.2%, P < 0.001). Additionally, IntTube patients were more likely to have medical comorbidities. Establishment of CVS was significantly less frequent in IntTube patients (61%) compared to UrgSurg patients (86%) and IntMed patients (85.9%) in unadjusted analysis (OR 0.26, P < 0.001) and in multivariable analysis after adjusting for potential confounders (OR 0.31, P < 0.001). There was no incidence of biliary injury, and no difference in rates of biliary reintervention among groups.

CONCLUSION

Interval Cholecystectomy after PCT is independently associated with a lower rate of achieving CVS, and higher rate of requirement for advanced cholecystectomy dissection techniques. We report a low rate of complications using current guidelines for minimally invasive surgery for both urgent and interval cholecystectomy for acute cholecystitis.

Ultrasonic dissection versus electrocautery dissection in laparoscopic cholecystectomy for acute cholecystitis: a randomized controlled trial (SONOCHOL-trial)

BACKGROUND

Laparoscopic cholecystectomy with ultrasonic dissection presents a compelling alternative to conventional electrocautery. The evidence for elective cholecystectomy supports the adoption of ultrasonic dissection, citing advantages such as reduced operating time, diminished bleeding, shorter hospital stays and decreased postoperative pain and nausea. However, the efficacy of this procedure in emergency surgery and patients diagnosed with acute cholecystitis remains uncertain. The aim of this study was to compare outcomes of electrocautery and ultrasonic dissection in patients with acute cholecystitis.

METHODS

A randomized, parallel, double-blinded, multicentre controlled trial was conducted across eight Swedish hospitals. Eligible participants were individuals aged ≥ 18 years with acute cholecystitis lasting ≤ 7 days. Laparoscopic cholecystectomy was performed in the emergency setting as soon as local circumstances permitted. Random allocation to electrocautery or ultrasonic dissection was performed in a 1:1 ratio. The primary endpoint was the total complication rate, analysed using an intention-to-treat approach. The primary outcome was analysed using logistic generalized estimated equations. Patients, postoperative caregivers, and follow-up personnel were blinded to group assignment.

RESULTS

From September 2019 to March 2023, 300 patients were enrolled and randomly assigned to electrocautery dissection (n = 148) and ultrasonic dissection (n = 152). No significant difference in complication rate was observed between the groups (risk difference [RD] 1.6%, 95% confidence interval [CI], - 7.2% to 10.4%, P = 0.720). No significant disparities in operating time, conversion rate, hospital stay or readmission rates between the groups were noted. Haemostatic agents were more frequently used in electrocautery dissection (RD 10.6%, 95% CI, 1.3% to 19.8%, P = 0.025).

CONCLUSIONS

Ultrasonic dissection and electrocautery dissection demonstrate comparable risks for complications in emergency surgery for patients with acute cholecystitis. Ultrasonic dissection is a viable alternative to electrocautery dissection or can be used as a complementary method in laparoscopic cholecystectomy for acute cholecystitis.

TRIAL REGISTRATION

The trial was registered prior to conducting the research on http://clinical.

TRIALS

gov , NCT03014817.

Utilization of the modified Kama scoring system for predicting bail-out cholecystectomy: a valuable tool in the era of rising laparoscopic surgery prevalence

PURPOSE

Recently, bail-out cholecystectomy (BOC) during laparoscopic cholecystectomy to avoid severe complications, such as vasculobiliary injury, has become widely used and increased in prevalence. However, current predictive factors or scoring systems are insufficient. Therefore, in this study, we aimed to test the validity of existing scoring systems and determine a suitable cutoff value for predicting BOC.

METHODS

We retrospectively assessed 305 patients who underwent laparoscopic cholecystectomy and divided them into a total cholecystectomy group (n = 265) and a BOC group (n = 40). Preoperative and operative findings were collected, and cutoff values for the existing scoring systems (Kama's and Nassar's) were modified using a prospectively maintained database.

RESULTS

The BOC rate was 13% with no severe complications. A logistic regression analysis revealed that the Kama's score (odds ratio, 0.93; 95% confidence interval 0.91-0.96; P < 0.01) was an independent predictor of BOC. A cutoff value of 6.5 points gave an area under the curve of 0.81, with a sensitivity of 87% and a specificity of 67%.

CONCLUSIONS

Kama's difficulty scoring system with a modified cutoff value (6.5 points) is effective for predicting BOC.

Comparative Assessment Between the Fundus-First Technique and Standard Laparoscopic Technique in Difficult Laparoscopic Cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy is a standard minimally invasive technique for the treatment in gallstone disease. In difficult laparoscopic cholecystectomies, bailout strategies have been developed of which the fundus-first technique is one. The present study aims to compare the outcomes of the fundus-first technique against the standard laparoscopic approach in managing difficult cholecystectomy cases by focusing on intraoperative factors such as bleeding, bile duct injury, operative time, and postoperative complications like biliary leakage.

METHODS

A prospective comparative study was conducted over a period of two years (June 2022-May 2024) with 200 consecutive patients. All patients were classified as difficult cases based on the Tokyo 2018 guidelines. Detailed data collection included patient history, physical examination, laboratory investigations, and operative findings. The study's follow-up period was six weeks.

