[Twelve years of laparoscopic cholecystectomy]

Comparative analysis of reliability and clinical effects of the critical view of safety approach used in laparoscopic cholecystectomy in the pediatric population

PURPOSE

With the increase in indications for cholecystectomy in children, the frequency of laparoscopic cholecystectomy procedures and related problems has increased. The Critical View of Safety (CVS) is the target-specific method for identifying the cystic duct during laparoscopic cholecystectomy to prevent common bile duct injury. We hypothesize that the use of CVS is reliable in the pediatric population.

METHODS

Data of 91 patients under 18 years of age who underwent elective laparoscopic cholecystectomy were retrospectively analyzed. Patients were divided into two groups depending on whether CVS was applied. The descriptive characteristics and complications of the two groups were compared.

RESULTS

CVS was applied to 41 patients. When the groups were compared in terms of operation time, postoperative length of stay, idiopathic gallbladder perforation, dropping stone, and presence of surgical site infection, no statistical significant difference was found. However, the time to start oral feeding was shorter in CVS group (p = 0.01).

CONCLUSION

We believe CVS is a reliable method to ensure safe cystic channel identification in the pediatric population. New studies are warranted on the effectiveness of CVS for safely performing laparoscopic cholecystectomy in children, as the procedure is being performed more frequently in the pediatric population.

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.

[Appendectomy in surgical residency. What has changed over the past 10 years?]

BACKGROUND

Surgical residents need to train laparoscopic skills for minimally invasive procedures at an early stage. The aim of this study was the investigation and assessment of appendectomy carried out at a university medical center over the previous decade regarding the frequency of operations by residents in training and the type of surgical technique used (laparoscopic vs. open).

METHODS

A retrospective analysis of appendectomies carried out from 2005 to 2014 at the clinic for general, visceral and transplant surgery was performed. Operators were stratified into two groups (group 1: residents and group 2: fellows/attending surgeons). Surgery was classified as laparoscopic or open appendectomy.

RESULTS

Out of 1,587 appendectomies analyzed 946 were performed laparoscopically (59.6 %). The percentage of laparoscopic appendectomies increased significantly over the decade analyzed (p < 0.001) and reached 94.4 % in 2014. From 2005 until 2007 the rate of appendectomies by residents was 17.9 % (77 out of 430). Laparoscopic appendectomy was performed in 5.8 % and was only performed by fellows or attending surgeons. From 2008 to 2014 the rate of surgeries by residents significantly increased (p < 0.001) and accounted for 57.6 % (range 19.4-66.9 %).

CONCLUSION

Regardless of the surgical technique used, appendectomy is still a primary training operation for surgical residents. An early and focused training of minimally invasive visceral surgery in the new regulations for continuing medical education starts with laparoscopic appendectomy.

Review of various liver retraction techniques in single incision laparoscopic surgery for the exposure of hiatus

BACKGROUND:

The main aspect of concern for upper GI procedures has been the retraction of the liver especially large left lobes as commonly encountered in Bariatric surgery. Not doing so would compromise the view of the hiatus, hence theoretically reducing the quality of the surgery and increasing the possibility of complications. The aim of this study was to review the various liver retraction techniques in single incision surgery being done at our institute and analyze them.

MATERIAL AND METHODS:

A retrospective study of the various techniques and a subsequent analysis was made based on advantages and disadvantages of each method. Objectively a quantitative measure of hiatal exposure was done using a scoring system based on the grade of exposure after reviewing the surgical videos. From January 2011 to January 2013 total 104 patients underwent single incision surgery with the various liver retraction techniques with following grades of exposure -liver suspension tube technique with naso gastric tubing (2.11) and with corrugated drain (2.09) needlescopic method (1.2), Umbilical tape sling (1.95), crural stitch method (2.5). Needeloscopic method has the best grade of exposure and is the easiest to start with. The average time to create the liver retraction was 2.8 to 8.6 min.There was no procedure related morbidity or mortality.

CONCLUSIONS:

The mentioned liver retraction techniques are cost effective and easy to learn. We recommend using these techniques to have a good exposure of hiatus, without compromising the safety of surgery in single incision surgery.

