Documenting correct assessment of biliary anatomy during laparoscopic cholecystectomy

Artificial intelligence applied to laparoscopic cholecystectomy: what is the next step? A narrative review

Artificial Intelligence (AI) is playing an increasing role in several fields of medicine. AI is also used during laparoscopic cholecystectomy (LC) surgeries. In the literature, there is no review that groups together the various fields of application of AI applied to LC. The aim of this review is to describe the use of AI in these contexts. We performed a narrative literature review by searching PubMed, Web of Science, Scopus and Embase for all studies on AI applied to LC, published from January 01, 2010, to December 30, 2023. Our focus was on randomized controlled trials (RCTs), meta-analysis, systematic reviews, and observational studies, dealing with large cohorts of patients. We then gathered further relevant studies from the reference list of the selected publications. Based on the studies reviewed, it emerges that AI could strongly improve surgical efficiency and accuracy during LC. Future prospects include speeding up, implementing, and improving the automaticity with which AI recognizes, differentiates and classifies the phases of the surgical intervention and the anatomic structures that are safe and those at risk.

Safety of laparoscopic cholecystectomy performed by trainee surgeons with different cholangiographic techniques (SCOTCH): a prospective non-randomized trial on the impact of fluorescent cholangiography during laparoscopic cholecystectomy performed by trainees

AIMS

The identification of the anatomical components of the Calot's Triangle during laparoscopic cholecystectomy (LC) might be challenging and its difficulty may increase when a surgical trainee (ST) is in charge, ultimately allegedly affecting also the incidence of common bile duct injuries (CBDIs). There are various methods to help reach the critical view of safety (CVS): intraoperative cholangiogram (IOC), critical view of safety in white light (CVS-WL) and near-infrared fluorescent cholangiography (NIRF-C). The primary objective was to compare the use of these techniques to obtain the CVS during elective LC performed by ST.

METHODS

This was a multicentre prospective observational study (Clinicalstrials.gov Registration number: NCT04863482). The impact of three different visualization techniques (IOC, CVS-WL, NIRF-C) on LC was analyzed. Operative time and time to achieve the CVS were considered. All the participating surgeons were also required to fill in three questionnaires at the end of the operation focusing on anatomical identification of the general task and their satisfaction.

RESULTS

Twenty-nine centers participated for a total of 338 patients: 260 CVS-WL, 10 IOC and 68 NIRF-C groups. The groups did not differ in the baseline characteristics. CVS was considered achieved in all the included case. Rates were statistically higher in the NIR-C group for common hepatic and common bile duct visualization (p = 0.046; p < 0.005, respectively). There were no statistically significant differences in operative time (p = 0.089) nor in the time to achieve the CVS (p = 0.626). Three biliary duct injuries were reported: 2 in the CVS-WL and 1 in the NIR-C. Surgical workload scores were statistically lower in every domain in the NIR-C group. Subjective satisfaction was higher in the NIR-C group. There were no other statistically significant differences.

CONCLUSIONS

These data showed that using NIRF-C did not prolong operative time but positively influenced the surgeon's satisfaction of the performance of LC.

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.

Attending guidance advised: educational quality of surgical videos on YouTube

INTRODUCTION

YouTube is the most used platform for case preparation by surgical trainees. Despite its popular use, studies have noted limitations in surgical technique, safety, and vetting of these videos. This study identified the most viewed laparoscopic cholecystectomy (LC) videos on YouTube and analyzed the ability of attendings, residents, and medical students to identify critical portions of the procedure, technique, and limitations of the videos.

METHODS

An incognito search was conducted on YouTube using the term "laparoscopic cholecystectomy." Results were screened for length, publication date, and language. The top ten most viewed videos were presented to general surgery attendings, residents, and medical students at a single academic institution. Established rubrics were used for evaluation, including the Critical View of Safety (CVS) for LC, a modified Global Operative Assessment of Laparoscopic Skills (GOALS) score, a task-specific checklist, and visual analog scales for case difficulty and operator competence. Educational quality and likelihood of video recommendation for case preparation were evaluated using a Likert scale. Attending assessments were considered the gold standard.

