Use of stapling devices for safe cholecystectomy in acute cholecystitis

Safety and efficacy of using stapler device for wide cystic duct ligation in acute setting of laparoscopic cholecystectomy

This research explores the challenges posed by variations in cystic duct anatomy during laparoscopic cholecystectomy and the potential use of stapler devices to address such complexities. It aims to assess the safety and efficacy of stapler devices, particularly in cases involving short, and wide cystic duct. The study, conducted at King Abdulaziz Medical City in Riyadh, Saudi Arabia, between 2021 and 2023. The study design involved a retrospective cohort approach, and the sample size encompassed all cases meeting the inclusion criteria during the study period. Data was analyzed using SPSS program. The study involving 568 patients, with the predominant technique for ligation being clipping (89.3%). The primary indication for using the Endo GIA stapler was a wide cystic duct (6.2%). Analysis revealed a significant association between stapler device use and hypertension (p = 0.042), diabetes (p = 0.001), CKD (p = 0.011), and obstructive jaundice (p = 0.006). Multivariate regression demonstrated that older patients were 2.1 times more likely to use stapler devices (AOR = 2.125; p = 0.039), while those with obstructive jaundice had a 2.2 times higher likelihood (AOR = 2.168; p = 0.049). Throughout the years, metal clips have shown the best prognosis compared to any other method for securing the cystic duct during closure in laparoscopic cholecystectomy. However, to avoid incomplete sealing of wide, short, or inflamed ducts, other instruments have emerged as possible alternatives for such conditions. Use of Endo-GIA is a safe and effective method for patients with wide, short cystic duct. Selective usage of endo-GIA is considered cost effective and may add a positive impact in decreasing post operative biliary leak.

Evidence-based surgery for laparoscopic cholecystectomy

Background

Laparoscopic cholecystectomy is frequently performed for acute cholecystitis and symptomatic cholelithiasis. Considerable variation in the execution of key steps of the operation remains. We conducted a systematic review of evidence regarding best practices for critical intraoperative steps for laparoscopic cholecystectomy.

Methods

We identified 5 main intraoperative decision points in laparoscopic cholecystectomy: (1) number and position of laparoscopic ports; (2) identification of cystic artery and duct; (3) division of cystic artery and duct; (4) indications for subtotal cholecystectomy; and (5) retrieval of the gallbladder. PubMed, EMBASE, and Web of Science were queried for relevant studies. Randomized controlled trials and systematic reviews were included for analysis, and evidence quality was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation framework.

Results

Fifty-two articles were included. Although all port configurations were comparable from a safety standpoint, fewer ports sometimes resulted in improved cosmesis or decreased pain but longer operative times. The critical view of safety should be obtained for identification of the cystic duct and artery but may be obtained through fundus-first dissection and augmented with cholangiography or ultrasound. Insufficient evidence exists to compare harmonic-shear, clipless ligation against clip ligation of the cystic duct and artery. Stump closure during subtotal cholecystectomy may reduce rates of bile leak and reoperation. Use of retrieval bag for gallbladder extraction results in minimal benefit. Most studies were underpowered to detect differences in incidence of rare complications.

Conclusion

Key operative steps of laparoscopic cholecystectomy should be informed by both compiled data and surgeon preference/patient considerations.

Novel laparoscopic cornual resection of interstitial pregnancy using the Endo GIA™ Universal Stapler (Medtronic): A series of 12 cases

BACKGROUND

The maternal mortality of interstitial pregnancy is five times greater than that of other ectopic gestations due to potential haemorrhage. Minimal access surgical techniques usually comprise cornual resection and cornuostomy, requiring laparoscopic suturing skills.

AIM

To describe a case series using a laparoscopic automatic stapling device with reloadable cartridges to resect the cornu, enabling surgeons less familiar with intracorporeal suturing to avoid laparotomy when managing interstitial pregnancy.

MATERIALS AND METHODS

Twelve cases of laparoscopic cornual resections for interstitial pregnancies with the Endo GIA™ Universal Stapler (Medtronic) were collected prospectively over eight years. Outcome measures include human chorionic gonadotropin beta subunit (hβCG) levels, successful laparoscopic completion, estimated blood loss, intra-and post-operative complications and length of stay.

RESULTS

Median age and gestation at surgery were 31 years (range: 20-44) and eight weeks (range: 5-12), respectively. All involved live interstitial gestations, and 4/12 cases had significant haemoperitoneum at laparoscopy. The median blood loss was 300 mL (range 100-3500), and five women had blood loss >500 mL. The median serum hβCG level was 6429 IU/L (range: 1800-58690), and the median ectopic size was 4 cm (range 2-6). All cases were completed laparoscopically with no intra- or post-operative complications, although two women required blood transfusions. Median length of stay was 40 h. Further pregnancies could only be followed in 2/12 cases due to the migratory nature of our local population.

CONCLUSION

We describe a case series of 12 laparoscopic cornual resections for interstitial pregnancies using Endo GIA™ Universal Stapler, which simultaneously staples and transects the tissues, thus minimising the need for laparoscopic intracorporeal suturing.