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Mehta P, Owen D, Grammatikopoulou M, Culshaw L, Kerr K, Stoyanov D, Luengo I. Hierarchical segmentation of surgical scenes in laparoscopy. Int J Comput Assist Radiol Surg 2024:10.1007/s11548-024-03157-4. [PMID: 38914722 DOI: 10.1007/s11548-024-03157-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 04/20/2024] [Indexed: 06/26/2024]
Abstract
PURPOSE Segmentation of surgical scenes may provide valuable information for real-time guidance and post-operative analysis. However, in some surgical video frames there is unavoidable ambiguity, leading to incorrect predictions of class or missed detections. In this work, we propose a novel method that alleviates this problem by introducing a hierarchy and associated hierarchical inference scheme that allows broad anatomical structures to be predicted when fine-grained structures cannot be reliably distinguished. METHODS First, we formulate a multi-label segmentation loss informed by a hierarchy of anatomical classes and then train a network using this. Subsequently, we use a novel leaf-to-root inference scheme ("Hiera-Mix") to determine the trade-off between label confidence and granularity. This method can be applied to any segmentation model. We evaluate our method using a large laparoscopic cholecystectomy dataset with 65,000 labelled frames. RESULTS We observed an increase in per-structure detection F1 score for the critical structures, when evaluated across their sub-hierarchies, compared to the baseline method: 6.0% for the cystic artery and 2.9% for the cystic duct, driven primarily by increases in precision of 11.3% and 4.7%, respectively. This corresponded to visibly improved segmentation outputs, with better characterisation of the undissected area containing the critical structures and fewer inter-class confusions. For other anatomical classes, which did not stand to benefit from the hierarchy, performance was unimpaired. CONCLUSION Our proposed hierarchical approach improves surgical scene segmentation in frames with ambiguity, by more suitably reflecting the model's parsing of the scene. This may be beneficial in applications of surgical scene segmentation, including recent advancements towards computer-assisted intra-operative guidance.
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Affiliation(s)
| | - David Owen
- Medtronic Digital Technologies, London, UK
| | | | | | - Karen Kerr
- Medtronic Digital Technologies, London, UK
| | - Danail Stoyanov
- Medtronic Digital Technologies, London, UK
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
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Wang S, Yuan W, Yu A, Gu W, Wang T, Zhang C, Zhang C. Efficacy of different indocyanine green doses in fluorescent laparoscopic cholecystectomy: A prospective, randomized, double-blind trial. J Surg Oncol 2024; 129:1534-1541. [PMID: 38736301 DOI: 10.1002/jso.27684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Revised: 04/25/2024] [Accepted: 05/06/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND AND OBJECTIVES Intraoperative bile duct injury is a significant complication in laparoscopic cholecystectomy (LC). Near-infrared fluorescence cholangiography (NIFC) can reduce this complication. Therefore, determining the optimal indocyanine green (ICG) dosage for effective NIFC is crucial. This study aimed to determine the optimal ICG dosage for NIFC. METHODS This was a prospective, randomized, double-blind clinical trial at a single tertiary referral center, including 195 patients randomly assigned to three groups: lower dose (0.01 mg/BMI) ICG (n = 63), medium dose (0.02 mg/BMI) ICG (n = 68), and higher dose (0.04 mg/BMI) ICG (n = 64). Surgeon satisfaction and detection rates for seven biliary structures were compared among the three dose groups. RESULTS Demographic parameters did not significantly differ among the groups. The medium dose (72.1%) and higher dose ICG groups (70.3%) exhibited superior visualization of the common hepatic duct compared to the lower dose group (41.3%) (p < 0.001). No differences existed between the medium and higher dose groups. Similar trends were observed for the common bile duct and cystic common bile duct junction. CONCLUSIONS In patients undergoing fluorescent laparoscopic cholecystectomy, the 0.02 mg/BMI dose of indocyanine green demonstrated better biliary structure detection rates than the 0.01 mg/BMI dose and was non-inferior to the 0.04 mg/BMI dose.
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Affiliation(s)
- Siyu Wang
- Department of General Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Wenkang Yuan
- Department of General Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Anhai Yu
- Department of General Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Wang Gu
- Department of General Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Tianqi Wang
- Department of General Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Chong Zhang
- Department of General Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Chao Zhang
- Department of General Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei, China
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Gutierrez JV, Chen DG, Yheulon CG, Mangieri CW. Acute cholecystitis, obesity, and steatohepatitis constitute the lethal triad for bile duct injury (BDI) during laparoscopic cholecystectomy. Surg Endosc 2024:10.1007/s00464-024-10727-9. [PMID: 38459210 DOI: 10.1007/s00464-024-10727-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 01/28/2024] [Indexed: 03/10/2024]
Abstract
OBJECTIVE The most feared complication during laparoscopic cholecystectomy remains a bile duct injury (BDI). Accurately risk-stratifying patients for a BDI remains difficult and imprecise. This study evaluated if the lethal triad of acute cholecystitis, obesity, and steatohepatitis is a prognostic measure for BDI. METHODS A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) registry was performed. All laparoscopic cholecystectomy cases within the main NSQIP database for 2012-2019 were queried. Two study cohorts were constructed. One with the lethal triad of acute cholecystitis, BMI ≥ 30, and steatohepatitis. The other cohort did not have the full triad present. Multivariate analysis was performed via logistic regression modeling with calculation of odds ratios (OR) to identify independent factors for BDI. An uncontrolled and controlled propensity score match analysis was performed. RESULTS A total of 387,501 cases were analyzed. 36,887 cases contained the lethal triad, the remaining 350,614 cases did not have the full triad. 860 BDIs were identified resulting in an overall incidence rate 0.22%. There were 541 BDIs within the lethal triad group with 319 BDIs in the other cohort and an incidence rate of 1.49% vs 0.09% (P < 0.001). Multivariate analysis identified the lethal triad as an independent risk factor for a BDI by over 15-fold (OR 16.35, 95%CI 14.28-18.78, P < 0.0001) on the uncontrolled analysis. For the controlled propensity score match there were 29,803 equivalent pairs identified between the cohorts. The BDI incidence rate remained significantly higher with lethal triad cases at 1.65% vs 0.04% (P < 0.001). The lethal triad was an even more significant independent risk factor for BDI on the controlled analysis (OR 40.13, 95%CI 7.05-356.59, P < 0.0001). CONCLUSIONS The lethal triad of acute cholecystitis, obesity, and steatohepatitis significantly increases the risk of a BDI. This prognostic measure can help better counsel patients and potentially alter management.
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Affiliation(s)
- Joseph V Gutierrez
- Division of Surgery, General Surgery, Department of Surgery, Tripler Army Medical Center, 1 Jarrett White Road, Honolulu, HI, 96859, USA.
| | - Daniel G Chen
- Division of Surgery, General Surgery, Department of Surgery, Tripler Army Medical Center, 1 Jarrett White Road, Honolulu, HI, 96859, USA
| | - Christopher G Yheulon
- Division of Surgery, General Surgery, Department of Surgery, Tripler Army Medical Center, 1 Jarrett White Road, Honolulu, HI, 96859, USA
- Department of General Surgery, Emory University School of Medicine, 201 Dowman Drive, Atlanta, GA, 30322, USA
| | - Christopher W Mangieri
- Division of Surgery, General Surgery, Department of Surgery, Tripler Army Medical Center, 1 Jarrett White Road, Honolulu, HI, 96859, USA
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Ortenzi M, Corallino D, Botteri E, Balla A, Arezzo A, Sartori A, Reddavid R, Montori G, Guerrieri M, Williams S, Podda M. 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. Surg Endosc 2024; 38:1045-1058. [PMID: 38135732 DOI: 10.1007/s00464-023-10613-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 11/26/2023] [Indexed: 12/24/2023]
Abstract
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.
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Affiliation(s)
- Monica Ortenzi
- Department of General and Emergency Surgery, Università Politecnica delle Marche, Ancona, Italy.
| | - Diletta Corallino
- Department of General Surgery and Surgical Specialties, Sapienza University of Rome, Rome, Italy
| | - Emanuele Botteri
- General Surgery, ASST Spedali Civili di Brescia PO Montichiari, Montichiari, Brescia, Italy
| | - Andrea Balla
- Coloproctology and Inflammatory Bowel Disease Surgery Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- UOC of General and Minimally Invasive Surgery, Hospital "San Paolo", Largo Donatori del Sangue 1, Civitavecchia, 00053, Rome, Italy
- Department of Surgical Sciences, University of Torino, Turin, Italy
| | - Alberto Arezzo
- Department of General Surgery, Ospedale Di Montebelluna, Montebelluna, Treviso, Italy
| | - Alberto Sartori
- Department of Colorectal Surgery, King's College Hospital, London, UK
| | | | | | - Mario Guerrieri
- Department of General and Emergency Surgery, Università Politecnica delle Marche, Ancona, Italy
| | | | - Mauro Podda
- Department of Surgical Science, University of Cagliari, Cagliari, Italy
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Baldari L, Boni L, Kurihara H, Cassinotti E. Identification of the ideal weight-based indocyanine green dose for fluorescent cholangiography. Surg Endosc 2023; 37:7616-7624. [PMID: 37474826 DOI: 10.1007/s00464-023-10280-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 07/02/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND Ideal visualization of fluorescent cholangiography during laparoscopic cholecystectomy is when maximum fluorescence into biliary ducts and absent signal into liver parenchyma, defined as "signal to background ratio" (SBR), is obtained. Such condition is mainly dependent by indocyanine green (ICG) dose and timing. The aim of this study was to identify the ideal ICG dose to obtain the best possible intraoperative visualization of the extra-hepatic biliary tree. METHODS The first part of the study was used to define a range of small weight-based ICG dosages using the mathematical function bisection method. During the second part of the study, the midpoint dose of the identified range, was tested in 50 consecutive cholecystectomies using a laser-based fluorescence laparoscopic camera (SynergyID system by Arthrex, Naples, FL, USA). Timing administration was set at 1 h before surgery, since this is the most common situation in clinical practice. Fluorescence intensity of bile ducts and liver parenchyma were assessed both subjectively, by blinded operative surgeon, as well as objectively, using an image analysis software (Fiji plugin), before and after Calot's triangle dissection. RESULTS Fourteen patients were included in the first part of the study and ICG dose between 0.01191406 and 0.0119873 mg/kg was identified. The second part confirmed previous results after testing the dosage equal to 0.0119 mg/kg (midpoint of the defined range) in 50 consecutive cholecystectomies. Cystic duct was identified in 66 and 100% of cases before and after dissection of Calot's triangle respectively. On the other hand, common bile duct was identified in 82 and 92% before and after dissection respectively. Subjective and objective SBRs confirmed the benefit of the identified ICG dose. CONCLUSION ICG dose calculated by 0.0119 mg/kg administered one hour before surgery allows an ideal intraoperative visualization of the extra-hepatic biliary tree. REGISTRATION NUMBER ISRCTN10190039.
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Affiliation(s)
- Ludovica Baldari
- Department of General and Minimally-Invasive Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy.
| | - Luigi Boni
- Department of General and Minimally-Invasive Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
- Department of Scienze Cliniche e Delle Comunità, Univeristy of Milan, Via Festa del Perdono 7, 20122, Milan, Italy
| | - Hayato Kurihara
- Department of General and Minimally-Invasive Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
| | - Elisa Cassinotti
- Department of General and Minimally-Invasive Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
- Department of Scienze Cliniche e Delle Comunità, Univeristy of Milan, Via Festa del Perdono 7, 20122, Milan, Italy
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Temperley HC, O'Sullivan NJ, Grainger R, Bolger JC. Is the use of a routine intraoperative cholangiogram necessary in laparoscopic cholecystectomy? Surgeon 2023; 21:e242-e248. [PMID: 36710125 DOI: 10.1016/j.surge.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 12/20/2022] [Accepted: 01/08/2023] [Indexed: 01/29/2023]
Abstract
INTRODUCTION Although laparoscopic cholecystectomy (LC) has been standard of care for symptomatic gallstone disease for almost 30 years, the use of routine intraoperative cholangiogram (IOC) remains controversial. There are marked variations in the use IOC during LC internationally. Debate has continued about its benefit, in part because of inconsistent benefit, time, and resources required to complete IOC. This literature review is presented as a debate to outline the arguments in favour of and against routine IOC in laparoscopic cholecystectomy. METHODS A standard literature review of PubMed, Medline, OVID, EMBASE, CINHIL and Web of Science was performed, specifically for literature pertaining to the use of IOC or alternative intra-operative methods for imaging the biliary tree in LC. Two authors assembled the evidence in favour, and two authors assembled the evidence against. RESULTS From this controversies piece we found that there is little discernible change in the number of BDIs requiring repair procedures. Although IOC is associated with a small absolute reduction in bile duct injury, there are other confounding factors, including a change in laparoscopic learning curves. Alternative technologies such as intra-operative ultrasound, indocyanine green imaging, and increased access to ERCP may contribute to a reduction in the need for routine IOC. CONCLUSIONS In spite of 30 years of accumulating evidence, routine IOC remains controversial. As technology advances, it is likely that alternative methods of imaging and accessing the bile duct will supplant routine IOC.
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Affiliation(s)
| | | | - Richard Grainger
- Department of Surgery, Tallaght University Hospital, Dublin 24, Ireland
| | - Jarlath C Bolger
- Department of Surgery, Toronto General Hospital/University Health Network, Toronto, ON, Canada; Department of Surgery, Royal College of Surgeons in Ireland, Dublin 2, Ireland
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Toale C, O'Byrne A, Morris M, Kavanagh DO. Characterizing individual trainee learning curves in surgical training: Challenges and opportunities. Surgeon 2023; 21:285-288. [PMID: 36446700 DOI: 10.1016/j.surge.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 11/09/2022] [Indexed: 11/27/2022]
Abstract
The surgical learning curve is an observable and measurable phenomenon. In the era of competency-based approaches to surgical training, monitoring the trajectory of individual trainee competence attainment could represent a meaningful method of formative and summative assessment. While technology can assist this approach, a number of significant barriers to the implementation of such assessment methods remain, including: accurate data collection, standard setting, and reliable assessment. Translating individual learning curve data into quantifiable case minimum targets in training poses further difficulties, and may not be possible for all procedures, particularly those that are less frequently performed and assessed. In spite of these challenges, significant benefits could be realized through an individualized approach to competency assessment using trainee learning curve data. Tracking competence acquisition against criterion-referenced standards could allow for targeted training and remediation, conforming with modern theories of adult education and empowering trainees to take control of their own learning. Learning curve data could also be used to assess the effects of educational interventions such as simulation-based training on subsequent competence acquisition rates. Ultimately, the individual learning curves of trainees could be used to inform personalised decisions regarding entrustment, credentialing, and certification, allowing training programmes to move beyond minimum operative experience targets as a crude proxy measure of competence.