RESULTS

Six attending surgeons achieved excellent internal consistency on CVS, educational quality, and likelihood of recommendation scales, with Cronbach alpha (⍺) of 0.93, 0.92, and 0.92, respectively. ⍺ was ≥ 0.7 in all the other scales measured. Attending evaluations revealed that only one of the ten videos attained all three established CVS criteria. Four videos demonstrated none of the CVS criteria. The mean educational quality (mEQ) was 4.63 on a 10-point scale. The mean likelihood of recommendation (mLoR) for case preparation was 2.3 on a 5-point scale. Senior resident assessments (Postgraduate Year (PGY)4 + , n = 12) aligned with attending surgeons, with no statistically significant differences in CVS attainment, mEQ, and mLoR. Junior residents (PGY1-3, n = 17) and medical students (MS3-4, n = 20) exhibited significant difference with attendings in CVS attainment, mEQ, and mLoR for more than half the videos. Both groups tended to overrate videos compared to attendings.

CONCLUSION

YouTube is the most popular unvetted resource used for case presentation by surgical trainees. Attending evaluations revealed that the most viewed LC videos on YouTube did not attain the CVS, and were deemed as inappropriate for case preparation, with low educational value. Senior resident video assessments closely aligned with attendings, while junior trainees were more likely to overstate video quality and value. Attending guidance and direction of trainees to high-quality, vetted resources for surgical case preparation is needed. This may also suggest a need for surgical societies with platforms for video sharing to prioritize the creation and dissemination of high-quality videos on easily accessible public platforms.

It's time for a minimum synoptic operation template in patients undergoing laparoscopic cholecystectomy: a systematic review

BACKGROUND

Despite the call to enhance accuracy and value of operation records few international recommended minimal standards for operative notes documentation have been described. This study undertook a systematic review of existing operative reporting systems for laparoscopic cholecystectomy (LC) to fashion a comprehensive, synoptic operative reporting template for the future.

METHODS

A search for all relevant articles was conducted using PubMed version of Medline, Scopus and Web of Science databases in June 2021, for publications from January 1st 2011 to October 25th 2021, using the keywords: laparoscopic cholecystectomy AND operation notes OR operative notes OR proforma OR documentation OR report OR narrative OR audio-visual OR synoptic OR digital. Two reviewers (NOC, GMC) independently assessed each published study using a MINORS score of ≥ 16 for comparative and ≥ 10 for non-comparative for inclusion. This systematic review followed PRISMA guidelines and was registered with PROSPERO. Synoptic operative templates from published data were assimilated into one "ideal" laparoscopic operative report template following international input from the World Society of Emergency Surgery board.

RESULTS

A total of 3567 articles were reviewed. Following MINORS grading 25 studies were selected spanning 14 countries and 4 continents. Twenty-two studies were prospective. A holistic overview of the operative procedure documentation was reported in 6/25 studies and a further 19 papers dealt with selective surgical aspects of LC. A unique synoptic LC operative reporting template was developed and translated into Chinese/Mandarin, French and Arabic.

CONCLUSION

This systematic review identified a paucity of publications dealing with operative reporting of LC. The proposed new template may be integrated digitally with hospitals' medical systems and include additional narrative text and audio-visual data. The template may help define new OR (operating room) recording standards and impact on care for patients undergoing LC.

Anatomic Variations of the Cystic Duct in Magnetic Resonance Cholangiopancreatography in Shiraz: A Cross-Sectional Study

BACKGROUND

Anatomic variations of the cystic duct (CD) are commonly encountered. Being aware of these variants will reduce complications subsequent to surgical, endoscopic, or percutaneous procedures. Magnetic resonance cholangiopancreatography (MRCP) is the least invasive and the most reliable modality for biliary anatomy surveys. This study aimed to determine the prevalence of cystic duct variations in the Iranian population.