Preoperative prediction of difficult lap chole: a scoring method

BACKGROUND

Laparoscopic cholecystectomy (LC) has become the procedure of choice for management of symptomatic gallstone disease. At times it is easy and can be done quickly. Occasionally it is difficult and takes longer time. But there is no scoring system available to predict the degree of difficulty of LC preoperatively.

AIM

To develop a scoring method to predict difficult LC preoperatively.

MATERIALS AND METHODS

There were 228 cases in 2 years, operated by a single experienced surgeon. There are total 15 score from history, clinical, sonological findings. Score up to 5 predicted easy, 6-10 difficult and >10 are very difficult.

RESULTS

Prediction came true in 88.8% for easy and 92% difficult cases there were no cases with score above 10. The factors like BMI > 27.5 (p < 0.010), previous hospitalization (p < 0.001), palpable GB (p < 0.01) US-Thick-walled GB (p < 0.038) are found of statistical significance in predicting difficult LC.

CONCLUSION

The proposed scoring system is reliable with a sensitivity and specificity of 75.00% and 90.24%, respectively.

Is routine MR cholangiopancreatography (MRCP) justified prior to cholecystectomy?

PURPOSE

We investigated routinely the bile ducts by magnetic resonance cholangiopancreaticography (MRCP) prior to cholecystectomy. The aim of this study was to analyze the rate of clinically inapparent common bile duct (CBD) stones, the predictive value of elevated liver enzymes for CBD stones, and the influence of the radiological results on the perioperative management.

METHODS

In this prospective study, 465 patients were cholecystectomized within 18 months, mainly laparoscopically. Preoperative MRCP was performed in 454 patients.

RESULTS

With MRCP screening, clinically silent CBD stones were found in 4%. Elevated liver enzymes have only a poor predictive value for the presence of CBD stones (positive predictive value, 21%; negative predictive value, 96%). Compared to the recent literature, the postoperative morbidity in this study was low (0 bile duct injury, 0.4% residual gallstones).

CONCLUSIONS

Although MRCP is diagnostically useful in the perioperative management in some cases, its routine use in the DRG-era may not be justified due to the costs.

Single-center experience of laparoscopic cholecystectomy

BACKGROUND

The laparoscopic cholecystectomy procedure is considered as the gold standard for the management of benign symptomatic gallbladder diseases. In this paper, we present our experience as a tertiary reference center in the management of this disease.

METHODS

A total of 9864 laparoscopic cholecystectomies have been performed in our institution since 1991. All patients undergo a routine hematologic work-up, high resolution ultrasonography, and, thereafter, a four-port cholecystectomy by the North American approach. We specifically considered 10 areas of controversy.

RESULTS

The male:female ratio was 45:55, with the average age being 40.4 years (range, 1 year 4 months to 92 years). Asymptomatic patients were 986 in number and 25% had acute cholecystitis, whereas 2.28% had associated choledocholithiasis. The "fundus first" approach was adopted in 88 patients. Three patients had occult gallbladder cancer, of which 2 were in situ and 1 was of the T1 stage. Nearly one third of the patients had gallstone spillage, primarily owing to the performance of a subtotal cholecystectomy procedure in the setting of acute cholecystitis. However, only 1 patient to date has had a problem directly attributable to gallstone spillage. Nearly 13% of patients had an additional procedure along with a cholecystectomy. The average operating time was 21.5 minutes, whereas the average length of postoperative stay was 1.6 days.

CONCLUSIONS

The laparoscopic approach is suitable for the management of all forms of benign gallbladder diseases. In addition, it is possible to use the laparoscopic approach for indications hitherto considered relatively contraindicated. In a dedicated center, it is possible to perform a large number of cases with low morbidity and minimal conversion rates.

Twenty years after Erich Muhe: Persisting controversies with the gold standard of laparoscopic cholecystectomy

This review article is a tribute to the genius of Professor Erich Muhe, a man ahead of his times. We trace the development of laparoscopic cholecystectomy and detail the tribulations faced by Muhe. On the occasion of the twentieth anniversary of the first laparoscopic cholecystectomy, we take another look at some of the controversies surrounding this gold standard in the management of gallbladder disease.