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Affiliation(s)
- C Toale
- Department of Surgical Affairs, Royal College of Surgeons in Ireland, Ireland.
| | - A O'Byrne
- School of Medicine, Trinity College Dublin, The University of Dublin, Ireland; Department of Surgery, Tallaght University Hospital, Dublin, Ireland
| | - M Morris
- Department of Surgical Affairs, Royal College of Surgeons in Ireland, Ireland
| | - D O Kavanagh
- Department of Surgical Affairs, Royal College of Surgeons in Ireland, Ireland; Department of Surgery, Tallaght University Hospital, Dublin, Ireland
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Borie F, Sabbagh C, Fabre JM, Fuchshuber P, Gravié JF, Gugenheim J, Asbun H. SAGES SAFE CHOLE program changes surgeons practice in France-results of the FCVD implementation of SAFE CHOLE in France. Surg Endosc 2023; 37:6483-6490. [PMID: 37253869 DOI: 10.1007/s00464-023-10128-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/08/2023] [Indexed: 06/01/2023]
Abstract
BACKGROUND With the Society of Gastrointestinal and Endoscopic Surgeons supervision, the Safe Cholecystectomy Task Force (SAFE CHOLE) was translated into French by the the Federation of Visceral and Digestive Surgery (FCVD) and adopted to run on its national e-learning platform for surgical continuing medical education (CME). The objective of this study was to assess the impact of the SAFE CHOLE (SF) program on the knowledge and practice of French surgeons performing cholecystectomy and participating in the FCVD lead CME activity. METHODS To obtain CME certification, each participant must fill out three FCVD validated questionnaires regarding (1) the participants' routine practice for cholecystectomy, (2) the participants' knowledge and practice after successful completion of the program, and (3) the educational value of the SC program. RESULTS From 2021 to 2022, 481 surgeons completed the program. The overall satisfaction rate for the program was 81%, and 53% of the surgeons were practicing routine cholangiography before the SC program. Eighty percent declared having acquired new knowledge. Fifty-six percent reported a change in their practice of cholecystectomy. Of those, 46% started routinely using the critical view of safety, 12% used a time-out prior transection of vital structures, and 11% adopted routine intraoperative cholangiography. Sixty-seven percent reported performing a sub-total cholecystectomy in case the CVS was unobtainable. If faced with BDI, 45% would transfer to a higher level of care, 33% would seek help from a colleague, and 10% would proceed with a repair. Ninety percent recommended adoption of SC by all general surgeons and 98% reported improvement of patient safety. CONCLUSIONS Large-scale implementation of the SC program in France is feasible within a broad group of diverse specialty surgeons and appears to have a significant impact on their practice. These data should encourage other surgeons and health systems to engage in this program.
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Affiliation(s)
- Frederic Borie
- Federation of Visceral and Digestive Surgery (FCVD), 12 rue Bayard, 31000, Toulouse, France.
- Research Unit INSERM University of Montpellier, IDESP Institute Desbrest of Epidemiology and Public Health, Montpellier, France.
| | - Charles Sabbagh
- Federation of Visceral and Digestive Surgery (FCVD), 12 rue Bayard, 31000, Toulouse, France
| | - Jean-Michel Fabre
- Federation of Visceral and Digestive Surgery (FCVD), 12 rue Bayard, 31000, Toulouse, France
| | | | - Jean-François Gravié
- Federation of Visceral and Digestive Surgery (FCVD), 12 rue Bayard, 31000, Toulouse, France
| | - Jean Gugenheim
- Federation of Visceral and Digestive Surgery (FCVD), 12 rue Bayard, 31000, Toulouse, France
| | - Horacio Asbun
- Baptist Health Miami Cancer Institute, Miami, FL, USA
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Humm G, Peckham-Cooper A, Hamade A, Wood C, Dawas K, Stoyanov D, Lovat LB. Automated analysis of intraoperative phase in laparoscopic cholecystectomy: A comparison of one attending surgeon and their residents. JOURNAL OF SURGICAL EDUCATION 2023; 80:994-1004. [PMID: 37164903 PMCID: PMC10664073 DOI: 10.1016/j.jsurg.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 03/12/2023] [Accepted: 04/14/2023] [Indexed: 05/12/2023]
Abstract
OBJECTIVE This study compares the intraoperative phase times in laparoscopic cholecystectomy performed by an attending surgeon and supervised residents over 10-years to assess operative times as a marker of performance and any impact of case severity on times. DESIGN Laparoscopic cholecystectomy videos were uploaded to Touch Surgery™ Enterprise, a combined software and hardware solution for securely recording, storing, and analysing surgical videos, which provide analytics of intraoperative phase times. Case severity and visualisation of the critical view of safety (CVS) were manually assessed using modified 10-point intraoperative gallbladder scoring system (mG10) and CVS scores, respectively. Attending and residents' times were compared unmatched and matched by mG10. SETTING Secondary analysis of anonymized laparoscopic cholecystectomy video, recorded as standard of care. PARTICIPANTS Adult patients who underwent elective laparoscopic cholecystectomy a single UK hospital. Cases were performed by one attending and their residents. RESULTS 159 (attending=96, resident=63) laparoscopic cholecystectomy videos and intraoperative phase times were reviewed on Touch Surgery™ Enterprise and analyzed. Attending cases were more challenging (p=0.037). Residents achieved higher CVS scores (p=0.034) and showed longer dissection of hepatocystic triangle (HCT) times (p=0.012) in more challenging cases. Residents' total operative time (p=0.001) and dissection of HCT (p=0.002) times exceeded the attending's in low-severity matched cases (mG10=1). Residents' total operative times (p<0.001), port insertion/gallbladder exposure (p=0.032), and dissection of HCT (p<0.001) exceeded the attending's in matched cases (mG10=2). Residents' total operative (p<0.001), dissection of HCT (p<0.001), and gallbladder dissection (p=0.010) times exceeded the attendings in unmatched cases. CONCLUSIONS Residents' total operative and dissection of HCT times significantly exceeded the attending's unmatched cases and low-severity matched cases which could suggest training need, however, also reflects an expected assessment of competence, and validates time as a marker of performance.
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Affiliation(s)
- Gemma Humm
- Wellcome/ Engineering and Physical Sciences Research Council Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom; UCL Division of Surgery and Interventional Science, University College London, London, United Kingdom.
| | - Adam Peckham-Cooper
- Leeds Institute of Emergency General Surgery, St James University Hospital, Leeds, United Kingdom
| | - Ayman Hamade
- Department of General and Colorectal Surgery. East Kent University Hospitals NHS Foundation Trust, Queen Elizabeth the Queen Mother Hospital, Margate, United Kingdom
| | - Christopher Wood
- UCL Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Khaled Dawas
- UCL Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Danail Stoyanov
- Wellcome/ Engineering and Physical Sciences Research Council Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
| | - Laurence B Lovat
- Wellcome/ Engineering and Physical Sciences Research Council Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom; UCL Division of Surgery and Interventional Science, University College London, London, United Kingdom
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Wu S, Chen Z, Liu R, Li A, Cao Y, Wei A, Liu Q, Liu J, Wang Y, Jiang J, Ying Z, An J, Peng B, Wang X. SurgSmart: an artificial intelligent system for quality control in laparoscopic cholecystectomy: an observational study. Int J Surg 2023; 109:1105-1114. [PMID: 37039533 PMCID: PMC10389595 DOI: 10.1097/js9.0000000000000329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 02/22/2023] [Indexed: 04/12/2023]
Abstract
BACKGROUND The rate of bile duct injury in laparoscopic cholecystectomy (LC) continues to be high due to low critical view of safety (CVS) achievement and the absence of an effective quality control system. The development of an intelligent system enables the automatic quality control of LC surgery and, eventually, the mitigation of bile duct injury. This study aims to develop an intelligent surgical quality control system for LC and using the system to evaluate LC videos and investigate factors associated with CVS achievement. MATERIALS AND METHODS SurgSmart, an intelligent system capable of recognizing surgical phases, disease severity, critical division action, and CVS automatically, was developed using training datasets. SurgSmart was also applied in another multicenter dataset to validate its application and investigate factors associated with CVS achievement. RESULTS SurgSmart performed well in all models, with the critical division action model achieving the highest overall accuracy (98.49%), followed by the disease severity model (95.45%) and surgical phases model (88.61%). CVSI, CVSII, and CVSIII had an accuracy of 80.64, 97.62, and 78.87%, respectively. CVS was achieved in 4.33% in the system application dataset. In addition, the analysis indicated that surgeons at a higher hospital level had a higher CVS achievement rate. However, there was still considerable variation in CVS achievement among surgeons in the same hospital. CONCLUSIONS SurgSmart, the surgical quality control system, performed admirably in our study. In addition, the system's initial application demonstrated its broad potential for use in surgical quality control.
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Affiliation(s)
- Shangdi Wu
- Division of Pancreatic Surgery, Department of General Surgery
- West China School of Medicine
| | - Zixin Chen
- Division of Pancreatic Surgery, Department of General Surgery
- West China School of Medicine
| | - Runwen Liu
- ChengDu Withai Innovations Technology Company
| | - Ang Li
- Division of Pancreatic Surgery, Department of General Surgery
- Guang’an People’s Hospital, Guang’an, Sichuan Province, China
| | - Yu Cao
- Operating Room
- West China School of Nursing, Sichuan University
| | - Ailin Wei
- Guang’an People’s Hospital, Guang’an, Sichuan Province, China
| | | | - Jie Liu
- ChengDu Withai Innovations Technology Company
| | - Yuxian Wang
- ChengDu Withai Innovations Technology Company
| | - Jingwen Jiang
- West China Biomedical Big Data Center, West China Hospital of Sichuan University
- Med-X Center for Informatics, Sichuan University, Chengdu
| | - Zhiye Ying
- West China Biomedical Big Data Center, West China Hospital of Sichuan University
- Med-X Center for Informatics, Sichuan University, Chengdu
| | - Jingjing An
- Operating Room
- West China School of Nursing, Sichuan University
| | - Bing Peng
- Division of Pancreatic Surgery, Department of General Surgery
- West China School of Medicine
| | - Xin Wang
- Division of Pancreatic Surgery, Department of General Surgery
- West China School of Medicine
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11
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Zhu H, Liu D, Zhou D, Wu J, Yu Y, Jin Y, Ye D, Ding C, Zhang X, Huang B, Peng S, Li J. Effectiveness of no drainage after elective day-case laparoscopic cholecystectomy, even with intraoperative gallbladder perforation: a randomized controlled trial. Langenbecks Arch Surg 2023; 408:112. [PMID: 36856748 DOI: 10.1007/s00423-023-02846-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 02/18/2023] [Indexed: 03/02/2023]
Abstract
BACKGROUND Laparoscopic cholecystectomy (LC) has been carried out as day-case surgery. Current guidelines do not mention the role of drainage after LC. In particular, data stay blank with no prospective study on drainage management when gallbladder perforation (GP) accidentally occurs intraoperatively. METHODS A randomized controlled trial was conducted to compare clinical outcomes of drainage and no drainage after elective day-case LC. Intraoperative GP was recorded. The primary and secondary outcomes were major and minor complications, respectively. RESULTS Two hundred patients were randomized. No major complications occurred in either group. In secondary outcomes, nausea/vomiting, pain, hospital stay, and cost were similar in the drainage group and no drainage group; postoperative fever, WBC, and CRP levels were significantly lower in the no drainage group. GP occurred in 32 patients. Male patients with higher BMI and CRP and abdominal pain within 1 month were more likely to occur GP. Subgroup analysis of GP, primary outcomes, and most secondary outcomes had no difference. Postoperative WBC and CRP were higher in the drainage group. Postoperative fever occurred in 63 patients. Univariate analysis of fever showed that blood loss, drainage, postoperative WBC, CRP, and hospital stay were significant. Multivariable logistic regression analysis demonstrated that drainage was an independent risk factor for fever after LC (OR 3.418, 95% CI 1.392-8.390; p = 0.007). CONCLUSIONS No drainage after elective day-case LC is safe and associated with fewer complications, even in intraoperative GP. The trial proves that drainage is an independent risk factor for postoperative fever. The use of a drain after LC may lead to an unsuccessful day-case procedure by causing fever, elevated CRP, and extended hospital stay (NCT03909360).
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Affiliation(s)
- Huanbing Zhu
- Department of Hepatobiliary and Pancreatic Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China
| | - Daren Liu
- Department of Hepatobiliary and Pancreatic Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China
| | - Donger Zhou
- Department of Hepatobiliary and Pancreatic Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China
| | - Jinhong Wu
- Department of Hepatobiliary and Pancreatic Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China
| | - Yuanquan Yu
- Department of Hepatobiliary and Pancreatic Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China
| | - Yun Jin
- Department of Hepatobiliary and Pancreatic Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China
| | - Dan Ye
- Department of Hepatobiliary and Pancreatic Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China
| | - Chao Ding
- Department of Hepatobiliary and Pancreatic Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China
| | - Xiaoxiao Zhang
- Department of Hepatobiliary and Pancreatic Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China
| | - Bingying Huang
- Department of Hepatobiliary and Pancreatic Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China
| | - Shuyou Peng
- Department of Hepatobiliary and Pancreatic Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China
| | - Jiangtao Li
- Department of Hepatobiliary and Pancreatic Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China.
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The artery first technique: re-examining the critical view of safety during laparoscopic cholecystectomy. Surg Endosc 2023:10.1007/s00464-023-09912-z. [PMID: 36792783 DOI: 10.1007/s00464-023-09912-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 01/28/2023] [Indexed: 02/17/2023]
Abstract
INTRODUCTION Significant discrepancies exist between surgeon-documented and actual rates of critical view of safety (CVS) achievement on retrospective review following laparoscopic cholecystectomy. This discrepancy may be due to surgeon utilisation of the artery first technique (AFT), an exception to the CVS first described by Strasberg et al. The present study aims to characterise the use of the AFT, hypothesising it is used as an adjunct in difficult dissections to maximise exposure of the hepato-cystic triangle ensuring safe cholecystectomy. METHODS Prospective digital recording of the operative procedure of patients' undergoing laparoscopic cholecystectomy were undertaken at Christchurch Public Hospital, New Zealand and North Shore Private Hospital, Sydney, Australia. Videos were uploaded to Touch Surgery™ Enterprise. Difficulty was graded, annotated and indications for the AFT quantified using a standardised protocol. RESULTS A total of 275 annotated procedures were included in this study. The AFT was employed in 54 (20%) patients; in 13 (24%) patients for bleeding, in 35 (65%) patients where windows one and two were visible, and in 6 (11%) patients no windows were visible within the hepato-cystic triangle. There were significant differences in utilisation across operative grade and by seniority of operator (p < 0.005). CONCLUSIONS The data presented here demonstrate the AFT is frequently used, particularly with Grade 3 cholecystectomy. However, more data are needed to confirm the utility and safety of this approach. Analysis of the AFT shows that to understand and improve safety in laparoscopic cholecystectomy appreciating how the operation was undertaken and not just that the CVS was achieved is crucial.
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Use of Critical View of Safety and Proctored Preceptorship in Preventing Bile Duct Injury During Laparoscopic Cholecystectomy-Experience of 3726 Cases From a Tertiary Care Teaching Institute. SURGICAL LAPAROSCOPY, ENDOSCOPY & PERCUTANEOUS TECHNIQUES 2023; 33:12-17. [PMID: 36730233 DOI: 10.1097/sle.0000000000001127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 09/06/2022] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Bile duct injury (BDI) continues to occur despite technological advances and improvements in surgical training over the past 2 decades. This study was conducted to audit our data on laparoscopic cholecystectomies performed over the past 2 decades to determine the role of Critical View of Safety (CVS) and proctored preceptorship in preventing BDI and postoperative complications. MATERIALS AND METHODS All patients undergoing elective laparoscopic cholecystectomy were analyzed retrospectively. The data were obtained from a prospectively maintained database from January 2004 to December 2019. Proctored preceptorship was used in all cases. Intraoperative details included the number of patients where CVS was defined, number of BDI and conversions. Postoperative outcomes, including hospital stay, morbidity, and bile duct stricture, were noted. RESULTS Three thousand seven hundred twenty-six patients were included in the final analysis. Trainee surgeons performed 31.6% of surgeries and 9.5% of these surgeries were taken over by the senior surgeon. A CVS could be delineated in 96.6% of patients. The major BDI rate was only 0.05%. CONCLUSION This study reiterates the fact that following the basic tenets of safe laparoscopic cholecystectomy, defining and confirming CVS, and following proctored preceptorship are critical in preventing major BDI.