RESULTS

The fundus-first technique demonstrated significant advantages, with a reduction in operative time, fewer intraoperative complications, and better operative outcomes compared to the standard approach. Patients in the fundus-first group had a mean operative time of 91.50 minutes as compared to 143.75 minutes in the standard group (p < 0.001) and 88% completed operative outcome vs 51%(p < 0.001). No significant differences were observed in postoperative complications such as bile leakage and bleeding between the two groups.

CONCLUSION

The fundus-first technique offers a safer and more efficient alternative to the standard approach in difficult laparoscopic cholecystectomy cases. By allowing better access to Calot's triangle, this method proves to be an effective bailout strategy, despite its steep learning curve. Further studies are needed to validate these findings and explore the broader application of the fundus-first technique in gallbladder surgeries.

Application of three-dimensional visualization technology in early surgical repair of bile duct injury during laparoscopic cholecystectomy

OBJECTIVE

This study aimed to explore the application value of three-dimensional (3D) visualization technology in the early surgical repair of bile duct injury during laparoscopic cholecystectomy (LC).

METHODS

A retrospective analysis was conducted on the clinical data of 15 patients who underwent early surgical repair of bile duct injury during LC with the assistance of 3D visualization technology at the Hepatobiliary Surgery Department of Ningxia Hui Autonomous Region People's Hospital from January 2019 to December 2022. Postoperative efficacy and long-term follow-up outcomes were summarized.

RESULTS

Before the repair surgery, 15 cases of bile duct injury during LC were evaluated using 3D visualization technology according to the Strasberg-Bismuth classification: 2 cases of type C, 4 of type E1, 3 of type E2, 3 of type E3, and 3 of type E4. Intraoperative findings were consistent with the 3D visualization reconstruction results, and all patients successfully underwent hepaticojejunostomy using Roux-en-Y anastomosis guided by the 3D visualization navigation. The time interval between LC and bile duct repair surgery ranged from 5 to 28 (14.2 ± 9.7) days. The surgical time was between 120 and 190 (156.40 ± 23.92) min, and estimated blood loss ranged from 80 to 250 (119.66 ± 47.60) mL. The length of hospital stay ranged from 12 to 25 days (median: 16 days). One patient experienced mild bile leakage after the operation, which healed with conservative treatment. All patients were followed up for 12-56 months (median: 34 months) without any loss to follow-up. During the follow-up period, no complications, such as anastomotic stricture or stone formation, were observed.

CONCLUSION

The application of 3D visualization technology for preoperative evaluation and intraoperative navigation can accurately and effectively facilitate early surgical repair of bile duct injury during LC and has clinical value for promotion and application.

Bile Duct Injuries after Cholecystectomy: An Individual Patient Data Systematic Review

Background: Post-cholecystectomy bile duct injuries (BDIs) represent a challenging complication, with negative impacts on clinical outcomes. Several surgical and endoscopic/interventional radiologist (IR) approaches have been proposed to manage these damages, though with high failure rates. This individual patient data (IPD) systematic review analyzes the potential risk factors for failure after treatment interventions for BDIs, both surgical and endoscopic/IR. Methods: An extensive literature search was conducted on MEDLINE and Scopus for relevant articles published in English on the management of BDIs after cholecystectomy, between 1 January 2010 and 31 December 2023. Our series of BDIs was included. BDIs were always categorized according to the Strasberg's classification. The composite primary endpoints evaluated were the failure of treatment interventions, defined as patient death or the requirement of any other procedure, whatever surgical and/or endoscopic/IR, after the primary treatment. Results: A total of 342 cases were retrieved from our literature analysis, including our series of 19 patients. Among these, three groups were identified: "upfront surgery", "upfront endoscopy and/or IR" and "no upfront treatment", consisting of 224, 109 and 9 patients, respectively. After eliminating the third group, treatment intervention failure was observed overall in 34.2% (114/333) of patients, of whom 80.7% (92/114) and 19.3% (22/114) in the "upfront surgery" and in the "upfront endoscopy/IR" groups, respectively. At multivariable analysis, injury type D and E, and repair in a non-specialized center represented independent predictors of treatment failure in both groups, whereas laparoscopic cholecystectomy (LC) converted to open and immediate attempt of surgical repair exclusively in the first group. Conclusions: Significant treatment failure rates are responsible for remarkable negative effects on immediate and longer-term clinical outcomes of post-cholecystectomy BDIs. Understanding the important risk factors for this outcome may better guide the most appropriate therapeutical approach and improve clinical decisions in case this serious complication occurs.

Safety of cholecystectomy performed by surgeons who prefer fundus first versus surgeons who prefer a standard laparoscopic approach

Background

An alternative method to standard laparoscopic cholecystectomy (SLC) is the "fundus first" method (FFLC). Concerns have been raised that FFLC can lead to misinterpretation of important anatomical structures, thus causing complications of a more serious kind than SLC. Comparisons between the methods are complicated by the fact that FFLC is often used as a rescue procedure in complicated cases. To avoid confounding related to this we conducted a population-based study with comparisons on the surgeon level.