METHODS

In this retrospective cross-sectional study, MRCP images of 350 patients referred to Shiraz Faraparto Medical Imaging and Interventional Radiology Center from October 2017 to October 2018 were reviewed. The CD course and insertion site to the extrahepatic bile duct (EHBD) was determined and documented in 290 cases. Descriptive statistics and Chi square test were applied for data analysis via SPSS software.

RESULTS

About 77% of cases revealed the classic right lateral insertion to the middle third of EHBD. The insertion of CD to the upper third and the right hepatic duct was 10%, and the insertion to the medial aspect of the middle third of EHBD from anterior or posterior was noted to be about 7.6%. From 2.8% of insertions to the lower third, 1% demonstrated parallel course, and finally, 0.3% of cases presented short CD.

CONCLUSION

CD variations are relatively common, and MRCP mapping prior to the hepatobiliary interventions could prevent unexpected consequences.

A Double Cystic Duct With a Single Gallbladder Successfully Treated With Laparoscopic Cholecystectomy: A Challenge to Laparoscopic Surgeons

Although the cystic duct has diverse variations, a double cystic duct is rarely found. Only 20 cases had been reported until late 2017. In the present study, we describe a 58-year-old woman with a double cystic duct who initially presented with a passed stone and pancreatitis concomitant with a gallbladder containing microlithiasis. The double cystic duct was not detected in preoperative endoscopic ultrasonography; and the anomaly was an incidental finding during laparoscopic cholecystectomy. The patient had no postoperative complications and was discharged uneventfully. Postoperative magnetic resonance cholangiography showed a normal biliary tree structure.

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.

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.

Patients support transfer of care for unexpected findings in laparoscopic cholecystectomy

INTRODUCTION

Surgeons often assume patients may be dissatisfied if their operations were stopped due to suspicious intraoperative findings requiring transfer of care. We sought to assess patient opinions regarding transfer of care for unexpected intraoperative findings during laparoscopic cholecystectomy with and without bile duct injury (BDI).

METHODS AND PROCEDURES

The investigators developed two clinical scenarios comparing transfer of care for unexpected intraoperative findings during elective laparoscopic cholecystectomy: without BDI and with BDI requiring open repair. A multi-institutional structured telephone interview process was conducted with patients ≥ 18 years of age who had an outpatient, uncomplicated laparoscopic cholecystectomy within the last year. The first scenario presented a case of suspicious findings prompting the surgeon to stop and transfer for specialized care; whereas the second case was a BDI requiring transfer of care. Textual and thematic analysis as well as descriptive statistics was used for analysis, with significance set at p < 0.05.

RESULTS

Forty-five patients completed the survey. Satisfaction with transfer of care for unexpected intraoperative findings without BDI was 69%, and over 95% of respondents were satisfied their surgeon stopped the procedure to initiate transfer due to safety concerns; 64% of patients would return to that surgeon for postoperative care; and 78% would see that surgeon again. In the scenario with BDI requiring open repair, 86% were satisfied with their surgeon's decision to stop the operation; 91% of patients were satisfied with transfer of care; and 32% would see their first surgeon again. Themes of prioritizing safety and transparency were frequently cited.

CONCLUSIONS

Patients prioritize safety and are satisfied with halting a procedure to facilitate transfer of care for suspicious intraoperative findings during routine laparoscopic cholecystectomy.

THE CRITICAL VIEW OF SAFETY PREVENTS THE APPEARANCE OF BILIARY INJURIES? ANALYSIS OF A SURVEY

BACKGROUND

The risk of bile duct injury (BDI) during cholecystectomy remains a concern, despite efforts proposed for increasing safety. The Critical View of Safety (CVS) has been adopted promoting to reduce its risk.

AIM

To perform a survey to assess the awareness of the CVS, estimating the proportion of surgeons that correctly identified its elements and its relationship with BDI.