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SAGES safe cholecystectomy modules improve practicing surgeons' judgment: results of a randomized, controlled trial. Surg Endosc 2023; 37:862-870. [PMID: 36006521 DOI: 10.1007/s00464-022-09503-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 07/23/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Despite the advantages of laparoscopic cholecystectomy, major bile duct injury (BDI) rates during this operation remain unacceptably high. In October 2018, SAGES released the Safe Cholecystectomy modules, which define specific strategies to minimize the risk of BDI. This study aims to investigate whether this curriculum can change the knowledge and behaviors of surgeons in practice. METHODS Practicing surgeons were recruited from the membership of SAGES and the American College of Surgeons Advisory Council for Rural Surgery. All participants completed a baseline assessment (pre-test) that involved interpreting cholangiograms, troubleshooting difficult cases, and managing BDI. Participants' dissection strategies during cholecystectomy were also compared to the strategies of a panel of 15 experts based on accuracy scores using the Think Like a Surgeon validated web-based platform. Participants were then randomized to complete the Safe Cholecystectomy modules (Safe Chole module group) or participate in usually scheduled CME activities (control group). Both groups completed repeat assessments (post-tests) one month after randomization. RESULTS Overall, 41 participants were eligible for analysis, including 18 Safe Chole module participants and 23 controls. The two groups had no significant differences in pre-test scores. However, at post-test, Safe Chole module participants made significantly fewer errors managing BDI and interpreting cholangiograms. Safe Chole module participants were less likely to convert to an open operation on the post-test than controls when facing challenging dissections. However, Safe Chole module participants displayed a similar incidence of errors when evaluating adequate critical views of safety. CONCLUSIONS In this randomized-controlled trial, the SAGES Safe Cholecystectomy modules improved surgeons' abilities to interpret cholangiograms and safely manage BDI. Additionally, surgeons who studied the modules were less likely to convert to open during difficult dissections. These data show the power of the Safe Cholecystectomy modules to affect practicing surgeons' behaviors in a measurable and meaningful way.
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15
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Ostapenko A, Kleiner D. Challenging Orthodoxy: beyond the Critical View of Safety. J Gastrointest Surg 2023; 27:89-92. [PMID: 36344799 DOI: 10.1007/s11605-022-05500-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 10/21/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND The critical view of safety (CVS) is the gold standard for performing safe cholecystectomies and minimizing common bile duct (CBD) injuries. It requires three criteria: complete clearance of the hepatocystic triangle, partial separation of the gallbladder from the cystic plate, and two structures alone entering the gallbladder. However, biliary anatomy varies widely, with frequent aberrant arterial supplies, which can mislead or disorient those attempting to acquire the CVS. This study was designed to examine the nature and frequency of cystic artery anatomic anomalies. METHODS We conducted a prospective observational study from 2018 to 2020, compiling photos of the critical view of safety of 100 consecutive elective cholecystectomies performed at our institution. Gallbladders were dissected up to the parallel portion of the cystic plate to achieve a critical view of safety. All tubular structures were preserved and clipped. Operative reports were examined for mention of posterior cystic arteries or aberrant arterial supplies. Photos were reviewed for an adequate critical view of the safety and presence of aberrant arterial supplies. The rate of aberrant arterial supply was determined and photos were reviewed for patterns of common abnormalities. RESULTS There were 121 patients who underwent an elective cholecystectomy; 21 lacked intraoperative pictures and were excluded from the study. Of the 100 patients included, 57 (57%) had an aberrant arterial supply with more than one cystic artery; seven had three concurrent arteries. Of those with more than one cystic artery, 21% had a recurrent cystic artery, 21% had a posterior dominant cystic artery, and 12% had a low-branching anterior cystic artery. CONCLUSION Even with appropriate dissection for the CVS, surgeons can expect to frequently visualize more than two structures entering the gallbladder when a posterior cystic artery is present. It is, therefore, integral to distinguish this aberrant anatomy to prevent inadvertent injury to the CBD.
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Affiliation(s)
- Alexander Ostapenko
- Department of General Surgery, Nuvance Health, Danbury, CT, USA.
- Department of Surgery, Larner College of Medicine, University of Vermont, Burlington, VT, USA.
| | - Daniel Kleiner
- Department of General Surgery, Nuvance Health, Danbury, CT, USA
- Department of Surgery, Larner College of Medicine, University of Vermont, Burlington, VT, USA
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Oo AM, Vallabhajosyula R. Perceived effectiveness of an innovative mobile-based serious game on the improvement of soft skills in minimally invasive surgical training. Asian J Endosc Surg 2023; 16:41-49. [PMID: 36594159 DOI: 10.1111/ases.13115] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/19/2022] [Accepted: 07/21/2022] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Soft skills have a pertinent role for the quality and efficient outcomes in minimally invasive surgical procedures that are difficult to practice due to time constraints, limited resources, and other logistical reasons. The literature says that serious games serve as better resources for learning soft skills but needs evaluation from stakeholders. This study explores the perceived effectiveness of serious gaming intervention as a learning tool to improve communication, collaborative skills among the residents in surgery, house officers and junior doctors. METHOD A total of nine participants volunteered to take part in the exploratory study. During the study, the participants responded to a pre-test quiz, followed by exploration of the game and a post-test quiz. The perceived perceptions on the effectiveness of the gaming intervention were collected on a five-point Likert scale questionnaire with open-ended questions. RESULTS There was no significant difference in pre-test and post-test scores on communication and collaborative skills. Among the three themes, there was significant effect of usefulness of the application of improvement of soft skills (90% response); however, technicalities should be addressed (50% of responses). The qualitative feedback renders that, better graphics, tutorial run, user-friendly interface and controls, and enhanced 3D environment would enhance the efficacy of the prototype. CONCLUSION An innovative mobile-based serious gaming intervention was developed and tested for its effectiveness as a resource to develop soft skills among surgeons in training. The results indicate that gamified interventions can serve as educational resources and supplement the self-directed learning in surgical education.
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Affiliation(s)
- Aung Myint Oo
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
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Geers J, Jaekers J, Topal H, Collignon A, Topal B. Bile duct injury in laparoscopic cholecystectomy with a posterior infundibular approach. INTERNATIONAL JOURNAL OF HEPATOBILIARY AND PANCREATIC DISEASES 2022. [DOI: 10.5348/100100z04mc2022ra] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Aims: Bile duct injury (BDI) in laparoscopic cholecystectomy (LC) has a significant impact on morbidity and mortality. Although the critical view of safety (CVS) concept is the most widely supported approach to prevent BDI, alternative approaches are used as well. The aim was to evaluate the incidence, severity, and management of bile duct injury in LC, using a posterior infundibular approach.
Methods: This retrospective, monocentric cohort study includes patients who underwent LC for gallstone disease. Data were collected in a prospectively maintained database. Patients with BDI were identified and were analyzed in-depth.
Results: Between 1999 and 2018, 8389 consecutive patients were included (M/F 3288/5101; mean age 55 (standard deviation; SD ± 17) years). Mean length of postoperative hospital stay was two days (SD ± 4). Fourteen patients died after LC and 21 patients were identified with BDI. Seventeen BDI (81%) patients were managed minimally invasive (14 endoscopic, 3 laparoscopic), and 4 patients via laparotomy (3 hepaticojejunostomy, 1 primary suture). Severe complications (Clavien-Dindo ≥3) after BDI repair were observed in 6 patients. There was no BDI-related mortality. Median follow-up time was 113 months (range 5–238).
Conclusion: A posterior infundibular approach in LC was associated with a low incidence of BDI and no BDI-related mortality.
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Affiliation(s)
- Joachim Geers
- Department of Visceral Surgery, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Joris Jaekers
- Department of Visceral Surgery, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Halit Topal
- Department of Visceral Surgery, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - André Collignon
- Department of Management Information and Reporting, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Baki Topal
- Department of Visceral Surgery, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium
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Tranter-Entwistle I, Eglinton T, Hugh TJ, Connor S. Use of prospective video analysis to understand the impact of technical difficulty on operative process during laparoscopic cholecystectomy. HPB (Oxford) 2022; 24:2096-2103. [PMID: 35961932 DOI: 10.1016/j.hpb.2022.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/28/2022] [Accepted: 07/19/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND An understanding of the impact of operative difficulty on operative process in laparoscopic cholecystectomy is lacking. The aim of the present study was to prospectively analyse digitally recorded laparoscopic cholecystectomy to assess the impact of operative technical difficulty on operative process. METHODS Video of laparoscopic cholecystectomy procedures performed at Christchurch Hospital, NZ and North Shore Private Hospital, Sydney Australia were prospectively recorded. Using a framework derived from a previously published standard process video was annotated using a standardized template and stratified by operative grade to evaluate the impact of grade on operative process. RESULTS 317 patients had their laparoscopic cholecystectomy operations prospectively recorded. Seventy one percent of these videos (n = 225) were annotated. Single ICC of operative grade was 0.760 (0.663-0.842 p < 0.010). Median operative time, rate of operative errors significantly increased and rate of CVS decreased with increasing operative grade. Significant differences in operative anatomy, operative process and instrumentation were seen with increasing grade. CONCLUSION Operative technical difficulty is accurately predicted by operative grade and this impacts on operative process with significant implications for both surgeons and patients. Consequently operative grade should be documented routinely as part of a culture of safe laparoscopic cholecystectomy.
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Affiliation(s)
| | - Tim Eglinton
- Department of Surgery, The University of Otago Medical School, Christchurch, New Zealand; Department of General Surgery Christchurch Hospital, Te Whatu Ora, New Zealand
| | - Thomas J Hugh
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital and North Shore Private Hospital, St Leonards, NSW, Australia; Northern Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Saxon Connor
- Department of General Surgery Christchurch Hospital, Te Whatu Ora, New Zealand
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Global Health Challenges: Why the Four S's Are Not Enough. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9121867. [PMID: 36553311 PMCID: PMC9777240 DOI: 10.3390/children9121867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/22/2022] [Accepted: 11/28/2022] [Indexed: 12/03/2022]
Abstract
A well-known tenant of global health is the need for the four-S's to be successful in providing care in any context; Staff, Stuff, Space and Systems. Advanced thoracoscopy is slow to gain traction in low- and middle-income countries (LMICs). To our knowledge, no pediatric advanced thoracoscopy had been attempted previously in either LMIC. Therefore, we report the challenges associated with the adoption of the first advanced thoracoscopic procedures in two LMIC hospitals by a visiting surgeon. To further identify aspects of care in promoting the introduction of advanced thoracoscopy, we added a fifth S as an additional category-Socialization. A key to accomplishing goals for the patients as a visiting surgeon, particularly when introducing an advanced procedure, is acceptance into the culture of a hospital. Despite facing significant obstacles in caring for complex thoracic pathology with heavy reliance on disposable and reusable instrumentation provided through donation and limitations in staff such as access to neonatologists and pediatric surgeons, many obstacles have been overcome. In this perspective article, we show that a "fifth S" is also integral-having local surgeons and anesthesiologists eager to learn with acceptance of the visiting surgeon's expertise opens a path towards attempting advanced procedures in limited-resource settings.
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Owen D, Grammatikopoulou M, Luengo I, Stoyanov D. Automated identification of critical structures in laparoscopic cholecystectomy. Int J Comput Assist Radiol Surg 2022; 17:2173-2181. [PMID: 36272018 DOI: 10.1007/s11548-022-02771-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 09/30/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE Bile duct injury is a significant problem in laparoscopic cholecystectomy and can have grave consequences for patient outcomes. Automatic identification of the critical structures (cystic duct and cystic artery) could potentially reduce complications during surgery by helping the surgeon establish Critical View of Safety, or eventually may even provide real time intra-operative guidance. METHODS A computer vision model was trained to identify the critical structures. Label relaxation enabled the model to cope with ambiguous spatial extent and high annotation variability. Pseudo-label self-supervision allowed the model to use unlabelled data, which can be particularly beneficial when scarce labelled data is available for training. Intrinsic variability in annotations was assessed across several annotators, quantifying the extent of annotation ambiguity and setting a baseline for model accuracy. RESULTS Using 3050 labelled and 3682 unlabelled cholecystectomy frames, the model achieved an IoU of 65% and presence detection F1 score of 75%. Inter-annotator IoU agreement was 70%, demonstrating the model was near human-level agreement on average in this dataset. The model's outputs were validated by three expert surgeons, who confirmed that its outputs were accurate and promising for future usage. CONCLUSION Identification of critical structures can achieve high accuracy, and is a promising step towards computer-assisted intervention in addition to potential applications in analytics and education. High accuracy and surgeon approval is maintained when detecting the structures separately as distinct classes. Future work will focus on guaranteeing safe identification of critical anatomy, including the bile duct, and validating the performance of automated approaches.
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Affiliation(s)
| | | | | | - Danail Stoyanov
- Digital Surgery, Medtronic, London, UK.,Wellcome / EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
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Lee BJH, Yap QV, Low JK, Chan YH, Shelat VG. Cholecystectomy for asymptomatic gallstones: Markov decision tree analysis. World J Clin Cases 2022; 10:10399-10412. [PMID: 36312509 PMCID: PMC9602237 DOI: 10.12998/wjcc.v10.i29.10399] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 05/13/2022] [Accepted: 09/01/2022] [Indexed: 02/05/2023] Open
Abstract
Gallstones are a common public health problem, especially in developed countries. There are an increasing number of patients who are diagnosed with gallstones due to increasing awareness and liberal use of imaging, with 22.6%-80% of gallstone patients being asymptomatic at the time of diagnosis. Despite being asymptomatic, this group of patients are still at life-long risk of developing symptoms and complications such as acute cholangitis and acute biliary pancreatitis. Hence, while early prophylactic cholecystectomy may have some benefits in selected groups of patients, the current standard practice is to recommend cholecystectomy only after symptoms or complications occur. After reviewing the current evidence about the natural course of asymptomatic gallstones, complications of cholecystectomy, quality of life outcomes, and economic outcomes, we recommend that the option of cholecystectomy should be discussed with all asymptomatic gallstone patients. Disclosure of material information is essential for patients to make an informed choice for prophylactic cholecystectomy. It is for the patient to decide on watchful waiting or prophylactic cholecystectomy, and not for the medical community to make a blanket policy of watchful waiting for asymptomatic gallstone patients. For patients with high-risk profiles, it is clinically justifiable to advocate cholecystectomy to minimize the likelihood of morbidity due to complications.