Method

In GallRiks, the Swedish registry for Gallbladder surgery, we stratified all cholecystectomies performed 2006-2020 in three groups: surgeries carried out by surgeons that uses FFLC in <20 % of the cases (N = 150,119), in 20-79 % of the cases (N = 10,212) and in 80 % or more of the cases (N = 3176). We compared the groups with logistic regression, adjusting for sex, age, surgical experience, year of surgery and history of acute cholecystitis. All surgical complications (bleeding, gallbladder perforation, visceral perforation, infection, and bile duct injury) were included as outcome. A separate analysis was done with regards to operation time.

Results

No difference in incidence of all surgical complications or bile duct injury were seen between groups. The rates of bleeding (OR 0.34 [0.14-0.86]) and gallbladder perforation (OR 0.61 [0.45-0.82]) were significantly lower in the "fundus first > 80% group" and the operative time was shorter (OR 0.76 [0.69-0.83]).

Conclusion

In this study including >160,000 cholecystectomies, both methods was found to be equally safe.

Key message

During laparoscopic cholecystectomy, the standard method of dissection and fundus first dissection are equally safe surgical techniques. Surgeons need to learn both methods to be able to use the one most appropriate for each individual case.

Liver pucker sign: predictor of difficult laparoscopic cholecystectomy: a case series

Introduction

Pucker sign is the depression of the liver in the region of the gallbladder due to a high degree of chronic contractive inflammation of the gallbladder. It usually develops in patients who have a delayed cholecystectomy after acute cholecystitis due to a high degree of chronic contractive inflammation of the gallbladder and contraction of the cystic plate. It is an essential finding either preoperatively or intraoperatively as it can act as a stopping rule during cholecystectomy (act as a guide that cholecystectomy will be difficult).

Case series

The authors here report three cases of pucker sign that were incidentally discovered during laparoscopy.

Discussion

Chronic cholecystitis is a prolonged, subacute condition caused by inflammation of the gallbladder, which mostly occurs in the setting of cholelithiasis. Laparoscopic cholecystectomy is the procedure of choice for symptomatic cholelithiasis. Hence, it would be beneficial to be aware of reliable signs that predict difficult Laparoscopic cholecystectomy. Pucker sign usually predicts increased operative difficulty as there is an operative danger of biliary or vascular injury.

Conclusion

The pucker sign is a novel indicator of significant persistent inflammation and heightened difficulty during surgery. It might establish a halting rule that modifies the procedure's management and raises its level of safety.

A systematic review on laparoscopic subtotal cholecystectomy for difficult gallbladders: a lifesaving bailout or an incomplete operation?

INTRODUCTION

Laparoscopic subtotal cholecystectomy (LSTC) is a bailout procedure that is undertaken when it is not safe to proceed with a laparoscopic total cholecystectomy owing to dense adhesions in Calot's triangle. The main aim of this review was to investigate the early (≤30 days) and late (>30 days) morbidity and mortality of LSTC.

METHODS

A literature search of the PubMed® (MEDLINE®), Google Scholar™ and Embase® databases was conducted to identify all studies on LSTC published between 1985 and December 2020. A systematic review was then performed.

RESULTS

Overall, 45 studies involving 2,166 subtotal cholecystectomy patients (51% female) were identified for inclusion in the review. The mean patient age was 55 years (standard deviation: 15 years). Just over half (53%) of the patients had an elective procedure. The conversion rate was 6.2% (n=135). The most common indication was acute cholecystitis (49%). Different techniques were used, with the majority having a closed cystic duct/gallbladder stump (71%). The most common closure technique was intracorporeal suturing (53%), followed by endoloop closure (15%). Four patients (0.18%) died within thirty days of surgery. Morbidity within 30 days included bile duct injury (0.23%), bile leak (18%) and intra-abdominal collection (4%). Reoperation was reported in 23 patients (1.2%), most commonly for unresolving intra-abdominal collections and failed endoscopic retrograde cholangiopancreatography to control bile leak. Long-term follow-up was reported in 30 studies, the median follow-up duration being 22 months. Late morbidity included incisional hernias (6%), symptomatic gallstones (4%) and common bile duct stones (2%), with 2% of cases requiring completion of cholecystectomy.

CONCLUSIONS

LSTC is an acceptable alternative in patients with a "difficult" Calot's triangle.

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

INTRODUCTION

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Comparative evaluation of three laparoscopic cholecystectomy techniques in rabbit's model

PURPOSE

The aim of this randomized study was to compare the complications and perioperative outcome of three different techniques of laparoscopic cholecystectomy (LC). Changes in the liver function test after LC techniques were investigated. Also, we compared the degree of postoperative adhesions and histopathological changes of the liver bed.

METHODS

Thirty rabbits were divided into three groups: group A) Fundus-first technique by Hook dissecting instrument and Roeder Slipknot applied for cystic duct (CD) ligation; group B) conventional technique by Maryland dissecting forceps and electrothermal bipolar vessel sealing (EBVS) for CD seal; group C) conventional technique by EBVS for gallbladder (GB) dissection and CD seal.