METHODS

An anonymous online survey was sent to 2096 surgeons inquiring on their common practices during cholecystectomy and their knowledge of the CVS.

RESULTS

A total of 446 surgeons responded the survey (21%). The percentage of surgeons that correctly identified the elements of CVS was 21.8% and 24.8% among surgeons claiming to know the CVS. The percentage of surgeons that reported BDI was higher among those that incorrectly identified the elements of the CVS (p=0.03). In the multivariate analysis, career length was the most significant factor related to BDI (p=0.002).

CONCLUSIONS

The percentage of surgeons that correctly identified the Critical View of Safety was low, even among those who claimed to know the CVS. The percentage of surgeons that reported BDI was higher among those that incorrectly identified the elements of the CVS.

Evaluation of crowd-sourced assessment of the critical view of safety in laparoscopic cholecystectomy

BACKGROUND

Faculty experts (FE) and crowd workers (CW) can assess technical skill, but assessment of operative technique has not been explored. We sought to evaluate if CW could be taught to assess completion of the critical view of safety (CVS) in laparoscopic cholecystectomy.

METHODS

We prepared 160 blinded, surgical videos of laparoscopic cholecystectomy from public domain websites. Videos were edited to ≤60 s, ending when a structure was cut/clipped. CW analyzed videos using Global Objective Assessment of Laparoscopic Skills (GOALS) and CVS criteria assessment tools after watching an instructional tutorial. Ten videos were randomly selected from each performance quartile based on GOALS. Five FE rated the 40 videos using GOALS and CVS. Linear mixed effects models derived average CW and FE ratings for GOALS and CVS for each video. Spearman correlation coefficients (SCC) were used to assess the degree of correlation between performance measures. Satisfactory completion of the CVS was defined as scoring an average CVS ≥ 5. Videos with an average GOALS ≥ 15 were considered top technical performers.

RESULTS

A high degree of correlation was seen between all performance measures: CVS ratings between CW and FE, SCC 0.89 (p < 0.001); GOALS and CVS ratings SCC 0.77 (p < 0.001) for CW, and SCC 0.71 (p < 0.001) for FE. Sixteen videos were assigned top technical performer ratings by both CW and FE but the average CVS was inadequate (3.8 and 3.6, respectively), and the percentage of satisfactory CVS ≥ 5 was 12.5%.

CONCLUSIONS

A high degree of correlation was found between CW and FE in assessment of the CVS. However, in this video analysis, high technical performers did not achieve a complete CVS in most cases. Educating CW to assess operative technique for the identification of low or average performers is feasible and may broaden the application of this assessment and feedback tool.

Could ICG-aided robotic cholecystectomy reduce the rate of open conversion reported with laparoscopic approach? A head to head comparison of the largest single institution studies

Comparative studies between robotic and laparoscopic cholecystectomy (LC) focus heavily on economic considerations under the assumption of comparable clinical outcomes. Advancement of the robotic technique and the further widespread use of this approach suggest a need for newer comparison studies. 676 ICG-aided robotic cholecystectomies (ICG-aided RC) performed at the University of Illinois at Chicago (UIC) Division of General, Minimally Invasive and Robotic Surgery were compiled retrospectively. Additionally, 289 LC were similarly obtained. Data were compared to the largest single institution LC data sets from within the US and abroad. Statistically significant variations were found between UIC-RC and UIC-LC in minor biliary injuries (p = 0.049), overall open conversion (p ≤ 0.001), open conversion in the acute setting (p = 0.002), and mean blood loss (p < 0.001). UIC-RC open conversions were also significantly lower than Greenville Health System LC (p ≤ 0.001). Additionally, UIC ICG-RC resulted in the lowest percentages of major biliary injuries (0 %) and highest percentage of biliary anomalies identified (2.07 %). ICG-aided cholangiography and the technical advantages associated with the robotic platform may significantly decrease the rate of open conversion in both the acute and non-acute setting. The sample size discrepancy and the non-randomized nature of our study do not allow for drawing definitive conclusions.