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Affiliation(s)
- Brian Juin Hsien Lee
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore S308232, Singapore
| | - Qai Ven Yap
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore S117597, Singapore
| | - Jee Keem Low
- Department of General Surgery, Tan Tock Seng Hospital, Singapore S308433, Singapore
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore S117597, Singapore
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore S308433, Singapore
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Garzali IU, Aburumman A, Alsardia Y, Alabdallat B, Wraikat S, Aloun A. Is fundus first laparoscopic cholecystectomy a better option than conventional laparoscopic cholecystectomy for difficult cholecystectomy? A systematic review and meta-analysis. Updates Surg 2022; 74:1797-1803. [PMID: 36207659 DOI: 10.1007/s13304-022-01403-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 10/03/2022] [Indexed: 11/30/2022]
Abstract
The gallstone disease prevalence is up to 27% in the general adult population. Though most of the patients are asymptomatic, about 1-4% of these patients became symptomatic every year and will require treatment. Fundus first laparoscopic cholecystectomy (FFLC) was first reported by Cooperman in 1990 when he utilized the approach to safely perform LC for patients with acute cholecystitis and dense adhesion around the calot's triangle which precluded safe dissection. Some surgeons reported that the FFLC may be quicker than the traditional dissection starting at the Calot's triangle, although no randomized trial has been undertaken to confirm that. We aim to perform this systematic review and meta-analysis to compare outcome of fundal first laparoscopic cholecystectomy with conventional laparoscopic cholecystectomy. Three reviewers independently searched the Pubmed, medline, google schoolar, Cochrane library and Embase databases for prospective or retrospective articles comparing outcomes of fundus first LC and conventional LC. The search terms were "retrograde cholecystectomy", "antegrade cholecystectomy", "fundus first cholecystectomy", "fundus down cholecystectomy", and "dome down cholecystectomy". Studies were selected based on predetermined criteria and data were extracted from the study for meta-analysis. Twelve studies were included for meta-analysis. Our analysis revealed that FFLC is associated with less conversion to open surgery, less time of surgery, less risk of bile duct injuries and shorter duration of hospital stay compared conventional cholecystectomy in patients with difficult cholecystectomy. In conclusion, fundus first laparoscopic cholecystectomy is a safer alternative to conventional laparoscopic cholecystectomy in patients with difficult cholecystectomy.
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Affiliation(s)
| | | | | | | | | | - Ali Aloun
- King Hussein Medical Center, Amman, Jordan.
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Fisher AT, Bessoff KE, Khan RI, Touponse GC, Yu MM, Patil AA, Choi J, Stave CD, Forrester JD. Evidence-based surgery for laparoscopic cholecystectomy. Surg Open Sci 2022; 10:116-134. [PMID: 36132940 PMCID: PMC9483801 DOI: 10.1016/j.sopen.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 08/15/2022] [Indexed: 11/30/2022] Open
Abstract
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.
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Fujinaga A, Hirashita T, Iwashita Y, Kawamura M, Nakanuma H, Kawasaki T, Kawano Y, Masuda T, Endo Y, Ohta M, Inomata M. An additional port in difficult laparoscopic cholecystectomy for surgical safety. Asian J Endosc Surg 2022; 15:737-744. [PMID: 35505453 DOI: 10.1111/ases.13073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/20/2022] [Accepted: 04/15/2022] [Indexed: 12/07/2022]
Abstract
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.
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Affiliation(s)
- Atsuro Fujinaga
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Teijiro Hirashita
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Yukio Iwashita
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Masahiro Kawamura
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Hiroaki Nakanuma
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Takahide Kawasaki
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Yoko Kawano
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Takashi Masuda
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Yuichi Endo
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Masayuki Ohta
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Masafumi Inomata
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
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Brunt LM. Should We Utilize Routine Cholangiography? Adv Surg 2022; 56:37-48. [PMID: 36096576 DOI: 10.1016/j.yasu.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Intraoperative cholangiography (IOC) is an essential skill that surgeons need for the safe performance of cholecystectomy and intraoperative diagnosis and management of bile duct stones. Whether it should be performed routinely or selectively is an ongoing debate that goes back to the early days of laparoscopic cholecystectomy (LC). Benefits of IOC include ability to detect bile duct stones, recognition of aberrant anatomy, and, in some circumstances, mitigation of the risk of bile duct injury. In this review, key aspects of this debate, technical aspects of performing IOC, evidence regarding its benefits, and imaging alternatives to IOC during LC are presented.
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Affiliation(s)
- L Michael Brunt
- Section of Minimally Invasive Surgery, Department of Surgery, Washington University School of Medicine, 660 S Euclid Avenue, St. Louis, MO 63110, USA.
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26
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Sewefy AM, Elsageer EM, Kayed T, Mohammed MM, Taha Zaazou MM, Hamza HM. Nasobiliary guided laparoscopic cholecystectomy following endoscopic retrograde cholangiopancreatography, randomized controlled trial. Surgeon 2022:S1479-666X(22)00101-9. [PMID: 35953433 DOI: 10.1016/j.surge.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 06/18/2022] [Accepted: 06/28/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC) is the most common management of gallstones combined with common bile duct (CBD) stones. This study aims to evaluate the impact of routine insertion of nasobiliary catheter during ERCP in cases of difficult LC. PATIENTS & METHODS From total 110 patients who underwent ERCP followed by LC in the period from April 2019 to April 2020, nasobiliary (NB) catheter was inserted during ERCP in 55 patients after CBD clearance (NB group). In the other 55 patients, only CBD clearance was done (Control group). In the NB group, dynamic trans-nasobiliary intraoperative cholangiography (TN-IOC) was done during dissection of Calot's triangle. At the end of the procedure, trans-nasobiliay methylene blue (MB) test was done to detect any missed biliary injury. The primary outcome to be analyzed was the incidence and severity of bile duct injury (BDI), secondary outcomes were the operative time, conversion to open surgery, and hospital stay. RESULTS Of the 110 patients, 57 patients (51.8%) were males and 53 (48.2%) were females. Median age was 55 years. One case of biliary leak was reported in the NB group (1.8%), while 2 cases (3.6%) were reported in the Control group. The average operative time in the NB group was 115 min versus 128 min in the Control group (P value < 0.001). No cases were converted to open cholecystectomy in the NB group (0%) with 5 cases (9.1%) converted to open in the Control group. The average postoperative hospital stay was 2 ± 0.1 days in the NB group versus 3.6 ± 5.3 days in the Control group (P value = 0.037). CONCLUSION Routine insertion of nasobiliary tube during ERCP, in patients with combined gallbladder and CBD stones, is a simple, safe and dynamic method for IOC. This maneuver does not statistically decrease the incidence of BDI but can diagnose, minimize and treat BDI with shorter operative time and hospital stay.
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Affiliation(s)
- Alaa M Sewefy
- Department of General Surgery, Faculty of Medicine, Minia University, Egypt
| | - Emad M Elsageer
- Department of General Surgery, Faculty of Medicine, Minia University, Egypt
| | - Taha Kayed
- Department of General Surgery, Faculty of Medicine, Minia University, Egypt
| | | | - Mohamed M Taha Zaazou
- Department of General Surgery, Faculty of Medicine, Misr University for Science and Technology, Egypt
| | - Hosam M Hamza
- Department of General Surgery, Faculty of Medicine, Minia University, Egypt.
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Jin Y, Liu R, Chen Y, Liu J, Zhao Y, Wei A, Li Y, Li H, Xu J, Wang X, Li A. Critical view of safety in laparoscopic cholecystectomy: A prospective investigation from both cognitive and executive aspects. Front Surg 2022; 9:946917. [PMID: 35978606 PMCID: PMC9377448 DOI: 10.3389/fsurg.2022.946917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 07/11/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThe achievement rate of the critical view of safety during laparoscopic cholecystectomy is much lower than expected. This original study aims to investigate and analyze factors associated with a low critical view of safety achievement.Materials and MethodsWe prospectively collected laparoscopic cholecystectomy videos performed from September 2, 2021, to September 19, 2021, in Sichuan Province, China. The artificial intelligence system, SurgSmart, analyzed videos under the necessary corrections undergone by expert surgeons. Also, we distributed questionnaires to surgeons and analyzed them along with surgical videos simultaneously.ResultsWe collected 169 laparoscopic cholecystectomy surgical videos undergone by 124 surgeons, among which 105 participants gave valid answers to the questionnaire. Excluding those who conducted the bail-out process directly, the overall critical view of safety achievement rates for non-inflammatory and inflammatory groups were 18.18% (18/99) and 9.84% (6/61), respectively. Although 80.95% (85/105) of the surgeons understood the basic concept of the critical view of safety, only 4.76% (5/105) of the respondents commanded all three criteria in an error-free way. Multivariate logistic regression results showed that an unconventional surgical workflow (OR:12.372, P < 0.001), a misunderstanding of the 2nd (OR: 8.917, P < 0.05) and 3rd (OR:8.206, P < 0.05) criterion of the critical view of safety, and the don't mistake “fundus-first technique” as one criterion of the critical view of safety (OR:0.123, P < 0.01) were associated with lower and higher achievements of the critical view of safety, respectively.ConclusionsThe execution and cognition of the critical view of safety are deficient, especially the latter one. Thus, increasing the critical view of safety surgical awareness may effectively improve its achievement rate.
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Affiliation(s)
- Yi Jin
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Runwen Liu
- Department of Algorithm, ChengduWithai Innovations Technology Company, Chengdu, China
| | - Yonghua Chen
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jie Liu
- Department of Algorithm, ChengduWithai Innovations Technology Company, Chengdu, China
| | - Ying Zhao
- National Chengdu Center for Safety Evaluation of Drugs, West China Hospital, Sichuan University, Chengdu, China
| | - Ailin Wei
- Department of Science and Technology, Guang'an People's Hospital, Guang'an, China
| | - Yichuan Li
- Department of Hepatobiliary Surgery, Guang'an People's Hospital, Guang'an, China
| | - Hai Li
- Department of Hepatobiliary Surgery, Chongzhou People's Hospital, Chengdu, China
| | - Jun Xu
- Department of Minimal Invasive Surgery, Shangjin Nanfu Hospital, Chengdu, China
| | - Xin Wang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
- Correspondence: Ang Li Xin Wang
| | - Ang Li
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
- Correspondence: Ang Li Xin Wang
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Mullens CL, Ibrahim AM. Invited Commentary: Advancing the Safety of Laparoscopic Cholecystectomy-Collaboration between Radiologists and Surgeons. Radiographics 2022; 42:E147-E148. [PMID: 35904984 DOI: 10.1148/rg.220008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Cody L Mullens
- From the Department of Surgery (C.L.M., A.M.I.), Taubman College of Architecture and Urban Planning (A.M.I.), and Center for Healthcare Outcomes and Policy (A.M.I.), University of Michigan, 2800 Plymouth Rd, Building 16, Ann Arbor, MI 48109
| | - Andrew M Ibrahim
- From the Department of Surgery (C.L.M., A.M.I.), Taubman College of Architecture and Urban Planning (A.M.I.), and Center for Healthcare Outcomes and Policy (A.M.I.), University of Michigan, 2800 Plymouth Rd, Building 16, Ann Arbor, MI 48109
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29
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Montalvo-Javé EE, Contreras-Flores EH, Ayala-Moreno EA, Mercado MA. Strasberg\'s Critical View: Strategy for a Safe Laparoscopic Cholecystectomy. Euroasian J Hepatogastroenterol 2022; 12:40-44. [PMID: 35990864 PMCID: PMC9357518 DOI: 10.5005/jp-journals-10018-1353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Every year, worldwide, the celebration for patient safety is carried out; since about 2.6 million people are documented who die each year from events that can potentially be avoided during their medical care, it is even estimated that around 15% of hospital costs can be attributed to treatment resulting in patient safety. As an important part of its dissemination in the medical–surgical community, we present the following article in relation to the critical vision of safety in the bile duct, promoted and published initially by Dr Steven Strasberg, which aims to reduce the number of complications during laparoscopic cholecystectomies. Materials and methods A bibliographic search was carried out in PubMed, Medline, Clinical Key, and Index Medicus. From May 2020 to July 2021 in Spanish and English with the following. Conclusions Strasberg's critical view is a proposed strategy to minimize the risk to zero during laparoscopic gallbladder surgery. It consists of obtaining a plane in which the surgeon can visualize the anatomical structures that make up the bile duct, as well as its irrigation and drainage. Being able to clearly observe these structures allows the surgeon to cut freely and safely to avoid bile duct injuries which are not so uncommon during this procedure. How to cite this article Montalvo-Javé EE, Contreras-Flores EH, Ayala-Moreno EA, et al. Strasberg's Critical View: Strategy for a Safe Laparoscopic Cholecystectomy. Euroasian J Hepato-Gastroenterol 2022;12(1):40–44.
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Affiliation(s)
- Eduardo E Montalvo-Javé
- Department of Surgery, Hepatopancreatobiliary Surgery Clinic, Hospital General de México “Dr Eduardo Liceaga”, Mexico City, Mexico; Department of Surgery, Faculty of Medicine, UNAM, Ciudad de Mexico, Mexico
- Eduardo E Montalvo-Javé, Department of Surgery, Hepatopancreatobiliary Surgery Clinic, Hospital General de México “Dr Eduardo Liceaga”, Mexico City, Mexico; Department of Surgery, Faculty of Medicine, UNAM, Ciudad de Mexico, Mexico, Phone: +5521806470, e-mail:
| | | | - Edwin A Ayala-Moreno
- Department of Surgery, Hospital General de México “Dr Eduardo Liceaga”, Mexico City, Mexico
| | - Miguel A Mercado
- Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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Conde Monroy D, Torres Gómez P, Rey Chaves CE, Recamán A, Pardo M, Sabogal JC. Early versus delayed reconstruction for bile duct injury a multicenter retrospective analysis of a hepatopancreaticobiliary group. Sci Rep 2022; 12:11609. [PMID: 35804006 PMCID: PMC9270444 DOI: 10.1038/s41598-022-15978-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 07/01/2022] [Indexed: 11/09/2022] Open
Abstract
Common bile duct injury is a severe complication. It is related to increased rates of morbidity and mortality. Early recognition and on-time diagnosis plus multidisciplinary management of this disease led by a hepatobiliary surgeon show fewer complications rate and best postoperative outcomes. However, no guidelines exist about the proper time of reconstruction. This study aims to describe the experience of a specialized Hepato-Pancreatic-Biliary (HPB) group and to analyze the outcomes regarding the time of bile duct injury (BDI) repair. A multicenter retrospective review of a prospective database was conducted. All the patients older than 18 years old that underwent common bile duct reconstruction between January 2014 and December 2021 were included. Analysis and description of preoperative characteristics and postoperative outcomes were performed. A reconstruction time-based group differentiation was made and analyzed. 44 patients underwent common bile duct reconstruction between January 2014 and December 2021. 56.82% of the patients were female. The mean age was 53.27 years ± 20.7 years. The most common injury was type E2 (29.55%). Hepaticojejunostomy was performed in 81.81% (of the patients. Delayed reconstruction (> 72 h) was performed in the majority of the cases (75.00%) due to delays in the referral centers or poor condition. No statistically significant difference regarding complications in early or delayed BDI reconstruction. The mortality rate was 2.7% (n = 1). 2-year follow-up bilioenteric stenosis was observed in 7 patients. Biloma showed a statistical relationship with complex bile duct injuries (p = 0.02). Bile duct injury is a severe and complex postoperative complication that increases morbidity and mortality rates in the short and long term in patients undergoing cholecystectomy. In our study, there were no statistical differences between the timing of bile duct reconstruction and the postoperative outcomes; we identified the presence of biloma as a statistically related factor associated with complex bile duct injury; however, further prospective or studies with an increased sample size are required to prove our results.