RESULTS

Group A presented a longer GB dissection time than groups B and C. GB perforation and bleeding from tissues adjacent to GB were similar among tested groups. Gamma-glutamyl transferase and alkaline phosphatase levels increased (p ≤ 0.05) on day 3 postoperatively in group A. By the 15th postoperative day, the enzymes returned to the preoperative values. Transient elevation of hepatic transaminases occurred after LC in all groups. Group A had a higher adherence score than groups B and C and was associated with the least predictable technique.

CONCLUSIONS

LC can be performed using different techniques, although the use of EBVS is highly recommended.

D-line Approach for Safe Laparoscopic Cholecystectomy: Initial Experience

Introduction The critical view of safety is an important concept for safe laparoscopic cholecystectomy. However, no standard step-by-step approach for achieving the critical view of safety has been established until now. Therefore, this study aims to evaluate a new approach for achieving the critical view of safety using the diagonal line of liver segment IV as an anatomical landmark. Patients and methods In this prospective non-randomized study, patients (n= 112) who underwent laparoscopic cholecystectomy for symptomatic cholelithiasis were included. The first 47 patients underwent laparoscopic cholecystectomy using the diagonal line approach (DLC group) whereas, the next 65 patients underwent laparoscopic cholecystectomy using the conventional method (CLC group).  Results No significant difference between both groups regarding the preoperative characteristics, operative time, and intraoperative blood loss. Laparoscopic subtotal cholecystectomy was performed more in the DLC group (6% vs 0%, p= 0.07). Whereas, in the CLC group, there was a tendency towards conversion to open cholecystectomy in difficult cases (6% vs 2%, p= 0.40). No intra- or postoperative complications occurred in either group.  Conclusion The diagonal line approach is a feasible and useful step-by-step technique to achieve the critical view of safety in laparoscopic cholecystectomy and enables surgeons to perform safe laparoscopic subtotal cholecystectomy in difficult cases.

How do magnetic resonance cholangiopancreatography findings predict conversion from laparoscopic cholecystectomy for acute cholecystitis to bailout procedures?

BACKGROUND

Acute cholecystitis is one of the most prevalent surgical abdominal conditions. The Tokyo Guidelines describe the management of acute cholecystitis and recommend bailout procedures for "difficult" cholecystitis cases. This study aimed to identify risk factors for conversion from laparoscopic cholecystectomy to bailout procedures in patients with acute cholecystitis.

METHODS

This retrospective cohort study was conducted at a single center between January 2017 and December 2021. Patients who underwent laparoscopic cholecystectomy for acute cholecystitis were enrolled and classified into bailout and non-bailout groups. The patients' characteristics and perioperative data were compared between the 2 groups.

RESULTS

In total, 161 patients who underwent laparoscopic cholecystectomy for acute cholecystitis were reviewed. Fourteen were excluded because of a lack of preoperative magnetic resonance cholangiopancreatography; thus, 147 patients were enrolled (bailout group, 21; non-bailout group, 126). Age (74 vs 67 years old; P = .048), days from onset to surgery (3 vs 2 days; P = .02), or defect of cystic duct in magnetic resonance cholangiopancreatography (57% vs 29%; P = .02) were significantly associated with conversion to bailout procedures. In the logistic regression analysis, a defect of the cystic duct in magnetic resonance cholangiopancreatography was an independent predictor for bailout procedures (odds ratio, 2.793; P = .04).

CONCLUSION

In this study, defect of the cystic duct in the magnetic resonance cholangiopancreatography can predict conversion to bailout procedures. To the best of our knowledge, this is the first report to describe magnetic resonance cholangiopancreatography finding of the cystic duct as a predictor of surgical difficulty in patients with acute cholecystitis.

When Critical View of Safety Fails: A Practical Perspective on Difficult Laparoscopic Cholecystectomy

The incidence of common bile duct injuries following laparoscopic cholecystectomy (LC) remains three times higher than that following open surgery despite numerous attempts to decrease intraoperative incidents by employing better training, superior surgical instruments, imaging techniques, or strategic concepts. This paper is a narrative review which discusses from a contextual point of view the need to standardise the surgical approach in difficult laparoscopic cholecystectomies, the main strategic operative concepts and techniques, complementary visualisation aids for the delineation of anatomical landmarks, and the importance of cognitive maps and algorithms in performing safer LC. Extensive research was carried out in the PubMed, Web of Science, and Elsevier databases using the terms "difficult cholecystectomy", "bile duct injuries", "safe cholecystectomy", and "laparoscopy in acute cholecystitis". The key content and findings of this research suggest there is high intersocietal variation in approaching and performing LC, in the use of visualisation aids, and in the application of safety concepts. Limited papers offer guidelines based on robust data and a timid recognition of the human factors and ergonomic concepts in improving the outcomes associated with difficult cholecystectomies. This paper highlights the most relevant recommendations for dealing with difficult laparoscopic cholecystectomies.

Liver transplantation for iatrogenic injuries secondary to cholecystectomy: a systematic review

INTRODUCTION

Iatrogenic injury to the liver hilum during cholecystectomy is a severe surgical complication, with liver transplantation (LT) as the final drastic solution. The authors report the experience of our center and conduct a review of the literature on the outcomes of LT performed in this setting.

METHODS

Data sources included MEDLINE, EMBASE, and CENTRAL from inception to 19 June 2022. Studies reporting on patients treated with LT for liver hilar injuries following cholecystectomy were included. Incidence, clinical outcomes, and survival data were synthesized through a narrative review.

