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Barnes A, Viscomi B, Gorham JK. Surgical Management of the Horrible Gallbladder. Adv Surg 2024; 58:143-160. [PMID: 39089774 DOI: 10.1016/j.yasu.2024.04.009] [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] [Indexed: 08/04/2024]
Abstract
Laparoscopic cholecystectomy is one of the most frequently performed operations by general surgeons, with up to 1 million cholecystectomies performed annually in the United States alone. Despite familiarity, common bile duct injury occurs in no less than 0.2% of cholecystectomies, with significant associated morbidity. Understanding biliary anatomy, surgical techniques, pitfalls, and bailout maneuvers is critical to optimizing outcomes when encountering the horrible gallbladder. This article describes normal and aberrant biliary anatomy, complicated cholelithiasis, ways to recognize cholecystitis, and considerations of surgical approach.
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Affiliation(s)
- Andrew Barnes
- Department of General Surgery, Ochsner Medical Center, 1514 Jefferson Highway, New Orleans, LA 70121, USA
| | - Brian Viscomi
- Department of General Surgery, Ochsner Medical Center, 1514 Jefferson Highway, New Orleans, LA 70121, USA
| | - Jessica Koller Gorham
- Department of General Surgery, Ochsner Medical Center, 1514 Jefferson Highway, New Orleans, LA 70121, USA.
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Vincenzi P, Mocchegiani F, Nicolini D, Benedetti Cacciaguerra A, Gaudenzi D, Vivarelli M. Bile Duct Injuries after Cholecystectomy: An Individual Patient Data Systematic Review. J Clin Med 2024; 13:4837. [PMID: 39200979 PMCID: PMC11355347 DOI: 10.3390/jcm13164837] [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: 06/13/2024] [Revised: 07/22/2024] [Accepted: 08/09/2024] [Indexed: 09/02/2024] Open
Abstract
Background: Post-cholecystectomy bile duct injuries (BDIs) represent a challenging complication, with negative impacts on clinical outcomes. Several surgical and endoscopic/interventional radiologist (IR) approaches have been proposed to manage these damages, though with high failure rates. This individual patient data (IPD) systematic review analyzes the potential risk factors for failure after treatment interventions for BDIs, both surgical and endoscopic/IR. Methods: An extensive literature search was conducted on MEDLINE and Scopus for relevant articles published in English on the management of BDIs after cholecystectomy, between 1 January 2010 and 31 December 2023. Our series of BDIs was included. BDIs were always categorized according to the Strasberg's classification. The composite primary endpoints evaluated were the failure of treatment interventions, defined as patient death or the requirement of any other procedure, whatever surgical and/or endoscopic/IR, after the primary treatment. Results: A total of 342 cases were retrieved from our literature analysis, including our series of 19 patients. Among these, three groups were identified: "upfront surgery", "upfront endoscopy and/or IR" and "no upfront treatment", consisting of 224, 109 and 9 patients, respectively. After eliminating the third group, treatment intervention failure was observed overall in 34.2% (114/333) of patients, of whom 80.7% (92/114) and 19.3% (22/114) in the "upfront surgery" and in the "upfront endoscopy/IR" groups, respectively. At multivariable analysis, injury type D and E, and repair in a non-specialized center represented independent predictors of treatment failure in both groups, whereas laparoscopic cholecystectomy (LC) converted to open and immediate attempt of surgical repair exclusively in the first group. Conclusions: Significant treatment failure rates are responsible for remarkable negative effects on immediate and longer-term clinical outcomes of post-cholecystectomy BDIs. Understanding the important risk factors for this outcome may better guide the most appropriate therapeutical approach and improve clinical decisions in case this serious complication occurs.