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Affiliation(s)
- Danny Conde Monroy
- HPB Surgery Department Bogotá, Méderi, Hospital Universitario Mayor, Bogotá, Colombia
- School of Medicine, Universidad del Rosario Bogotá, Bogotá, Colombia
| | | | | | - Andrea Recamán
- School of Medicine, Universidad del Rosario Bogotá, Bogotá, Colombia
| | - Manuel Pardo
- School of Medicine, Universidad del Rosario Bogotá, Bogotá, Colombia
| | - Juan Carlos Sabogal
- HPB Surgery Department Bogotá, Méderi, Hospital Universitario Mayor, Bogotá, Colombia
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Tonelli CM, Lorenzo I, Bunn C, Kulshrestha S, Cohn T, Abdelsattar Z, Luchette FA, Baker MS. Are Residents Able to Perform a Laparoscopic Cholecystectomy with Acceptable Outcomes When the Attending Is Not Scrubbed? J Am Coll Surg 2022; 235:60-68. [PMID: 35703963 DOI: 10.1097/xcs.0000000000000262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Recent socioeconomic pressures in healthcare and work hour resections have limited opportunities for resident autonomy and independent decision-making. We sought to evaluate whether contemporary senior residents are being given the opportunity to operate independently and whether patient outcomes are affected when the attending is not directly involved in an operation. STUDY DESIGN The VA Surgical Quality Improvement Program (VASQIP) Database was queried to identify patients undergoing elective laparoscopic cholecystectomy between 2004 and 2019. Cases were categorized as "attending" or "resident" depending on whether the attending surgeon was scrubbed. Cohorts were 1:1 propensity score-matched (PSM) for demographics, comorbidities, and facility case-mix. Clinical outcomes for matched cohorts were compared by standard methods. RESULTS There were 23,831 records for patients who underwent laparoscopic cholecystectomy; 20,568 (86%) performed with the attending scrubbed, and 3,263 (14%) without the attending scrubbed. Over time there was a significant decrease in the proportion of cases without the attending scrubbed, 18% in 2004-2009 to 13% in 2015-2019 (p < 0.001). On PSM, 3,263 patients undergoing laparoscopic cholecystectomy by the residents without the attending scrubbed were successfully matched (1:1) to cases with the attending scrubbed. On comparison of matched cohorts, procedures performed without the attending scrubbed were statistically longer (102 vs 98 minutes, p = 0.001) but with no difference in rates of postoperative complications (5% vs 5%, p = 0.9). CONCLUSION In comparison with cases done with more direct attending involvement, residents perform laparoscopic cholecystectomies efficiently without increased complications. Over time, attendings are more frequently scrubbed for the operation.
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Affiliation(s)
- Celsa M Tonelli
- From the Department of Surgery (Tonelli, Bunn, Kulshrestha, Cohn, Luchette, Baker), Loyola University Medical Center, Maywood, IL
- Department of Thoracic and Cardiovascular Surgery (Abdelsattar), Loyola University Medical Center, Maywood, IL
| | - Isabela Lorenzo
- Stritch School of Medicine, Loyola University Chicago, Maywood, IL (Lorenzo)
| | - Corinne Bunn
- From the Department of Surgery (Tonelli, Bunn, Kulshrestha, Cohn, Luchette, Baker), Loyola University Medical Center, Maywood, IL
| | - Sujay Kulshrestha
- From the Department of Surgery (Tonelli, Bunn, Kulshrestha, Cohn, Luchette, Baker), Loyola University Medical Center, Maywood, IL
| | - Tyler Cohn
- From the Department of Surgery (Tonelli, Bunn, Kulshrestha, Cohn, Luchette, Baker), Loyola University Medical Center, Maywood, IL
| | - Zaid Abdelsattar
- Department of Thoracic and Cardiovascular Surgery (Abdelsattar), Loyola University Medical Center, Maywood, IL
| | - Frederick A Luchette
- From the Department of Surgery (Tonelli, Bunn, Kulshrestha, Cohn, Luchette, Baker), Loyola University Medical Center, Maywood, IL
- Department of Surgery, Edward Hines Jr. Veterans Administration Hospital, Hines, IL (Tonelli, Luchette, Baker)
| | - Marshall S Baker
- From the Department of Surgery (Tonelli, Bunn, Kulshrestha, Cohn, Luchette, Baker), Loyola University Medical Center, Maywood, IL
- Department of Surgery, Edward Hines Jr. Veterans Administration Hospital, Hines, IL (Tonelli, Luchette, Baker)
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Torretta A, Kaludova D, Roy M, Bhattacharya S, Valente R. Simultaneous early surgical repair of post-cholecystectomy major bile duct injury and complex abdominal evisceration: A case report. Int J Surg Case Rep 2022; 94:107110. [PMID: 35658286 PMCID: PMC9093007 DOI: 10.1016/j.ijscr.2022.107110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/16/2022] [Accepted: 04/16/2022] [Indexed: 10/30/2022] Open
Abstract
BACKGROUND Major bile duct injuries (BDIs) are hazardous complications during 0.4%-0.6% of laparoscopic cholecystectomies. Major BDIs usually require surgical repair, ideally either immediately or at least six weeks after the damage. The complexity of our case lies in the coexistence of early BDI followed by 2-week biliary peritonitis with massive midline evisceration which, in combination, has over 40% mortality risk. METHODS & CASE REPORT We describe the case of a 65-year-old male, transferred to our tertiary HPB service on day 14 after common bile duct complete transection during cholecystectomy and postoperative laparotomy. The patient presented with biliary peritonitis along with full wound dehiscence and extensive evisceration. During emergency peritoneal wash-out surgery we deemed immediate BDI repair feasible by primary Roux-en-Y hepaticojejunostomy (HJ), with multi-stage abdominal closure. In the following days we performed progressive abdominal wall closure in multiple sessions under general anesthesia, aided by vacuum-assisted wound closure and intraperitoneal mesh-mediated fascial traction-approximation (VAWCM) with permeable mesh. An expected late incisional hernia was eventually repaired through component separation and biological mesh. DISCUSSION & CONCLUSION The simultaneous use of Roux-en-Y HJ and VAWCM has proven safe and effective in the treatment of BDI and 2-week biliary peritonitis with massive midline evisceration.
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Affiliation(s)
- Alfredo Torretta
- Department of General Surgery, "Val Vibrata" Hospital, ASL Teramo, Italy; HPB Surgery Service, Barts and the London Centre, Barts Health NHS Trust, London, UK
| | - Dimana Kaludova
- HPB Surgery Service, Barts and the London Centre, Barts Health NHS Trust, London, UK.
| | - Mayank Roy
- HPB Surgery Service, Barts and the London Centre, Barts Health NHS Trust, London, UK
| | - Satya Bhattacharya
- HPB Surgery Service, Barts and the London Centre, Barts Health NHS Trust, London, UK.
| | - Roberto Valente
- HPB Surgery Service, Barts and the London Centre, Barts Health NHS Trust, London, UK; Department of Surgery and Interventional Science, University College London, UK; Department of Surgery, Ospedale Policlinico San Martino Genova, Italy.
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Manuel-Vázquez A, Latorre-Fragua R, Alcázar C, Requena PM, de la Plaza R, Blanco Fernández G, Serradilla-Martín M, Ramia JM. Reaching a consensus on the definition of "difficult" cholecystectomy among Spanish experts. A Delphi project. A qualitative study. Int J Surg 2022; 102:106649. [PMID: 35525412 DOI: 10.1016/j.ijsu.2022.106649] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Being able to predict preoperatively the difficulty of a cholecystectomy can increase safety and improve results. However, there is a need to reach a consensus on the definition of a cholecystectomy as "difficult". The aim of this study is to achieve a national expert consensus on this issue. METHODS A two-round Delphi study was performed. Based on the previous literature, history of biliary pathology, preoperative clinical, analytical, and radiological data, and intraoperative findings were selected as variables of interest and rated on a Likert scale. Inter-rater agreement was defined as "unanimous" when 100% of the participants gave an item the same rating on the Likert scale; as "consensus" when ≥80% agreed; as "majority" when the agreement was ≥70%. The delta of change between the two rounds was calculated. RESULTS After the two rounds, the criteria that reached "consensus" were bile duct injury (96.77%), non-evident anatomy (93.55%), Mirizzi syndrome (93.55%), severe inflammation of Calot's triangle (90.32%), conversion to laparotomy (87.10%), time since last acute cholecystitis (83.87%), scleroatrophic gallbladder (80.65%) and pericholecystic abscess (80.65%). CONCLUSION The ability to predict difficulty in cholecystectomy offers important advantages in terms of surgical safety. As a preliminary step, the items that define a surgical procedure as difficult should be established. Standardization of the criteria can provide scores to predict difficulty both preoperatively and intraoperatively, and thus allow the comparison of groups of similar difficulty.
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Affiliation(s)
| | | | | | | | | | | | | | - J M Ramia
- Hospital General Universitario de Alicante, Spain
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34
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Jackson HT, Hung CMS, Potarazu D, Habboosh N, DeAngelis EJ, Amdur RL, Estroff JM, Quintana MT, Lin P, Vaziri K, Lee J. Attending guidance advised: educational quality of surgical videos on YouTube. Surg Endosc 2022; 36:4189-4198. [PMID: 34668066 DOI: 10.1007/s00464-021-08751-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 09/27/2021] [Indexed: 01/29/2023]
Abstract
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.
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Affiliation(s)
- Hope T Jackson
- Department of Surgery, The George Washington University School of Medicine and Health Sciences, 2150 Pennsylvania Ave, NW, Suite 6B-402, Washington, DC, 20037, USA.
| | - Chen-Min S Hung
- Department of Surgery, The George Washington University School of Medicine and Health Sciences, 2150 Pennsylvania Ave, NW, Suite 6B-402, Washington, DC, 20037, USA
| | - Deepika Potarazu
- Department of Surgery, The George Washington University School of Medicine and Health Sciences, 2150 Pennsylvania Ave, NW, Suite 6B-402, Washington, DC, 20037, USA
| | - Noor Habboosh
- Department of Surgery, The George Washington University School of Medicine and Health Sciences, 2150 Pennsylvania Ave, NW, Suite 6B-402, Washington, DC, 20037, USA
| | - Erik J DeAngelis
- Department of Surgery, The George Washington University School of Medicine and Health Sciences, 2150 Pennsylvania Ave, NW, Suite 6B-402, Washington, DC, 20037, USA
| | - Richard L Amdur
- Department of Surgery, The George Washington University School of Medicine and Health Sciences, 2150 Pennsylvania Ave, NW, Suite 6B-402, Washington, DC, 20037, USA
| | - Jordan M Estroff
- Department of Surgery, The George Washington University School of Medicine and Health Sciences, 2150 Pennsylvania Ave, NW, Suite 6B-402, Washington, DC, 20037, USA
| | - Megan T Quintana
- Department of Surgery, The George Washington University School of Medicine and Health Sciences, 2150 Pennsylvania Ave, NW, Suite 6B-402, Washington, DC, 20037, USA
| | - Paul Lin
- Department of Surgery, The George Washington University School of Medicine and Health Sciences, 2150 Pennsylvania Ave, NW, Suite 6B-402, Washington, DC, 20037, USA
| | - Khashayar Vaziri
- Department of Surgery, The George Washington University School of Medicine and Health Sciences, 2150 Pennsylvania Ave, NW, Suite 6B-402, Washington, DC, 20037, USA
| | - Juliet Lee
- Department of Surgery, The George Washington University School of Medicine and Health Sciences, 2150 Pennsylvania Ave, NW, Suite 6B-402, Washington, DC, 20037, USA
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Berlet M, Jell A, Bulian D, Friess H, Wilhelm D. [Clinical value of alternative technologies to standard laparoscopic cholecystectomy - single port, reduced port, robotics, NOTES]. Chirurg 2022; 93:566-576. [PMID: 35226123 DOI: 10.1007/s00104-022-01608-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2022] [Indexed: 11/25/2022]
Abstract
Surgical interventions should ideally treat an existing disease curatively and achieve this with a low complication rate and minimal trauma. In this sense, laparoscopic cholecystectomy has become established as the recognized standard for the treatment of cholecystolithiasis. Newer procedures, such as single-port surgery or natural orifice transluminal endoscopic surgery (NOTES) have recently emerged to reduce the already low interventional trauma even further and to provide a better cosmetic outcome. With all new methods the main aim is the reduction of the transabdominal access points. Based on published results and diagnosis-related groups (DRG) data, this article examines whether this goal has been achieved, also with respect to the overall quality of treatment and the complication rates. In this context and in addition to the already mentioned approaches, robotic cholecystectomy and the reduced port approach are also considered.
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Affiliation(s)
- M Berlet
- Fakultät für Medizin, Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar, Technische Universität München, Ismaningerstr. 22, 81675, München, Deutschland
- Forschungsgruppe MITI, Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar, München, Deutschland
| | - A Jell
- Fakultät für Medizin, Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar, Technische Universität München, Ismaningerstr. 22, 81675, München, Deutschland
- Forschungsgruppe MITI, Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar, München, Deutschland
| | - D Bulian
- Klinik für Viszeral‑, Tumor‑, Transplantations- und Gefäßchirurgie, Zentrum für interdisziplinäre Viszeralmedizin (ZIV), Kliniken der Stadt Köln gGmbH, Köln, Deutschland
| | - H Friess
- Fakultät für Medizin, Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar, Technische Universität München, Ismaningerstr. 22, 81675, München, Deutschland
| | - D Wilhelm
- Fakultät für Medizin, Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar, Technische Universität München, Ismaningerstr. 22, 81675, München, Deutschland.
- Forschungsgruppe MITI, Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar, München, Deutschland.
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Yildirim AC, Zeren S, Ekici MF, Yaylak F, Algin MC, Arik O. Comparison of Fenestrating and Reconstituting Subtotal Cholecystectomy Techniques in Difficult Cholecystectomy. Cureus 2022; 14:e22441. [PMID: 35345702 PMCID: PMC8942168 DOI: 10.7759/cureus.22441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2022] [Indexed: 11/25/2022] Open
Abstract
Purpose Cholecystectomy is one of the most frequently performed surgeries. Although laparoscopy is considered the gold standard approach, it cannot prevent biliary injuries. Subtotal cholecystectomy has been performed mainly to prevent biliary injuries during difficult cholecystectomies. This study aimed to analyse our subtotal cholecystectomy results for difficult cholecystectomy cases and to evaluate the fenestrating and reconstituting techniques. Methods Retrospective data were collected and analysed statistically for cases that underwent subtotal cholecystectomy in a single referral centre between 2015 and 2020. Comparisons were made of the patients’ age, gender, preoperative American Society of Anaesthesiologists (ASA) score, comorbidities, surgical timing, surgical procedure choice, postoperative complications, and mortality. Results The number of patients who underwent subtotal cholecystectomy was 46; 30.4% underwent emergent surgery and 69.6% underwent elective surgery. Twelve patients had subtotal fenestrating cholecystectomy and 34 had subtotal reconstituting cholecystectomy. Wound issues were noted in 17.4% of the patients, while 10.9% had temporary biliary fistulas that resolved spontaneously. Reoperation was performed in one patient due to high-output biliary drainage. Patients with postoperative complications had significantly higher co-morbid conditions (p=0.000), but surgery timing (p=0.192) and type of subtotal cholecystectomy (p=0.409) had no statistically significant effect on complications. Mortality showed a statistically significant correlation with patient comorbidities, surgery timing, and the type of procedure (p<0.05). Postoperative complications showed a statistically significant correlation with mortality (p<0.05). Conclusion Subtotal cholecystectomy prevents major biliary complications after cholecystectomy. Yet, the frequency of postoperative complications after subtotal cholecystectomy is incontrovertible. Intraoperative characteristics and the surgeon’s expertise decide the optimal choice of the subtotal cholecystectomy technique.