RESULTS

Twenty-seven articles were identified, including 213 patients. Eleven (40.7%) articles highlighted deaths within 90-days post-LT. Post-LT mortality was reported in 28 (13.1%) patients. Severe complications (≥Clavien III) occurred in at least 25.8% ( n =55) of patients. Within larger cohorts, 1-year overall survival (OS) was 76.5-84.3%, and 5-year OS was 67.2-83.0%. The authors also highlight our own experience managing 14 patients with liver hilar injury secondary to cholecystectomy, of which two required LT.

CONCLUSION

While short-term morbidity and mortality is significant, available long-term data suggests reasonable OS in these patients following LT. Future studies are necessary to better understand the relationship between different types of liver hilar injury, transplant indication, and outcomes of LT in this setting.

Subtotal cholecystectomy: is it a safe option for difficult gall bladders?

INTRODUCTION

Subtotal cholecystectomy (STC) is an alternative to total cholecystectomy (TC) in patients with severe inflammation/adhesions around the hepatocystic triangle. This study aimed to evaluate the safety profile of STC.

METHODS

We retrospectively reviewed all patients who had STC at our unit between February 2009 and August 2019. STC was divided into two types, reconstituting (R-STC) and fenestrating (F-STC), depending on whether the gall bladder remnant was closed or left open. Patients who had cholecystectomy for gall bladder malignancy or as part of another operation were excluded from the study.

RESULTS

A total of 5,664 patients underwent cholecystectomy during the study period. Of these, 97 (1.7%) underwent STC. The laparoscopic to open conversion rate was high at 48.8% (47 cases), as was the overall postoperative complication rate (45.4%, 44 cases). No patient suffered iatrogenic bile duct injury. Nineteen patients (19.6%) suffered postoperative bile leak. This was significantly higher in patients who had STC in the acute setting (41% vs 13% for elective STC cases; p=0.04). There was no significant difference in rate of bile leak or other complications between R-STC and F-STC types. The 90-day readmission rate was 8.2% (8 cases). No mortalities were recorded within 90 days post STC.

CONCLUSIONS

STC seems to be an effective technique to avoid bile duct injury in difficult cholecystectomy cases. However, the perioperative morbidity associated with STC is relatively high. Surgeons should be aware of the risks of STC and take appropriate steps to minimise them.

Vascular injury during laparoscopic cholecystectomy: An often-overlooked complication

Laparoscopic cholecystectomy is one of the most frequently performed procedures in gastrointestinal surgery worldwide. Bleeding complications due to vascular injuries represent an important cause of morbidity and mortality, especially when facing major bleeding during laparoscopy, where bleeding control can be technically challenging in inexperienced hands. Interestingly, the reported incidence rate of conversion to open surgery due to vascular lesions is approximately 0%-1.9%, with a mortality rate of approximately 0.02%. The primary aim of this article was to perform an up-to-date overview regarding the incidence and surgical management of vascular injuries during laparoscopic cholecystectomy according to the available scientific evidence.

Outcomes of hepaticojejunostomy for post-cholecystectomy bile duct injury

OBJECTIVES

Long-term results of hepaticojejunostomy (HJ) for complex bile duct injury (BDI) remain under-reported. The objective of this study was to assess short-term and long-term outcomes of HJ for post-cholecystectomy BDI.

METHODS

This was a retrospective cohort study and included patients who underwent Roux-en-Y HJ for BDI (n = 87). Short-term (90-day) and long-term morbidity and mortality were assessed.

RESULTS

At presentation, 42 (48.2%) patients had E3 or E4 BDI, 27 (31%) patients had vascular injury, and liver resection was performed in 12 (13.7%) patients. The 90-day morbidity was 51.7% (n = 45), and the 90-day mortality was 2.3% (n = 2). The long-term mortality was 3.4% (n = 3). The 10-year estimated stricture-free survival was 95%. The 10-year estimated overall survival rate was 100% in patients who underwent major hepatectomy and 91% in patients who did not. The 10-year estimated overall survival rate was 100% in patients with vasculobiliary injury and was not reached in patients without vascular injury.

CONCLUSIONS

Vascular injury with proximal BDI is not uncommon. Excellent long-term outcomes might be achieved with Roux-en-Y HJ for BDI with vascular injury and in patients requiring liver resection.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

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.

Body-first approach of laparoscopic cholecystectomy for minimizing vasculobiliary injury: Initial experience

INTRODUCTION

Vasculobiliary injury (VBI) is a rare but critical complication of laparoscopic cholecystectomy (Lap-C). Dividing first the gallbladder body and then the gallbladder neck from the gallbladder bed (the "body-first approach") may decrease the possibility of VBI.

METHODS

The surgical outcome of 62 patients who underwent Lap-C with a body-first approach were evaluated. In this procedure, after serosal resection of the gallbladder, the gallbladder body is divided from the cystic plate; then the gallbladder neck and cystic duct are isolated. No connective tissue of the hepatic hilum is touched.