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Affiliation(s)
- Paolo Vincenzi
- Division of HPB and Abdominal Transplant Surgery, Department of Gastroenterology and Transplants, Azienda Ospedaliero-Universitaria delle Marche, 60126 Ancona, Italy; (P.V.); (D.N.); (D.G.)
| | - Federico Mocchegiani
- Division of HPB and Abdominal Transplant Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, 60126 Ancona, Italy; (A.B.C.); (M.V.)
| | - Daniele Nicolini
- Division of HPB and Abdominal Transplant Surgery, Department of Gastroenterology and Transplants, Azienda Ospedaliero-Universitaria delle Marche, 60126 Ancona, Italy; (P.V.); (D.N.); (D.G.)
| | - Andrea Benedetti Cacciaguerra
- Division of HPB and Abdominal Transplant Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, 60126 Ancona, Italy; (A.B.C.); (M.V.)
| | - Diletta Gaudenzi
- Division of HPB and Abdominal Transplant Surgery, Department of Gastroenterology and Transplants, Azienda Ospedaliero-Universitaria delle Marche, 60126 Ancona, Italy; (P.V.); (D.N.); (D.G.)
| | - Marco Vivarelli
- Division of HPB and Abdominal Transplant Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, 60126 Ancona, Italy; (A.B.C.); (M.V.)
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Ismaeil DA. Avoidance of bile duct injury in laparoscopic cholecystectomy with feasible intraoperative resources: A cohort study. Biomed Rep 2024; 21:110. [PMID: 38872852 PMCID: PMC11168025 DOI: 10.3892/br.2024.1798] [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: 02/20/2024] [Accepted: 05/08/2024] [Indexed: 06/15/2024] Open
Abstract
Laparoscopic cholecystectomy (LC) is one of the most commonly performed surgeries and is considered the standard treatment for cholelithiasis. However, it is associated with a risk of bile duct or hepatic artery injuries. This study evaluated the safety of LCs and the conversion rate (CR) by achieving a critical view of safety (CVS) and identification of Rouviere's sulcus (RS). This was a single-group cohort study that included consecutive patients undergoing LC at Smart Health Tower (Sulaimani, Iraq) from January 2021 to January 2023. The data were prospectively collected from patients' profiles or surgical notes within the hospital's database. A total of 419 patients underwent LC, of which females were the predominant gender (78.5%). The mean and median ages of the cases were 46.3±15.8 and 45 years, with a range of 2-90 years, respectively. The most common indications for surgery were biliary colic (69.5%), followed by acute cholecystitis (23.9%). The duration of the operations was significantly shorter for cases in which the CVS (45.6±17.9 min) or identification of RS (45.6±18.6 min) was achieved compared to those where the CVS (63.7±27.7 min) or RS (50.7±21.7 min) was not observed. Surgeries for patients with both CVS achievement and RS identification were also significantly less time-consuming (44.3±17.6) than counterparts (53.3±22.6). Among the cases without CVS achievement or RS identification (n=97, 23%), eight (8.2%) had adhesions, 12 (12.4%) had a distended gallbladder (GB) and 10 (10.3%) had thick GB walls. In addition, four (4.1%) experienced GB perforation, two (2.1%) had bleeding and one (1%) had stone spillage. There was no conversion. The achievement of CVS and identification of RS are practical landmarks in performing safe LC and decreasing the CR.
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Affiliation(s)
- Deari A. Ismaeil
- Department of Surgery, College of Medicine, University of Sulaimani, Sulaimani, Kurdistan 46001, Iraq
- Scientific Affairs Department, Smart Health Tower, Sulaimani, Kurdistan 46001, Iraq
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Edergren Å, Sandblom G, Franko M, Agustsson T, Cengiz Y, Jaafar G. Safety of cholecystectomy performed by surgeons who prefer fundus first versus surgeons who prefer a standard laparoscopic approach. Surg Open Sci 2024; 19:141-145. [PMID: 38706518 PMCID: PMC11066465 DOI: 10.1016/j.sopen.2024.04.004] [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: 04/11/2024] [Accepted: 04/20/2024] [Indexed: 05/07/2024] Open
Abstract
Background An alternative method to standard laparoscopic cholecystectomy (SLC) is the "fundus first" method (FFLC). Concerns have been raised that FFLC can lead to misinterpretation of important anatomical structures, thus causing complications of a more serious kind than SLC. Comparisons between the methods are complicated by the fact that FFLC is often used as a rescue procedure in complicated cases. To avoid confounding related to this we conducted a population-based study with comparisons on the surgeon level. Method In GallRiks, the Swedish registry for Gallbladder surgery, we stratified all cholecystectomies performed 2006-2020 in three groups: surgeries carried out by surgeons that uses FFLC in <20 % of the cases (N = 150,119), in 20-79 % of the cases (N = 10,212) and in 80 % or more of the cases (N = 3176). We compared the groups with logistic regression, adjusting for sex, age, surgical experience, year of surgery and history of acute cholecystitis. All surgical complications (bleeding, gallbladder perforation, visceral perforation, infection, and bile duct injury) were included as outcome. A separate analysis was done with regards to operation time. Results No difference in incidence of all surgical complications or bile duct injury were seen between groups. The rates of bleeding (OR 0.34 [0.14-0.86]) and gallbladder perforation (OR 0.61 [0.45-0.82]) were significantly lower in the "fundus first > 80% group" and the operative time was shorter (OR 0.76 [0.69-0.83]). Conclusion In this study including >160,000 cholecystectomies, both methods was found to be equally safe. Key message During laparoscopic cholecystectomy, the standard method of dissection and fundus first dissection are equally safe surgical techniques. Surgeons need to learn both methods to be able to use the one most appropriate for each individual case.