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Abdelfattah MR. The Laparoscopic Anatomy of Rouviere’s Sulcus. OPEN ACCESS SURGERY 2021. [DOI: 10.2147/oas.s341710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Abstract
Cholecystectomy is one of the most common general surgery procedures performed worldwide. Complications include bile duct injury, strictures, bleeding, infection/abscess, retained gallstones, hernias, and postcholecystectomy syndrome. Obtaining a critical view of safety and following the other tenets of the Safe Cholecystectomy Task Force will aid in the prevention of bile duct injury and other morbidity associated with cholecystectomy.
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Affiliation(s)
- Xiaoxi Chelsea Feng
- Department of Surgery, Cedars Sinai Medical Center, 8635 W Third Street, West Medical Office Tower, Suite 795, Los Angeles, CA 90048, USA
| | - Edward Phillips
- Department of Surgery, Cedars Sinai Medical Center, 8635 W Third Street, West Medical Office Tower, Suite 795, Los Angeles, CA 90048, USA
| | - Daniel Shouhed
- Department of Surgery, Cedars Sinai Medical Center, 459 North Croft Avenue, Los Angeles, CA 90048, USA.
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The Value of Combined Application of Oxycodone Hydrochloride Injection and Dexmedetomidine in Anesthesia for LC for Patients with Gallbladder Lesions. JOURNAL OF HEALTHCARE ENGINEERING 2021; 2021:1290650. [PMID: 34512931 PMCID: PMC8433014 DOI: 10.1155/2021/1290650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 06/15/2021] [Accepted: 07/24/2021] [Indexed: 11/18/2022]
Abstract
Objective To analyze the effect of combined application of oxycodone hydrochloride injection and dexmedetomidine in anesthesia for laparoscopic cholecystectomy (LC) for patients with gallbladder lesions. Method 93 patients with gallbladder lesions in our hospital were divided into 2 groups by the random number table method. 46 patients in the control group applied oxycodone hydrochloride injection in anesthesia, and 47 patients in the observation group applied oxycodone hydrochloride injection combined with dexmedetomidine in anesthesia. Result The T1 and T2 MAP levels in the observation group were lower than those in the control group (P < 0.05), and the difference between T3 and the control group was not significantly significant (P > 0.05). The T1 to T3 HR level in the observation group were lower than those in the control group (P < 0.05). The rate of excessive sedation (10.64%) and sedation inefficiency (12.77%) in the observation group was lower than that in the control group (28.26% and 30.43%), and the rate of satisfactory sedation (76.60%) was higher than that in the control group (41.30%) (P < 0.05). The postoperative awakening, tracheal tube removal, and first anal venting time were shorter in the observation group than in the control group (P < 0.05). The WHO scores of incisional pain at 6, 12, 24, and 48 hours after the operation were lower in the observation group than in the control group (P < 0.05). The T2 SOD level in the observation group was higher than that in the control group, and the ROS and MDA levels were lower than those in the control group (P < 0.05). The incidence of side effects of anesthetic in the observation group was 17.02%, which was not statistically different from the control group of 13.04% (P > 0.05). Conclusion The combined application of oxycodone hydrochloride injection and dexmedetomidine in anesthesia for LC for patients with gallbladder lesions can achieve better sedation and analgesia effect, accelerate postoperative awakening and recovery, and control oxidative stress and fluctuations in signs, without increasing anesthesia-related side effects.
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Mascagni P, Rodríguez-Luna MR, Urade T, Felli E, Pessaux P, Mutter D, Marescaux J, Costamagna G, Dallemagne B, Padoy N. Intraoperative Time-Out to Promote the Implementation of the Critical View of Safety in Laparoscopic Cholecystectomy: A Video-Based Assessment of 343 Procedures. J Am Coll Surg 2021; 233:497-505. [PMID: 34325017 DOI: 10.1016/j.jamcollsurg.2021.06.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 06/18/2021] [Accepted: 06/21/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND The critical view of safety (CVS) is poorly adopted in surgical practices although it is ubiquitously recommended to prevent major bile duct injuries during laparoscopic cholecystectomy (LC). This study aims to investigate whether performing a short intraoperative time out can improve CVS implementation. STUDY DESIGN In this before versus after study, surgeons performing LCs at an academic center were invited to use a 5-second long time out to verify CVS before dividing the cystic duct (5-second rule). The primary aim was to compare the rate of CVS achievement for LCs performed in the year before versus the year after implementation of the 5-second rule. The CVS achievement rate was computed after exclusion of bailout procedures using a mediated video-based assessment made by two independent reviewers. Clinical outcomes, LC workflows, and postoperative reports were also compared. RESULTS 343 of the 381 LCs performed between December 2017 and November 2019 (171 before and 172 after implementation of the 5-second rule) were analyzed. The 5-second rule was associated with a significantly increased rate of CVS achievement (15.9 vs. 44.1% before vs. after the 5-second rule, respectively; P<0.001). Significant differences were also observed with respect to the rate of bailout procedures (8.2 vs. 15.7%; P=0.04), the median [IQR] time to clip the cystic duct or artery (00:17:26 [00:11:48, 00:28:35] vs. 00:23:12 [00:14:29, 00:31:45] duration; P=0.007), and the rate of postoperative CVS reporting (1.3 vs. 28.8%; P<0.001). Postoperative morbidity was comparable (1.8 vs. 2.3%; P=0.68). CONCLUSION Performing a short intraoperative time out was associated with an improved CVS achievement rate. Systematic intraoperative cognitive aids should be studied to sustain the uptake of guidelines.
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Affiliation(s)
- Pietro Mascagni
- ICube, University of Strasbourg, CNRS, IHU Strasbourg, France; Gastrointestinal Endoscopic Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | | | - Takeshi Urade
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France
| | - Emanuele Felli
- Department of Digestive and Endocrine Surgery, University of Strasbourg, Strasbourg, France
| | - Patrick Pessaux
- Department of Digestive and Endocrine Surgery, University of Strasbourg, Strasbourg, France
| | - Didier Mutter
- Institute for Research against Digestive Cancer (IRCAD), Strasbourg, France; IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France; Department of Digestive and Endocrine Surgery, University of Strasbourg, Strasbourg, France
| | - Jacques Marescaux
- Institute for Research against Digestive Cancer (IRCAD), Strasbourg, France
| | - Guido Costamagna
- Gastrointestinal Endoscopic Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Center for Endoscopic Research, Therapeutics and Training (CERTT), Università Cattolica S. Cuore, Rome, Italy
| | - Bernard Dallemagne
- Institute for Research against Digestive Cancer (IRCAD), Strasbourg, France; IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France; Department of Digestive and Endocrine Surgery, University of Strasbourg, Strasbourg, France
| | - Nicolas Padoy
- ICube, University of Strasbourg, CNRS, IHU Strasbourg, France; IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France
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Sgaramella LI, Gurrado A, Pasculli A, de Angelis N, Memeo R, Prete FP, Berti S, Ceccarelli G, Rigamonti M, Badessi FGA, Solari N, Milone M, Catena F, Scabini S, Vittore F, Perrone G, de Werra C, Cafiero F, Testini M. The critical view of safety during laparoscopic cholecystectomy: Strasberg Yes or No? An Italian Multicentre study. Surg Endosc 2021; 35:3698-3708. [PMID: 32780231 PMCID: PMC8195809 DOI: 10.1007/s00464-020-07852-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 07/24/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Laparoscopic cholecystectomy is considered the gold standard for the treatment of gallbladder lithiasis; nevertheless, the incidence of bile duct injuries (BDI) is still high (0.3-0.8%) compared to open cholecystectomy (0.2%). In 1995, Strasberg introduced the "Critical View of Safety" (CVS) to reduce the risk of BDI. Despite its widespread use, the scientific evidence supporting this technique to prevent BDI is controversial. METHODS Between March 2017 and March 2019, the data of patients submitted to laparoscopic cholecystectomy in 30 Italian surgical departments were collected on a national database. A survey was submitted to all members of Italian Digestive Pathology Society to obtain data on the preoperative workup, the surgical and postoperative management of patients and to judge, at the end of the procedure, if the isolation of the elements was performed according to the CVS. In the case of a declared critical view, iconographic documentation was obtained, finally reviewed by an external auditor. RESULTS Data from 604 patients were analysed. The study population was divided into two groups according to the evidence (Group A; n = 11) or absence (Group B; N = 593) of BDI and perioperative bleeding. The non-use of CVS was found in 54.6% of procedures in the Group A, and 25.8% in the Group B, and evaluating the operator-related variables the execution of CVS was associated with a significantly lower incidence of BDI and intraoperative bleeding. CONCLUSIONS The CVS confirmed to be the safest technique to recognize the elements of the Calot triangle and, if correctly performed, it significantly impacted on preventing intraoperative complications. Additional educational programs on the correct application of CVS in clinical practice would be desirable to avoid extreme conditions that may require additional procedures.
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Affiliation(s)
- Lucia Ilaria Sgaramella
- Unit of General Surgery “V. Bonomo”, Department of Biomedical Sciences and Human Oncology, University of Bari “Aldo Moro”, Policlinico, Piazza Giulio Cesare, 11, 70124 Bari, Italy
| | - Angela Gurrado
- Unit of General Surgery “V. Bonomo”, Department of Biomedical Sciences and Human Oncology, University of Bari “Aldo Moro”, Policlinico, Piazza Giulio Cesare, 11, 70124 Bari, Italy
| | - Alessandro Pasculli
- Unit of General Surgery “V. Bonomo”, Department of Biomedical Sciences and Human Oncology, University of Bari “Aldo Moro”, Policlinico, Piazza Giulio Cesare, 11, 70124 Bari, Italy
| | - Nicola de Angelis
- Department of Digestive Surgery, Assistance Publique Hôpitaux de Paris, Henri Mondor Hospital, Université Paris-Est (UEP), Créteil, France
| | - Riccardo Memeo
- Department of Emergency and Organ Transplantation, University “Aldo Moro” of Bari, Bari, Italy
| | - Francesco Paolo Prete
- Unit of General Surgery “V. Bonomo”, Department of Biomedical Sciences and Human Oncology, University of Bari “Aldo Moro”, Policlinico, Piazza Giulio Cesare, 11, 70124 Bari, Italy
| | - Stefano Berti
- Department of General Surgery, “Sant’Andrea” Hospital La Spezia, La Spezia, Italy
| | - Graziano Ceccarelli
- Division of General Surgery, Department of Surgery, San Donato Hospital, via Pietro Nenni 20-22, 52100 Arezzo, Italy
| | | | | | - Nicola Solari
- Department of Surgery, IRCSS Ospedale Policlinico San Martino, Genova, Italy
| | - Marco Milone
- Department of Clinical Medicine and Surgery, Federico II” University, Napoli, Italy
| | - Fausto Catena
- Department of Emergency and Trauma Surgery, Parma University Hospital, Parma, Italy
| | - Stefano Scabini
- Department of Surgery, IRCSS Ospedale Policlinico San Martino, Genova, Italy
| | - Francesco Vittore
- Unit of General Surgery “V. Bonomo”, Department of Biomedical Sciences and Human Oncology, University of Bari “Aldo Moro”, Policlinico, Piazza Giulio Cesare, 11, 70124 Bari, Italy
| | - Gennaro Perrone
- Department of Emergency and Trauma Surgery, Parma University Hospital, Parma, Italy
| | - Carlo de Werra
- Department of Clinical Medicine and Surgery, Federico II” University, Napoli, Italy
| | - Ferdinando Cafiero
- Department of Surgery, IRCSS Ospedale Policlinico San Martino, Genova, Italy
| | - Mario Testini
- Unit of General Surgery “V. Bonomo”, Department of Biomedical Sciences and Human Oncology, University of Bari “Aldo Moro”, Policlinico, Piazza Giulio Cesare, 11, 70124 Bari, Italy
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de'Angelis N, Catena F, Memeo R, Coccolini F, Martínez-Pérez A, Romeo OM, De Simone B, Di Saverio S, Brustia R, Rhaiem R, Piardi T, Conticchio M, Marchegiani F, Beghdadi N, Abu-Zidan FM, Alikhanov R, Allard MA, Allievi N, Amaddeo G, Ansaloni L, Andersson R, Andolfi E, Azfar M, Bala M, Benkabbou A, Ben-Ishay O, Bianchi G, Biffl WL, Brunetti F, Carra MC, Casanova D, Celentano V, Ceresoli M, Chiara O, Cimbanassi S, Bini R, Coimbra R, Luigi de'Angelis G, Decembrino F, De Palma A, de Reuver PR, Domingo C, Cotsoglou C, Ferrero A, Fraga GP, Gaiani F, Gheza F, Gurrado A, Harrison E, Henriquez A, Hofmeyr S, Iadarola R, Kashuk JL, Kianmanesh R, Kirkpatrick AW, Kluger Y, Landi F, Langella S, Lapointe R, Le Roy B, Luciani A, Machado F, Maggi U, Maier RV, Mefire AC, Hiramatsu K, Ordoñez C, Patrizi F, Planells M, Peitzman AB, Pekolj J, Perdigao F, Pereira BM, Pessaux P, Pisano M, Puyana JC, Rizoli S, Portigliotti L, Romito R, Sakakushev B, Sanei B, Scatton O, Serradilla-Martin M, Schneck AS, Sissoko ML, Sobhani I, Ten Broek RP, Testini M, Valinas R, Veloudis G, Vitali GC, Weber D, Zorcolo L, Giuliante F, Gavriilidis P, Fuks D, Sommacale D. 2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy. World J Emerg Surg 2021; 16:30. [PMID: 34112197 PMCID: PMC8190978 DOI: 10.1186/s13017-021-00369-w] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 05/18/2021] [Indexed: 12/16/2022] Open
Abstract
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.