Anatomical Variations of Cystic Ducts in Magnetic Resonance Cholangiopancreatography and Clinical Implications

Background. Anatomical variations of cystic duct (CD) are frequently unrecognized. It is important to be aware of these variations prior to any surgical, percutaneous, or endoscopic intervention procedures. Objectives. The purpose of our study was to demonstrate the imaging features of CD and its variants using magnetic resonance cholangiopancreatography (MRCP) and document their prevalence in our population. Materials and Methods. This study included 198 patients who underwent MRCP due to different indications. Images were evaluated in picture archiving communication system (PACS) and variations of CD were documented. Results. Normal lateral insertion of CD at middle third of common hepatic duct was seen in 51% of cases. Medial insertion was seen in 16% of cases, of which 4% were low medial insertions. Low insertion of CD was noted in 9% of cases. Parallel course of CD was present in 7.5% of cases. High insertion was noted in 6% and short CD in 1% of cases. In 1 case, CD was draining into right hepatic duct. Congenital cystic dilation of CD was noted in one case with evidence of type IV choledochal cyst. Conclusion. Cystic duct variations are common and MRCP is an optimal imaging modality for demonstration of cystic duct anatomy.

Are we getting the critical view? A prospective study of photographic documentation during laparoscopic cholecystectomy

BACKGROUND

At laparoscopic cholecystectomy, most surgeons have adopted the operative approach where the 'critical view of safety' (CVS) is achieved prior to dividing the cystic duct and artery. This prospective study evaluated whether an adequate critical view was achieved by scoring standardized intra-operative photographic views and whether there were other factors that might impact on the ability to obtain an adequate critical view.

METHODS

One hundred consecutive patients undergoing a laparoscopic cholecystectomy were studied. At each operation, two photographs were taken. Two independent experienced hepatobiliary surgeons scored the photographs on whether a critical view of safety was achieved. Inter-observer agreement was calculated using the weighted kappa coefficient. The Cochran-Mantel-Haenszel test was used to analyse the scores with potential confounding clinical factors.

RESULTS

The kappa coefficient for adequate display of the cystic duct and artery was 0.49; 95% confidence interval (CI) 0.33 to 0.64; P = 0.001. No bias was detected in the overall scorings between the two observers (χ(2) 1.33; P = 0.312). Other clinical factors including surgeon seniority did not alter the outcome [odds ratio (OR) 0.902; 95% confidence interval 0.622 to 1.264].

CONCLUSION

Heightened awareness of the CVS through mandatory documentation may improve both trainee and surgeon technique.

Effectiveness of intraoperative cholangiography using indocyanine green (versus contrast fluid) for the correct assessment of extrahepatic bile ducts during day-case laparoscopic cholecystectomy

INTRODUCTION

During cholecystectomy, intraoperative cholangiography using contrast fluid (IOC-CF) is still the "gold standard" for biliary tract identification but has many associated pitfalls. A new IOC technique using indocyanine green (IOC-IG) appears to be promising. Here, we studied the effectiveness of IOC-IG (vs IOC-CF) during day-case laparoscopic cholecystectomy.

MATERIALS AND METHODS

Over a 6-month period, we included 23 patients (with no cirrhosis or risk factors for choledocholithiasis) scheduled for day-case laparoscopic cholecystectomy. The primary efficacy criterion was the "analyzability rate" (i.e., the ability to identify the cystic duct, the cystic duct-hepatic duct junction, and the common bile duct) for the IOC-CF and IOC-IG procedures after dissection. Indocyanine green was infused under general anesthesia. The same near-infrared laparoscopic imaging system was used for IOC-IG and conventional visual inspection. IOC-CF was always attempted after dissection. Each patient served as his/her own control. Cholecystectomies were video-recorded for subsequent off-line, blind analysis.