RESULTS

A total of five patients had anatomical anomalies of the biliary tract that raised concerns of cholecystectomy. Furthermore, seven patients underwent subtotal cholecystectomy. No patients required conversion to open surgery, and none developed VBI or postoperative complications of Clavien-Dindo grade 3a or worse.

CONCLUSION

The body-first approach may minimize the risk of VBI during Lap-C.

Laparoscopic Lumen-guided cholecystectomy in face of the difficult gallbladder

BACKGROUND

Where the critical view of safety cannot be established during cholecystectomy, certain salvage techniques are indicated to reduce the likelihood of bile duct injury. The present study describes a salvage technique termed the "laparoscopic lumen-guided cholecystectomy" (LLC) and reports its peri-operative outcomes.

METHOD

A summary of the technique is as follows: (1) Hartmann's pouch is incised and stones are evacuated; (2) the cystic anatomy is inspected from the inside of the gallbladder; (3) the lumen is used to guide retrograde dissection towards the cystic pedicle; (4) cystic duct control is achieved if deemed safe. LLC cases performed between June 2020 and January 2022 in a single health board were included. The operative details and peri-operative outcomes of the technique are reported and compared to cases of similar difficulty where the LLC was not attempted.

RESULTS

LLC was performed in 4.6% (27/587) of cases. In all 27 cases, LLC was performed for a "frozen" cholecystohepatic triangle. Hartmann's pouch was completely excised in all cases (27/27) and cystic duct control was achieved in 85.2% of cases (23/27). No cases of bile leak or ductal injury were reported. Rates of bile leak, post-operative complications and ERCP were lower following LLC compared to the group where LLC was not attempted (p < 0.01).

CONCLUSION

LLC is a safe salvage technique and should be considered in cases where the critical view of safety cannot be established. The technique achieves cystic duct control in the majority of cases and favourable outcomes in the face of a difficult cholecystectomy.

An additional port in difficult laparoscopic cholecystectomy for surgical safety

BACKGROUND

Tokyo Guidelines 2018, clinical practice guidelines for acute cholangitis and cholecystitis, recommend bailout procedures to prevent bile duct injury (BDI) during laparoscopic cholecystectomy (LC) for difficult gallbladder. We first insert an additional port (AP) for difficult gallbladder that may require bailout procedures. Because the usefulness of an AP during LC is unclear, we therefore examined the efficacy of the AP during LC in this study.

METHODS

Data were collected from 115 patients who underwent LC for acute cholecystitis in our department. The indications for AP were excessive bleeding, scarring, and poor visual field around Calot's triangle. AP was inserted into the right middle abdomen so as not to interfere with other trocars and was used by the assistant. Surgical outcomes were evaluated based on AP use during LC.

RESULTS

AP was inserted in 19 patients during LC (AP group). The indications for AP were excessive bleeding in nine patients, scarring around Calot's triangle in seven patients, and poor visual field around Calot's triangle in three patients. Open conversion was performed in two patients in the non-AP group. BDI occurred in one patient in the non-AP group. In patients with Difficulty Score 3, operation time was significantly shorter (P = .038) and Critical View of Safety (CVS) score was significantly higher in the AP group (P = .046).

CONCLUSION

AP is useful in patients with excessive bleeding to shorten operation time and increase the CVS score. AP may be one useful option for difficult gallbladder.

The Critical View of Safety in Laparoscopic Cholecystectomy: User Trends Among Residents and Consultants

BACKGROUND

The Critical View of Safety (CVS) aims at preventing bile duct injuries (BDIs) in laparoscopic cholecystectomy (LCC). This study investigated CVS utilization among surgeons.

METHODS

Photos from LCCs were scored for satisfactory CVS. Rates of satisfactory CVS, BDIs, and postoperative complications among residents and consultants were compared. A lecture on CVS was given halfway through the study.

RESULTS

The study comprised 1532 patients. Residents had higher rates of satisfactory CVS in elective LCCs compared with consultants (34.9% vs. 23.0%, P<0.001), but not in emergency LCCs (18.4% vs. 15.0%, P=0.252). No significant differences in BDIs or postoperative complications emerged between residents and consultants. After the lecture, elective LCCs were photographed more frequently (80.3% vs. 74.0%, P=0.032), but rates of satisfactory CVS, BDIs, and postoperative complications remained unchanged.

CONCLUSIONS

Utilization of CVS can be affected by a single lecture but affecting rates of satisfactory CVS may require stronger interventions.

Learning by doing: an observational study of the learning curve for ultrasonic fundus-first dissection in elective cholecystectomy

BACKGROUND

Surgical safety and patient-related outcomes are important considerations when introducing new surgical techniques. Studies about the learning curves for different surgical procedures are sparse. The aim of this observational study was to evaluate the learning curve for ultrasonic fundus-first (FF) dissection in elective laparoscopic cholecystectomy (LC).

METHODS

The study was conducted at eight hospitals in Sweden between 2017 and 2019. The primary endpoint was dissection time, with secondary endpoints being intra- and postoperative complication rates and the surgeon's self-assessed performance level. Participating surgeons (n = 16) were residents or specialists who performed LC individually but who had no previous experience in ultrasonic FF dissection. Each surgeon performed fifteen procedures. Video recordings from five of the procedures were analysed by two external surgeons. Patient characteristics and data on complications were retrieved from the Swedish Registry of Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks).