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Affiliation(s)
- Nicola de'Angelis
- Unit of Minimally Invasive and Robotic Digestive Surgery, General Regional Hospital "F. Miulli", Strada Prov. 127 Acquaviva - Santeramo Km. 4, 70021 Acquaviva delle Fonti BA, Bari, Italy. .,Unit of Digestive, Hepatobiliary and Pancreatic Surgery, CARE Department, Henri Mondor University Hospital (AP-HP), and Faculty of Medicine, University of Paris Est, UPEC, Creteil, France.
| | - Fausto Catena
- Department of Emergency and Trauma Surgery of the University Hospital of Parma, Parma, Italy
| | - Riccardo Memeo
- Department of Hepato-Pancreatic-Biliary Surgery, General Regional Hospital "F. Miulli", Acquaviva delle Fonti, Bari, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Department, Pisa University Hospital, Pisa, Italy
| | - Aleix Martínez-Pérez
- Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Oreste M Romeo
- Trauma, Burn, and Surgical Care Program, Bronson Methodist Hospital, Kalamazoo, Michigan, USA
| | - Belinda De Simone
- Service de Chirurgie Générale, Digestive, et Métabolique, Centre hospitalier de Poissy/Saint Germain en Laye, Saint Germain en Laye, France
| | - Salomone Di Saverio
- Department of Surgery, Cambridge University Hospital, NHS Foundation Trust, Cambridge, UK
| | - Raffaele Brustia
- Unit of Digestive, Hepatobiliary and Pancreatic Surgery, CARE Department, Henri Mondor University Hospital (AP-HP), and Faculty of Medicine, University of Paris Est, UPEC, Creteil, France
| | - Rami Rhaiem
- Department of HBP and Digestive Oncologic Surgery, Robert Debré University Hospital, Reims, France
| | - Tullio Piardi
- Department of HBP and Digestive Oncologic Surgery, Robert Debré University Hospital, Reims, France.,Department of Surgery, HPB Unit, Troyes Hospital, Troyes, France
| | - Maria Conticchio
- Department of Hepato-Pancreatic-Biliary Surgery, General Regional Hospital "F. Miulli", Acquaviva delle Fonti, Bari, Italy
| | - Francesco Marchegiani
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Nassiba Beghdadi
- Unit of Digestive, Hepatobiliary and Pancreatic Surgery, CARE Department, Henri Mondor University Hospital (AP-HP), and Faculty of Medicine, University of Paris Est, UPEC, Creteil, France
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Ruslan Alikhanov
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Scientific Center, Shosse Enthusiastov, 86, 111123, Moscow, Russia
| | | | - Niccolò Allievi
- 1st Surgical Unit, Department of Emergency, Papa Giovanni Hospital XXIII, Bergamo, Italy
| | - Giuliana Amaddeo
- Service d'Hepatologie, APHP, Henri Mondor University Hospital, Creteil, and Faculty of Medicine, University of Paris Est, UPEC, Creteil, France
| | - Luca Ansaloni
- General Surgery, San Matteo University Hospital, Pavia, Italy
| | | | - Enrico Andolfi
- Department of Surgery, Division of General Surgery, San Donato Hospital, 52100, Arezzo, Italy
| | - Mohammad Azfar
- Department of Surgery, Al Rahba Hospital, Abu Dhabi, UAE
| | - Miklosh Bala
- Trauma and Acute Care Surgery Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Amine Benkabbou
- Surgical Oncology Department, National Institute of Oncology, Mohammed V University in Rabat, Rabat, Morocco
| | - Offir Ben-Ishay
- Department of General Surgery, Rambam Healthcare Campus, Haifa, Israel
| | - Giorgio Bianchi
- Unit of Minimally Invasive and Robotic Digestive Surgery, General Regional Hospital "F. Miulli", Strada Prov. 127 Acquaviva - Santeramo Km. 4, 70021 Acquaviva delle Fonti BA, Bari, Italy
| | - Walter L Biffl
- Division of Trauma and Acute Care Surgery, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Francesco Brunetti
- Unit of Digestive, Hepatobiliary and Pancreatic Surgery, CARE Department, Henri Mondor University Hospital (AP-HP), and Faculty of Medicine, University of Paris Est, UPEC, Creteil, France
| | | | - Daniel Casanova
- Hospital Universitario Marqués de Valdecilla, University of Cantabria, Santander, Spain
| | - Valerio Celentano
- Colorectal Unit, Chelsea and Westminster Hospital, NHS Foundation Trust, London, UK
| | - Marco Ceresoli
- Emergency and General Surgery Department, University of Milan Bicocca, Milan, Italy
| | - Osvaldo Chiara
- General Surgery and Trauma Team, ASST Niguarda Milano, University of Milano, Milan, Italy
| | - Stefania Cimbanassi
- General Surgery and Trauma Team, ASST Niguarda Milano, University of Milano, Milan, Italy
| | - Roberto Bini
- General Surgery and Trauma Team, ASST Niguarda Milano, University of Milano, Milan, Italy
| | - Raul Coimbra
- Riverside University Health System Medical Center, Comparative Effectiveness and Clinical Outcomes Research Center - CECORC and Loma Linda University School of Medicine, Loma Linda, USA
| | - Gian Luigi de'Angelis
- Gastroenterology and Endoscopy Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Francesco Decembrino
- Gastroenterology and Endoscopy Unit, General Regional Hospital "F. Miulli", Acquaviva delle Fonti, Bari, Italy
| | - Andrea De Palma
- General, Emergency and Trauma Department, Pisa University Hospital, Pisa, Italy
| | - Philip R de Reuver
- Department of Surgery, Radboud University Medical Centre Nijmegen, Nijmegen, The Netherlands
| | - Carlos Domingo
- Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia, Spain
| | | | - Alessandro Ferrero
- Department of General and Oncological Surgery, Azienda Ospedaliera Ordine Mauriziano "Umberto I", Turin, Italy
| | - Gustavo P Fraga
- Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, SP, Brazil
| | - Federica Gaiani
- Gastroenterology and Endoscopy Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Federico Gheza
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Angela Gurrado
- Unit of General Surgery "V. Bonomo", Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Bari, Italy
| | - Ewen Harrison
- Department of Clinical Surgery and Centre for Medical Informatics, Usher Institute, University of Edinburgh, Little France Crescent, Edinburgh, UK
| | | | - Stefan Hofmeyr
- Division of Surgery, Surgical Gastroenterology Unit, Tygerberg Academic Hospital, University of Stellenbosch Faculty of Medicine and Health Sciences, Stellenbosch, South Africa
| | - Roberta Iadarola
- Department of Emergency and Trauma Surgery of the University Hospital of Parma, Parma, Italy
| | - Jeffry L Kashuk
- Department of Surgery, Tel Aviv University, Sackler School of Medicine, Tel Aviv, Israel
| | - Reza Kianmanesh
- Department of HBP and Digestive Oncologic Surgery, Robert Debré University Hospital, Reims, France
| | - Andrew W Kirkpatrick
- Department of Surgery, Critical Care Medicine and the Regional Trauma Service, Foothills Medical Center, Calgari, Alberta, Canada
| | - Yoram Kluger
- Department of General Surgery, Rambam Healthcare Campus, Haifa, Israel
| | - Filippo Landi
- Department of HPB and Transplant Surgery, Hospital Clínic, Universidad de Barcelona, Barcelona, Spain
| | - Serena Langella
- Department of General and Oncological Surgery, Azienda Ospedaliera Ordine Mauriziano "Umberto I", Turin, Italy
| | - Real Lapointe
- Department of HBP Surgery and Liver Transplantation, Department of Surgery, Centre Hospitalier de l'Université de Montreal, Montreal, QC, Canada
| | - Bertrand Le Roy
- Department of Digestive Surgery, University Hospital of Saint-Etienne, Saint-Priest-en-Jarez, France
| | - Alain Luciani
- Unit of Radiology, Henri Mondor University Hospital (AP-HP), Creteil, and Faculty of Medicine, University of Paris Est, UPEC, Creteil, France
| | - Fernando Machado
- Department of Emergency Surgery, Hospital de Clínicas, School of Medicine UDELAR, Montevideo, Uruguay
| | - Umberto Maggi
- General Surgery and Liver Transplantation Unit, Fondazione IRCCS Ca'Granda, Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Ronald V Maier
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Alain Chichom Mefire
- Department of Surgery and Obstetrics/Gynecologic, Regional Hospital, Limbe, Cameroon
| | - Kazuhiro Hiramatsu
- Department of General Surgery, Toyohashi Municipal Hospital, Toyohashi, Aichi, Japan
| | - Carlos Ordoñez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundacion Valle del Lili, Universidad del Valle Cali, Cali, Colombia
| | - Franca Patrizi
- Unit of Gastroenterology and Endoscopy, Maggiore Hospital, Bologna, Italy
| | - Manuel Planells
- Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Andrew B Peitzman
- Department of Surgery, UPMC, University of Pittsburg, School of Medicine, Pittsburg, USA
| | - Juan Pekolj
- General Surgery, Liver Transplant Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Fabiano Perdigao
- Liver Transplant Unit, APHP, Unité de Chirurgie Hépatobiliaire et Transplantation hépatique, Hôpital Pitié Salpêtrière, Paris, France
| | - Bruno M Pereira
- Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, SP, Brazil
| | - Patrick Pessaux
- Hepatobiliary and Pancreatic Surgical Unit, Visceral and Digestive Surgery, IHU mix-surg, Institute for Minimally Invasive Image-Guided Surgery, University of Strasbourg, Strasbourg, France
| | - Michele Pisano
- 1st Surgical Unit, Department of Emergency, Papa Giovanni Hospital XXIII, Bergamo, Italy
| | - Juan Carlos Puyana
- Trauma & Acute Care Surgery - Global Health, University of Pittsburgh, Pittsburgh, USA
| | - Sandro Rizoli
- Trauma and Acute Care Service, St Michael's Hospital, Toronto, ON, Canada
| | - Luca Portigliotti
- Chirurgia Epato-Gastro-Pancreatica, Azienda Ospedaliera-Universitaria Maggiore della Carità, Novara, Italy
| | - Raffaele Romito
- Chirurgia Epato-Gastro-Pancreatica, Azienda Ospedaliera-Universitaria Maggiore della Carità, Novara, Italy
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Behnam Sanei
- Department of Surgery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Olivier Scatton
- Liver Transplant Unit, APHP, Unité de Chirurgie Hépatobiliaire et Transplantation hépatique, Hôpital Pitié Salpêtrière, Paris, France
| | - Mario Serradilla-Martin
- Instituto de Investigación Sanitaria Aragón, Department of Surgery, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Anne-Sophie Schneck
- Digestive Surgery Unit, Centre Hospitalier Universitaire de Guadeloupe, Pointe-À-Pitre, Les Avymes, Guadeloupe, France
| | - Mohammed Lamine Sissoko
- Service de Chirurgie, Hôpital National Blaise Compaoré de Ouagadougou, Ouagadougou, Burkina Faso
| | - Iradj Sobhani
- Department of Gastroenterology and Digestive Endoscopy, Henri Mondor Hospital, AP-HP, Creteil, and Faculty of Medicine, University of Paris Est, UPEC, Creteil, France
| | - Richard P Ten Broek
- Department of Surgery, Radboud University Medical Centre Nijmegen, Nijmegen, The Netherlands
| | - Mario Testini
- Unit of General Surgery "V. Bonomo", Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Bari, Italy
| | - Roberto Valinas
- Department of Surgery "F", Faculty of Medicine, Clinic Hospital "Dr. Manuel Quintela", Montevideo, Uruguay
| | | | - Giulio Cesare Vitali
- Division of Transplantation, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
| | - Dieter Weber
- Department of Trauma Surgery, Royal Perth Hospital, Perth, Australia
| | - Luigi Zorcolo
- Department of Surgery, Colorectal Surgery Unit, University of Cagliari, Cagliari, Italy
| | - Felice Giuliante
- Hepatobiliary Surgery Unit, Foundation "Policlinico Universitario A. Gemelli", IRCCS, Rome, Italy
| | - Paschalis Gavriilidis
- Division of Gastrointestinal and HBP Surgery, Imperial College HealthCare, NHS Trust, Hammersmith Hospital, London, UK
| | - David Fuks
- Institut Mutualiste Montsouris, Paris, France
| | - Daniele Sommacale
- Unit of Digestive, Hepatobiliary and Pancreatic Surgery, CARE Department, Henri Mondor University Hospital (AP-HP), and Faculty of Medicine, University of Paris Est, UPEC, Creteil, France
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Araujo SEA, Kim NJ, Cendoroglo NM, Klajner S. Value of Nontechnical Skills in Minimally Invasive Surgery. Clin Colon Rectal Surg 2021; 34:131-135. [PMID: 33814993 DOI: 10.1055/s-0040-1718688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Nontechnical skills are of increasing importance in surgery and surgical training. The main studies on its impact on the safety and effectiveness of surgical interventions were mainly published in the first decade of the 2000s. Due to the significant technical complexity and great diversity of instruments for nontechnical skills evaluation, the interest in training and in measuring the impact on surgical safety has relatively decreased. However, the advent of minimally invasive surgery and its peculiar technical characteristics of sophisticated technique and constant innovation through the adoption of new materials and drugs has rekindled interest in this expertise area. In the present review, we have revisited the main instruments available to measure nontechnical skill of surgical teams and analyzed the role of the main competencies on which they are based, such as situational awareness, leadership and communication skills, and the consistency of the intraoperative decision-making process. We conclude that despite the great consensus that exists among all members of the health team on the importance of nontechnical skills for the surgical team in minimally invasive surgery, the reproducible evidence on the subject is scarce and laborious to obtain. To the extent that protecting and expanding nontechnical skills is fundamental to the path toward the high reliability of health institutions, it is possible to anticipate here the role of these institutions as promoters of continuity and new research models in this area of knowledge, especially in minimally invasive surgery, an access route to which more and more patients undergoing surgical treatment in these same institutions are submitted.
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Affiliation(s)
| | - Nam Jin Kim
- Hospital Israelita Albert Einstein, São Paulo, Brasil
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Wu D, Liu S, Zhou J, Chen R, Wang Y, Feng Z, Lin H, Qian J, Tang BZ, Cai X. Organic Dots with Large π-Conjugated Planar for Cholangiography beyond 1500 nm in Rabbits: A Non-Radioactive Strategy. ACS NANO 2021; 15:5011-5022. [PMID: 33706510 DOI: 10.1021/acsnano.0c09981] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Iatrogenic extrahepatic bile duct injury remains a dreaded complication while performing cholecystectomy. Although X-ray based cholangiography could reduce the incidence of biliary tract injuries, the deficiencies including radiation damage and expertise dependence hamper its further clinical application. The effective strategy for intraoperative cholangiography is still urgently required. Herein, a fluorescence-based imaging approach for cholangiography in the near-infrared IIb window (1500-1700 nm) using TT3-oCB, a bright aggregation-induced emission luminogen with large π-conjugated planar unit, is reported. In phantom studies, TT3-oCB nanoparticles exhibit high near-infrared IIb emission and show better image clarity at varying penetrating depths. When intrabiliary injected into the gallbladder or the common bile duct of the rabbit, TT3-oCB nanoparticles enable the real-time imaging of the biliary structure with deep penetrating capability and high signal-to-background ratio. Moreover, the tiny iatrogenic biliary injuries and the gallstones in established disease models could be precisely diagnosed by TT3-oCB nanoparticle assisted near-infrared IIb imaging. In summary, we reported a feasible application for aggregation-induced emission dots as biliary contrast agent and realized high-quality cholangiography in the near-infrared IIb window with precise diagnostic ability and nonradioactive damage, which could possibly be applied for intraoperative diagnosis.