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Affiliation(s)
- Åsa Edergren
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institute & Department of Surgery, Södersjukhuset, Sjukhusbacken 10, 11883 Stockholm, Sweden
| | - Gabriel Sandblom
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institute & Department of Surgery, Södersjukhuset, Sjukhusbacken 10, 11883 Stockholm, Sweden
| | - Mikael Franko
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institute, Sjukhusbacken 10, 11883 Stockholm, Sweden
| | - Thorhallur Agustsson
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institute & Department of Surgery, Södersjukhuset, Sjukhusbacken 10, 11883 Stockholm, Sweden
| | - Yucel Cengiz
- Department of Surgical and Perioperative Sciences, Umeå University, 90185 Umeå, Sweden
| | - Gona Jaafar
- Department of Clinical Sciences, Intervention and Technology, Karolinska Institute & Department of Emergency Care, Karolinska University Hospital, Ana Futura, Alfred Nobels Allé 8, 141 52 Huddinge, Sweden
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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; 38:2475-2482. [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] [MESH Headings] [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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Hou YK, Liu WK, Gao YB, Tian XD, Yang YM. Enhanced fluorescence cholangiography with indocyanine green: A methodology for reducing the potential hazard of bile duct injury during laparoscopic cholecystectomy. Hepatobiliary Pancreat Dis Int 2024:S1499-3872(24)00065-1. [PMID: 38704349 DOI: 10.1016/j.hbpd.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 03/28/2024] [Indexed: 05/06/2024]
Affiliation(s)
- Yu-Kun Hou
- Department of Hepatobiliary and Pancreatic Surgery, Peking University First Hospital, Beijing 100034, China
| | - Wei-Kang Liu
- Department of Hepatobiliary and Pancreatic Surgery, Peking University First Hospital, Beijing 100034, China
| | - Yi-Bo Gao
- Kunming Medical University, Kunming 650500, China
| | - Xiao-Dong Tian
- Department of Hepatobiliary and Pancreatic Surgery, Peking University First Hospital, Beijing 100034, China
| | - Yin-Mo Yang
- Department of Hepatobiliary and Pancreatic Surgery, Peking University First Hospital, Beijing 100034, China.
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Aburayya BI, Obeidat LR, Kitana FI, Al Khatib O, Romman S, Hamed OH. Complete Common Bile Duct Injury after Laparoscopic Cholecystectomy in Situs Inversus Totalis: A Case Report, Review of the Literature and Illustrative Case Video. Int J Surg Case Rep 2024; 115:109265. [PMID: 38244377 PMCID: PMC10831892 DOI: 10.1016/j.ijscr.2024.109265] [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: 11/27/2023] [Revised: 01/08/2024] [Accepted: 01/10/2024] [Indexed: 01/22/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Situs Inversus Totalis (SIT) is a rare condition characterized by the transposition of internal organs. Given the anatomical variations in SIT, surgeons must exercise extreme caution when performing laparoscopic cholecystectomy to avoid iatrogenic bile duct injury. Despite the high difficulty index associated with laparoscopic cholecystectomy in SIT, there is only one case report of common bile duct (CBD) injury in the English-language literature. CASE PRESENTATION A 41-year-old female patient, known to have Kartagener syndrome, underwent laparoscopic cholecystectomy for acute cholecystitis and was discharged home on post-operative day one. However, on post-operative day five, the patient presented to the emergency room with abdominal pain, fever, and jaundice. Laboratory tests revealed leukocytosis and hyperbilirubinemia. Radiological images revealed complete occlusion of the CBD. A delayed approach was chosen, and six weeks after her initial operation, a hepaticojejunostomy was performed. CLINICAL DISCUSSION Laparoscopic cholecystectomy is the standard operative procedure for gallbladder disease. The unique anatomy of SIT increases the risk of CBD injury during laparoscopic cholecystectomy. Surgeons are required to perform a mirror-image procedure and adhere to the basic principles of safe laparoscopic cholecystectomy in SIT. This is only the second reported case of CBD injury in SIT patients. CONCLUSION Laparoscopic cholecystectomy in SIT presents a significant challenge. In patients with SIT, preventing CBD injury is the best approach, and referral to an experienced hepato-pancreato-biliary (HPB) surgeon is recommended. A delayed approach to CBD injuries in SIT allows thorough planning and understanding of the complex anatomical variations in these patients.