RESULTS

Dissection time decreased as experience increased (p = 0.001). Surgeons with limited experience showed more rapid progress. The overall complication rate was 14 (5.8%), including 3 (1.3%) potentially technique-related complications. Video assessment scores showed no correlation with the number of procedures performed. The self-assessed performance level was rated lower when the operation was more complicated (p < 0.001).

CONCLUSIONS

Our results show that dissection time decreased with increasing experience. Most surgeons identified both favourable and unfavourable aspects of the ultrasonic FF technique. The ultrasonic device is considered well suited for gallbladder surgery, but most participating surgeons preferred to dissect the gallbladder the traditional way, beginning in the triangle of Calot. Nevertheless, LC with ultrasonic FF dissection can be considered easy to learn with a low complication rate during the initial learning curve, for both residents and specialists.

Setting up a surgical complex gallstone service in a non-HPB unit

Objective: Complex gallstone disease is associated with a higher risk of complication during laparoscopic cholecystectomy than biliary colic and simple cholecystitis. It is traditionally managed in a hepatopancreaticobiliary (HPB) unit where there is expertise for common bile duct exploration and repair. We developed a mentorship scheme for a busy upper gastro-intestinal (UGI) unit, with support from a specialist HPB unit to treat complex gallstone disease, to reduce the burden on the HPB unit and enable local treatment of patients.

Material and Methods: Through the creation of a service level agreement, the specialist HPB unit were commissioned to provide mentorship for two surgeons at a large UGI unit with an interest in providing a complex gallstone service to their local population. Eight sessions of mentored operating were supported, with the provision for additional support if complications occurred.

Results: There were 14 patients included in the mentorship phase of the programme from November 2015 to May 2017. Cholecystectomies were performed on patients with previously complex histories, which included: previous cholecystostomy; CBD stones and multiple ERCPs; suspected choledochoduodenal fistula; suspected cholecystoduodenal fistula; suspected Mirrizzi’s syndrome; previous significant intra-abdominal operation; and significant medical co-morbidities. There was one post-operative complication requiring a return to theatre, and one minor wound infection associated with the complex gallstone lists.

Conclusion: We demonstrated a method to reduce the burden on specialist HPB unit for the operative management of complex gallstone disease and safely implement such a service at large UGI unit with an interest in providing a complex gallstone service.

[Measures for preventing bile duct injuries during difficult cholecystectomies-Bail-out procedures]

BACKGROUND

Cholecystectomies can sometimes be very complex operations, which place high demands on the surgeon.

OBJECTIVE

Are there preoperative and intraoperative procedures available for reducing the risk of intraoperative bile duct injuries during a complex cholecystectomy?

RESULTS

The complexity of the operation should be estimated preoperatively. Extended diagnostic examinations, preoperative biliary stenting and the performance of the operation by an experienced surgeon may help to reduce the operative risk. In high-risk patients, postponing the cholecystectomy may be indicated. The timely intraoperative recognition of the impossibility to perform a regular cholecystectomy is of decisive importance. In this situation, so-called bail-out procedures, such as fundus-down cholecystectomy or subtotal cholecystectomy are warranted. Conversion from laparoscopic to open surgery is not always necessary.

CONCLUSION

Bail-out procedures are useful to reduce the risk of bile duct injuries during complex cholecystectomy and can enable a safe completion of the operation.

Preoperative risk factors for technical difficulty in emergent laparoscopic cholecystectomy for acute cholecystitis

AIM

We have routinely performed emergent laparoscopic cholecystectomy (LC) as soon as we diagnosed acute cholecystitis (AC), if patients could tolerate surgery. This study was conducted to identify the preoperative risk factors that predict the technical difficulty of emergent LC for AC.

METHODS

A retrospective review of patients with AC who underwent emergent LC between 2012 and 2019 was conducted. Technical difficulty was defined as the presence of the following conditions: open conversion, operative time ≥120 min, or blood loss ≥500 ml.

RESULTS

In all, 327 patients were included and divided into difficult LC (DLC, n = 61) and nondifficult LC (non-DLC, n = 266). Multivariate logistic analysis revealed that symptom duration ≥72 h was the only independent risk factor for DLC. Comparison of late LC (beyond 72 h, LLC) and early LC (within 72 h, ELC) showed a lower rate of creation of the critical view of safety and a longer hospital stay, as well as a longer operative time, a larger amount of bleeding, and a higher open conversion rate in LLC. However, the postoperative complication rates were equivalent.

CONCLUSION

LC for AC with symptom duration ≥72 h tends to be technically difficult. However, it is acceptable regarding operative outcomes.

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.