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Affiliation(s)
- Di Wu
- Department of General Surgery, Sir Run-Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, China
| | - Shunjie Liu
- Department of Chemistry, Hong Kong Branch of Chinese National Engineering Research Center for Tissue Restoration and Reconstruction, Division of Life Science and State Key Laboratory of Molecular Neuroscience, and Division of Biomedical Engineering, The Hong Kong University of Science and Technology, Kowloon, Hong Kong, China
| | - Jing Zhou
- State Key Laboratory of Modern Optical Instrumentations, Centre for Optical and Electromagnetic Research, College of Optical Science and Engineering, International Research Center for Advanced Photonics, Zhejiang University, Hangzhou 310058, China
| | - Runze Chen
- State Key Laboratory of Modern Optical Instrumentations, Centre for Optical and Electromagnetic Research, College of Optical Science and Engineering, International Research Center for Advanced Photonics, Zhejiang University, Hangzhou 310058, China
| | - Yifan Wang
- Department of General Surgery, Sir Run-Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, China
| | - Zhe Feng
- State Key Laboratory of Modern Optical Instrumentations, Centre for Optical and Electromagnetic Research, College of Optical Science and Engineering, International Research Center for Advanced Photonics, Zhejiang University, Hangzhou 310058, China
| | - Hui Lin
- Department of General Surgery, Sir Run-Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, China
| | - Jun Qian
- State Key Laboratory of Modern Optical Instrumentations, Centre for Optical and Electromagnetic Research, College of Optical Science and Engineering, International Research Center for Advanced Photonics, Zhejiang University, Hangzhou 310058, China
| | - Ben Zhong Tang
- Department of Chemistry, Hong Kong Branch of Chinese National Engineering Research Center for Tissue Restoration and Reconstruction, Division of Life Science and State Key Laboratory of Molecular Neuroscience, and Division of Biomedical Engineering, The Hong Kong University of Science and Technology, Kowloon, Hong Kong, China
- Center for Aggregation-Induced Emission, SCUT-HKUST Joint Research Institute, State Key Laboratory of Luminescent Materials and Devices, South China University of Technology, Guangzhou 510640, China
- HKUST-Shenzhen Research Institute, Nanshan, Shenzhen 518057, China
| | - Xiujun Cai
- Department of General Surgery, Sir Run-Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, China
- Key Laboratory of Laparoscopic Technology of Zhejiang Province; Zhejiang Minimal Invasive Diagnosis and Treatment Technology Research Center of Severe Hepatobiliary Disease; Zhejiang Research and Development Engineering Laboratory of Minimally Invasive Technology and Equipment, Zhejiang University Cancer Center, Hangzhou 310016, China
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45
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OR black box and surgical control tower: Recording and streaming data and analytics to improve surgical care. J Visc Surg 2021; 158:S18-S25. [PMID: 33712411 DOI: 10.1016/j.jviscsurg.2021.01.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Effective and safe surgery results from a complex sociotechnical process prone to human error. Acquiring large amount of data on surgical care and modelling the process of surgery with artificial intelligence's computational methods could shed lights on system strengths and limitations and enable computer-based smart assistance. With this vision in mind, surgeons and computer scientists have joined forces in a novel discipline called Surgical Data Science. In this regard, operating room (OR) black boxes and surgical control towers are being developed to systematically capture comprehensive data on surgical procedures and to oversee and assist during operating rooms activities, respectively. Most of the early Surgical Data Science works have focused on understanding risks and resilience factors affecting surgical safety, the context and workflow of procedures, and team behaviors. These pioneering efforts in sensing and analyzing surgical activities, together with the advent of precise robotic actuators, bring surgery on the verge of a fourth revolution characterized by smart assistance in perceptual, cognitive and physical tasks. Barriers to implement this vision exist, but the surgical-technical partnerships set by ambitious efforts such as the OR black box and the surgical control tower are working to overcome these roadblocks and translate the vision and early works described in the manuscript into value for patients, surgeons and health systems.
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Chavira AM, Rivas JF, Molina APRF, de la Cruz SA, Zárate AC, Musa AB, Osorio VJC. The educational quality of the critical view of safety in videos on youtube® versus specialized platforms: which is better? Critical view of safety in virtual resources. Surg Endosc 2021; 36:337-345. [PMID: 33527206 DOI: 10.1007/s00464-021-08286-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 01/05/2021] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The surgical education has evolved by adopting the visual platforms as a resource of searching. The videos complement the visual learning of surgical techniques of trainees, residents, and surgeons. YouTube® is the most frequently consulted platform in the surgical field. WebSurg® and GIBLIB® are two recognized medical platforms. The Critical View of Safety (CVS) is the most important and effective method to reduce the risk of bile duct injury (BDI) in laparoscopic cholecystectomy (LC). Reaching a satisfactory CVS is a crucial point. We evaluated the CVS of videos on WebSurg® and GIBLIB®, comparing the results with those of the worldwide most popular video platform. METHODS We performed a search under the term "Laparoscopic cholecystectomy" on the virtual platforms YouTube®, GIBLIB®, and WebSurg®. Three evaluators reviewed the 77 selected videos using the "Sanford-Strasberg' CVS score." The inferential analysis was performed between two groups: YouTube® and Non-YouTube (GIBLIB® and WebSurg®). The characteristics of each video were analyzed including country of origin, type of profile, number of views, and number of Likes. RESULTS Satisfactory CVS obtained from each of the platforms was GIBLIB® 40%; WebSurg® 44.4%; YouTube® 27.7%. The comparative analysis of CVS quality and CVS score for the Non-YouTube and YouTube® groups did not show a significant difference (p = 0.142, p = 0.377, respectively). CONCLUSION The videos on GIBLIB® and WebSurg® offer a higher probability of satisfactory CVS compared to YouTube®. Nevertheless, there is no significant superiority of GIBLIB® and WebSurg® over YouTube®.
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Affiliation(s)
- Antonio Marmolejo Chavira
- Department of Surgery, Hospital Central Sur de Alta Especialidad, PEMEX, 7th Floor, Periférico Sur 4091 Fuentes del Pedregal, Tlalpan, 14140, Mexico City, Mexico.
| | - Jorge Farell Rivas
- Department of Surgery, Director of Surgical Residency Program, Hospital Central Sur de Alta Especialidad, PEMEX, 7th Floor, Periférico Sur 4091 Fuentes del Pedregal, Tlalpan, 14140, Mexico City, Mexico
| | - Ana Paula Ruiz Funes Molina
- Department of Surgery, Hospital Central Sur de Alta Especialidad, PEMEX, 7th Floor, Periférico Sur 4091 Fuentes del Pedregal, Tlalpan, 14140, Mexico City, Mexico
| | - Sergio Ayala de la Cruz
- Department of Clinical Pathology, Hospital Universitario "Dr. José E. González", Av. Francisco I. Madero Pte. Mitras Centro, 1st Floor, 64460, Monterrey, Nuevo Leon, Mexico
| | - Alejandro Cruz Zárate
- Department of Surgery, Hospital Central Sur de Alta Especialidad, PEMEX, 7th Floor, Periférico Sur 4091 Fuentes del Pedregal, Tlalpan, 14140, Mexico City, Mexico
| | - Alfonso Bandin Musa
- Department of Transplants, Hospital Central Sur de Alta Especialidad, PEMEX, 10th Floor, Periférico Sur 4091 Fuentes del Pedregal, Tlalpan, 14140, Mexico City, Mexico
| | - Víctor José Cuevas Osorio
- Department of Surgery, Hospital Central Sur de Alta Especialidad, PEMEX, 7th Floor, Periférico Sur 4091 Fuentes del Pedregal, Tlalpan, 14140, Mexico City, Mexico
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Dip F, Aleman R, Frieder JS, Gomez CO, Menzo EL, Szomstein S, Rosenthal RJ. Understanding intraoperative fluorescent cholangiography: ten steps for an effective and successful procedure. Surg Endosc 2021; 35:7042-7048. [PMID: 33475844 DOI: 10.1007/s00464-020-08219-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 12/03/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Common bile duct injuries (BDI) during laparoscopic cholecystectomy (LC) continue to be the source of morbidity and mortality. The reason for BDI is mostly related to the misidentification of the extrahepatic bile duct structures and the anatomic variability. Near-infrared fluorescent cholangiography (NIFC) has proven to enhance visualization of extrahepatic biliary structures during LCs. The purpose of this study was to describe the most important steps in the performance of NIFC. METHODS In accordance to the most current surgical practice of LC at our institution, a consensus was achieved on the most relevant steps to be followed when utilizing NIFC. Dose of indocyanine green (ICG), time of administration, and identification of critical structures were previously determined based on prospective and randomized controlled studies performed at CCF. RESULTS The ten steps identified as critical when performing NIFC during LC are preoperative administration of ICG, exposure of the hepatoduodenal ligament, initial anatomical evaluation, identification of the cystic duct and common bile duct junction, the cystic duct and its junction to the gallbladder, the CHD, the common bile duct, accessory ducts, cystic artery and, time-out and identification of Calot's triangle, and evaluation of the liver bed. CONCLUSIONS Routine use of NIFC is a useful diagnostic tool to better visualize the extrahepatic biliary structures during LC. The implementation of specific standardized steps might provide the surgeon with a better algorithm to use this technology and consequently reduce the incidence of BDI.
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Affiliation(s)
- Fernando Dip
- Department of Minimally Invasive Surgery and The Bariatric and Metabolic Institute at the Cleveland Clinic Florida, Weston, FL, USA. .,Hospital de Clinicas "Jose de San Martin", Av. Córdoba 2351, Buenos Aires, Argentina.
| | - Rene Aleman
- Department of Minimally Invasive Surgery and The Bariatric and Metabolic Institute at the Cleveland Clinic Florida, Weston, FL, USA
| | - Joel S Frieder
- Department of Minimally Invasive Surgery and The Bariatric and Metabolic Institute at the Cleveland Clinic Florida, Weston, FL, USA
| | - Camila Ortiz Gomez
- Department of Minimally Invasive Surgery and The Bariatric and Metabolic Institute at the Cleveland Clinic Florida, Weston, FL, USA
| | - Emanuele Lo Menzo
- Department of Minimally Invasive Surgery and The Bariatric and Metabolic Institute at the Cleveland Clinic Florida, Weston, FL, USA
| | - Samuel Szomstein
- Department of Minimally Invasive Surgery and The Bariatric and Metabolic Institute at the Cleveland Clinic Florida, Weston, FL, USA
| | - Raul J Rosenthal
- Department of Minimally Invasive Surgery and The Bariatric and Metabolic Institute at the Cleveland Clinic Florida, Weston, FL, USA
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Cystic Lymph Node Identification Is More Reliable Than Critical View of Safety in Difficult Cholecystectomies. Surg Laparosc Endosc Percutan Tech 2021; 31:155-159. [PMID: 33782336 DOI: 10.1097/sle.0000000000000900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 11/19/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND The cystic lymph node (CLN) represents an anatomic safety marker and a surrogate marker of technique during laparoscopic cholecystectomy (LC). We aim to demonstrate the value of CLN in comparison to the critical view of safety (CVS) and study the effects of increasing difficulty on the 2 approaches. METHODS A prospective study of consecutive LC was conducted. Patient demographics, type of admission, clinical presentation, operative difficulty grade, visualization of CLN, identification of CVS, operative time, and complications were recorded and analyzed. RESULTS Of 393 LCs, half of the admissions were emergencies. Thirty-four percent had obstructive jaundice or acute cholecystitis. The CLN was visually identified in 81.7% with a small difference between operative difficulty grades 1 to 3 versus 4 to 5. Although CVS was unachievable in 62 patients, 43 (69.4%) still had an identifiable CLN. The median operating time was 68 minutes with 1 mortality but no conversions or intraoperative complications. CONCLUSIONS Identifying the CLN during LC could compliment the CVS in avoiding major ductal injury. Dissecting lateral to the CLN to commence the process of displaying the cystic pedicle structures may be a strategy in safely achieving the CVS. During the more difficult LC where displaying the CVS is impossible, the CLN may be the key anatomic landmark.
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Knowledge of the Culture of Safety in Cholecystectomy (COSIC) Among Surgical Residents: Do We Train Them Well For Future Practice? World J Surg 2021; 45:971-980. [PMID: 33454794 DOI: 10.1007/s00268-020-05911-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Biliary injury is the most feared complication of laparoscopic cholecystectomy (LC). This study aimed to assess the awareness of culture of safety in cholecystectomy (COSIC) concept among the surgical residents in India. METHODS A manual survey was conducted among general surgery residents attending a postgraduate course. Survey consisted of questions pertaining to knowledge of various aspects of COSIC, e.g., the critical view of safety (CVS). RESULTS With a response rate of 51%, 259 residents were included in this study. They had more exposure to LC (63.3% assisted / performed > 15 LC) than to open cholecystectomy (60.6% assisted / performed ≤ 10 open cholecystectomy). The majority (80.2%) clearly differentiated Calot triangle from the hepatocystic triangle (HCT). However, 25.8% could not correctly define HCT. The majority (88.5%) had seen the Rouviere's sulcus during LC. While almost all (98.4%) respondents claimed to know about the segment 4, only 41.9% could correctly describe it. Awareness of the correct direction of the gallbladder retraction was lower for the infundibulum (53.5%) than for fundus (89.2%). The majority (88.3%) claimed to know CVS but only 11.5% knew it correctly, and 15.1% described > 3 components. The majority (78.7%) practiced to identify the cystic duct-common bile duct junction. Awareness was low for time-out (28.1%), intraoperative cholangiography (20.6%), bailout techniques (18.9%), and for overall COSIC concept (15.7%). CONCLUSIONS Knowledge of COSIC among surgical residents seems to be suboptimal, especially for the CVS, time-out, bailout techniques, and overall concept of COSIC. Strategies to educate them more effectively about COSIC are highly imperative to train them well for future practice.
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50
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Koong JK, Ng GH, Ramayah K, Koh PS, Yoong BK. Early identification of the critical view of safety in laparoscopic cholecystectomy using indocyanine green fluorescence cholangiography: A randomised controlled study. Asian J Surg 2020; 44:537-543. [PMID: 33223453 DOI: 10.1016/j.asjsur.2020.11.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 10/24/2020] [Accepted: 11/03/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Achieving critical view of safety (CVS) is vital during laparoscopic cholecystectomy (LC). There is no known study determining use of indocyanine green fluorescence cholangiography (ICGFC) in early identification of CVS during LC. This study aims to compare use of ICGFC in LC against conventional LC in early identification of CVS. METHODOLOGY Patients undergoing LC in a single centre were randomized into ICGFC-LC and conventional LC. Surgery was performed by a single surgeon and the time taken to achieve CVS from the time of gallbladder fundus retraction was measured. Difficulty level for each surgery was rated and analysed using a modified scoring system (Level 1- Easy to Level 4-Very difficult). RESULTS 63 patients were recruited where mean time (min) to achieve CVS was 22.3 ± 12.9 in ICGFC-LC (n = 30) and 22.8 ± 14.3 in conventional LC (p = 0.867). The time taken to achieve CVS was shorter in ICGFC-LC group across all difficulty levels, although not significant (p > 0.05). No major complication was observed in the study. CONCLUSIONS This study had shown ICGFC-LC reduces time to CVS across all difficulty levels but not statistically significant. ICGFC-LC maybe useful in difficult LC and in surgical training. TRIAL REGISTRATION Clinical Trials NCT04228835. STUDY GRANT UMMI Surgical - Karl Storz Distributor (Malaysia).
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Affiliation(s)
- Jun Kit Koong
- Department of Surgery, Faculty of Medicine, University of Malaya, Jalan Universiti, 50603, Kuala Lumpur, Wilayah Perseketuan, Malaysia.
| | - Gaik Huey Ng
- Department of Surgery, Faculty of Medicine, University of Malaya, Jalan Universiti, 50603, Kuala Lumpur, Wilayah Perseketuan, Malaysia.
| | - Kamarajan Ramayah
- Department of Surgery, Faculty of Medicine, University of Malaya, Jalan Universiti, 50603, Kuala Lumpur, Wilayah Perseketuan, Malaysia.
| | - Peng Soon Koh
- Department of Surgery, Faculty of Medicine, University of Malaya, Jalan Universiti, 50603, Kuala Lumpur, Wilayah Perseketuan, Malaysia.
| | - Boon Koon Yoong
- Department of Surgery, Faculty of Medicine, University of Malaya, Jalan Universiti, 50603, Kuala Lumpur, Wilayah Perseketuan, Malaysia.
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