RESULTS

The analyzability rate was 74 % for IOC-IG after dissection, 70 % for IOC-CF (p = 0.03), 26 % for conventional visual inspection, and 48 % for IOC-IG before dissection. When each IOC modality (conventional visual inspection, IOC-IG before and after dissection) was considered as a diagnostic test, the accuracy for simultaneous identification of the three anatomic elements was respectively 48, 52, and 74 %. No adverse events occurred during the IOC-IG procedure.

CONCLUSION

IOC-IG was feasible and safe. Our results suggest that this technique is more effective than IOC-CF for biliary tract identification after dissection and may constitute a powerful diagnostic test for the detection of extrahepatic ducts.

Impact of routine intraoperative cholangiography during laparoscopic cholecystectomy on bile duct injury

BACKGROUND

The role of intraoperative cholangiography (IOC) in the diagnosis, prevention and management of bile duct injury (BDI) remains controversial. The aim of the present study was to determine the value of routine IOC in the diagnosis and management of BDI sustained during laparoscopic cholecystectomy (LC) at a high-volume centre.

METHODS

A retrospective analysis of a single-institution database was performed. Patients who underwent LC with routine IOC between October 1991 and May 2012 were included.

RESULTS

Among 11,423 consecutive LCs IOC was performed successfully in 95.7 per cent of patients. No patient had IOC-related complications. Twenty patients (0.17 per cent) sustained a BDI during LC, and the diagnosis was made during surgery in 18 patients. Most BDIs were type D according to the Strasberg classification. The sensitivity of IOC for the detection of BDI was 79 per cent; specificity was 100 per cent. All injuries diagnosed during surgery were repaired during the same surgical procedure. Two patients developed early biliary strictures that were treated by percutaneous dilatation and a Roux-en-Y hepaticojejunostomy with satisfactory long-term results.

CONCLUSION

The routine use of IOC during LC in a high-volume teaching centre was associated with a low incidence of BDI, and facilitated detection and repair during the same surgical procedure with a good outcome.

A simple effective method for generation of a permanent record of the Critical View of Safety during laparoscopic cholecystectomy by intraoperative "doublet" photography

BACKGROUND

The Critical View of Safety (CVS) is an established method for identifying the cystic duct during laparoscopic cholecystectomy. Its goal is to prevent misidentification of the bile ducts and avoid biliary injury. However, a visual record of CVS is not usually made. Intraoperative photography has the potential to record CVS and increase the safety of laparoscopic cholecystectomy. The objective of this study was to develop a simple and effective technique for recording CVS during laparoscopic cholecystectomy.

STUDY DESIGN

Techniques for photographing and rating photographs of CVS were developed. Surgeons were trained in methods of photographing both anterior and posterior views of CVS during laparoscopic cholecystectomy. Independent observers scored these views individually and together. The term doublet view was used when both anterior and posterior views of CVS were used for rating. Three criteria for CVS were used for scoring photographs. A total score of ≥ 5 of 6 points was considered satisfactory, and a total score <5 of 6 points was considered unsatisfactory.

RESULTS

Photographs of 28 patients were obtained. Critical View of Safety photographs were satisfactory in either anterior or posterior single images in 43 of 56 (76.8%) instances, and doublet photographs were satisfactory in 27 of 28 (96.4%) instances (p = 0.02). Body mass index >40 predicted a higher likelihood of unsatisfactory individual CVS photos (p = 0.02); however, there was no correlation between patient or pathologic factors and the scores of doublet views.

CONCLUSIONS

With training and adherence to straightforward photographic techniques, intraoperative doublet photography can record CVS accurately. This method is performed easily, and could be used for recording of CVS in the medical record.

Intraoperative cholangiography in the laparoscopic cholecystectomy era: why are we still debating?

Laparoscopic cholecystectomy is now one of the most frequently performed abdominal surgical procedures in the world. The most common major complication is bile duct injury, which can have catastrophic repercussions for patients and it has been suggested that intraoperative cholangiography may reduce the rate of bile duct injury. Whether this procedure should be performed routinely is still an active subject of debate. We discuss the available evidence and likely implications for the future.