2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy

Bile duct injury (BDI) is a dangerous complication of cholecystectomy, with significant postoperative sequelae for the patient in terms of morbidity, mortality, and long-term quality of life. BDIs have an estimated incidence of 0.4-1.5%, but considering the number of cholecystectomies performed worldwide, mostly by laparoscopy, surgeons must be prepared to manage this surgical challenge. Most BDIs are recognized either during the procedure or in the immediate postoperative period. However, some BDIs may be discovered later during the postoperative period, and this may translate to delayed or inappropriate treatments. Providing a specific diagnosis and a precise description of the BDI will expedite the decision-making process and increase the chance of treatment success. Subsequently, the choice and timing of the appropriate reconstructive strategy have a critical role in long-term prognosis. Currently, a wide spectrum of multidisciplinary interventions with different degrees of invasiveness is indicated for BDI management. These World Society of Emergency Surgery (WSES) guidelines have been produced following an exhaustive review of the current literature and an international expert panel discussion with the aim of providing evidence-based recommendations to facilitate and standardize the detection and management of BDIs during cholecystectomy. In particular, the 2020 WSES guidelines cover the following key aspects: (1) strategies to minimize the risk of BDI during cholecystectomy; (2) BDI rates in general surgery units and review of surgical practice; (3) how to classify, stage, and report BDI once detected; (4) how to manage an intraoperatively detected BDI; (5) indications for antibiotic treatment; (6) indications for clinical, biochemical, and imaging investigations for suspected BDI; and (7) how to manage a postoperatively detected BDI.

Severe case of post cholecystectomy vasculobiliary injury successfully treated by right hepatectomy with a jump graft to the remaining left hepatic lobe

Vasculobiliary injuries (VBI) caused by cholecystectomies are infrequent but extremely serious. We report a case of a severe VBI successfully treated at our center. A 22-year-old woman underwent an open cholecystectomy as treatment for acute cholecystitis and bile duct stones. She was transferred to our center on postoperative Day 4 because of progressive jaundice and encephalopathy. After a proper investigation, we found an extreme VBI with infarction of the right hepatic lobe associated with complete interruption of the portal vein and proper hepatic artery flows and full section of the common hepatic duct. Right hepatectomy with portal—Rex shunt revascularization of the left hepatic lobe and Roux-en-Y hepaticojejunostomy to the left hepatic duct was done. The patient was discharged on the 60th postoperative day.

Discussion: This case shows the successful surgical treatment of a severe cholecystectomy’s VBI, avoiding an emergency liver transplant.

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.

The “critical view of safety (CVS)” cannot be applied—What to do? Strategies to avoid bile duct injuries

Laparoscopic cholecystectomy has become the standard procedure worldwide since the early 1990s for those patients whose gallbladder has to be removed as part of their underlying disease (NIH Consensus Statement 1992). The most common complication is iatrogenic bile duct injury, which has not improved significantly since the introduction of open laparoscopic cholecystectomy as compared with open cholecystectomy. The intraoperative injuries are mostly the result of a misinterpretation of anatomical structures due to severe inflammation or topographical variations. In order to minimize this risk, a number of improved operative techniques and behavioral measures have been formulated. Here, we present methodological and operative possibilities as well as techniques that in unclear situations can help to minimize the risk of intraoperative injuries of the biliary tract and the accompanying vascular system.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Less is more in the difficult gallbladder: recent evolution of subtotal cholecystectomy in a single HPB unit

INTRODUCTION

Subtotal cholecystectomy (SC) is a technique to manage the difficult gallbladder and avoid hazardous dissection and biliary injury. Until recently it was used infrequently. However, because of reduced exposure to open total cholecystectomy in resident training, we recently adopted subtotal cholecystectomy as the bail-out procedure of choice for resident teaching. This study reports our experience and outcomes with subtotal cholecystectomy in the years immediately preceding adoption and since adoption.

METHODS

A retrospective analysis was conducted of patients undergoing SC from July 2010 to June 2019. Outcomes, including bile leak, reoperation and need for additional procedures, were analyzed. Complications were graded by the Modified Accordion Grading Scale (MAGS).

RESULTS

1571 cholecystectomies were performed of which 71 were SC. Subtotal cholecystectomy patients had several indicators of difficulty including prior attempted cholecystectomy and previous cholecystostomy tube insertion. The most common indication for SC was marked inflammation in the hepatocystic triangle (51%). As our experience increased, fewer patients required open conversion to accomplish SC and SC was completed laparoscopically, usually subtotal fenestrating cholecystectomy (SFC). Most patients (85%) had a drain placed and 28% were discharged with a drain. The highest MAGS complication observed was grade 3 (11 patients, 15%). Six patients had a bile leak from the cystic duct resolved by ERCP. At mean follow-up of about 1 year no patient returned with recurrent symptoms.

CONCLUSIONS

Subtotal fenestrating cholecystectomy is a useful technique to avoid biliary injury in the difficult gallbladder and can be performed with very satisfactory rates of bile fistula, ERCP, and reoperation.

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.

Porta Hepatis Injury during Laparoscopic Cholecystectomy

Iatrogenic porta hepatis injury is a rare but devastating surgical complication of laparoscopic cholecystectomy. There are no systematic studies examining the best treatment strategy in patients with this injury. We present a case of a 23-year-old woman with a large abscess in the right hepatic lobe due to an extreme vasculobiliary injury after laparoscopic cholecystectomy. Although rare, the impact of vasculobiliary injuries after cholecystectomy highlights the need for constant alertness and prompt management in order to minimize mortality and morbidity usually associated with the routine operative procedure.

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

Introduction

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

Aim

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

Material and methods

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

Results

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

Conclusions

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

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.

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.