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Affiliation(s)
- Bahaa I Aburayya
- Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan.
| | | | | | | | - Saleh Romman
- Specialty Hospital, Jaber Ibn Hayyan St, Amman, Jordan
| | - Osama H Hamed
- Arab Medical Center, Jabal Amman, 5th Circle, Amman 11181, Jordan.
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Zhong H, Li S, Wu X, Luo F. Posterior Calot's Triangle Approach First Would Be a Better Choice for Chronic Atrophic Cholecystitis: A Retrospective Controlled Study. J Laparoendosc Adv Surg Tech A 2023; 33:1211-1217. [PMID: 37787943 DOI: 10.1089/lap.2023.0328] [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] [Indexed: 10/04/2023] Open
Abstract
Objective: Compare the clinical efficacy of anterior and posterior Calot's triangle approach in laparoscopic cholecystectomy (LC) for chronic atrophic cholecystitis, to find out which approach is much safer and more reliable. Patients and Methods: From June 2020 to June 2022, 102 patients with chronic atrophic cholecystitis underwent LC in our hospital. They were divided into anterior Calot's triangle approach group and posterior Calot's triangle approach group. In addition, their clinical data, intraoperative conditions, surgical results, and postoperative recovery were analyzed. Results: LC was performed in 41 females and 28 males by the anterior Calot's triangle approach, and in 20 females and 13 males by the posterior Calot's triangle approach. There were no differences in age, gender, and body mass index between the two groups (P > .05). The probability of rupture of cystic artery between both groups was not significantly different (P = .549), and the intraoperative blood loss was more in the anterior group (P = .014). The operative time of the posterior approach appeared to be shorter (P = .013). Bile duct injury and conversion to open cholecystectomy revealed no significant difference (P > .05). The recovery time of gastrointestinal function, wound infection, white blood cell count, liver function, and postoperative hospital stay time were found to be not significantly different (P > .05). Conclusion: By the posterior Calot's triangle approach, LC is a convenient and feasible surgical procedure for chronic atrophic cholecystitis with less blood loss and can become easier without increasing the risk of surgery.
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Affiliation(s)
- Hua Zhong
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Shaoyin Li
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaojian Wu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Fang Luo
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Gibert BK, Matveev IA, Borodin NA, Matveev AI, Zaitsev EY, Chakhchakhov YA, Dgebuadze DT. [Bile duct repair after complete intersection]. Khirurgiia (Mosk) 2023:34-39. [PMID: 37707329 DOI: 10.17116/hirurgia202309134] [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] [Indexed: 09/15/2023]
Abstract
OBJECTIVE To determine the training period for imposing hepaticojejunostomy for bile duct repair. MATERIAL AND METHODS Reconstructive surgery on the bile ducts was performed in 53 patients. We analyzed the learning curves based on the incidence of anastomotic leakage after hepaticojejunostomy. RESULTS The learning curve has a downward nature. The number of anastomotic failures decreases by 2 times after 42 procedures. Surgeon had to perform 39-42 operations to reduce the incidence of this complication. CONCLUSION Treatment of patients with iatrogenic intersections of the bile ducts should be provided in appropriate hospitals.
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Affiliation(s)
- B K Gibert
- Tyumen State Medical University, Tyumen, Russia
| | - I A Matveev
- Tyumen State Medical University, Tyumen, Russia
| | - N A Borodin
- Tyumen State Medical University, Tyumen, Russia
| | - A I Matveev
- Tyumen State Medical University, Tyumen, Russia
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