CRITICAL VIEW OF SAFETY: A PROSPECTIVE SURGICAL AND PHOTOGRAPHIC ANALYSIS IN LAPAROSCOPIC CHOLECYSTECTOMY - DOES IT HELP TO PREVENT IATROGENIC LESIONS?

BACKGROUND

The incidence of biliary duct injuries remains higher in laparoscopic cholecystectomy (LC) in comparison to open surgery. The Critical View of Safety (CVS) was introduced by Strasberg as a strategy for reducing this catastrophic complication. AIM: The aim of this study was to evaluate how often an adequate CVS is achieved during LC, the determining factors for its success, and the associated surgical outcomes.

METHODS

This is a prospective study. CVS photographs of all patients who underwent LC by the same surgeon between 2020 and 2023 were taken. Success in achieving CVS was analyzed by the surgeon herself and posteriorly by hepatobiliary specialists. Patients were classified into two groups: CVS achieved and CVS not achieved. Finally, multivariable logistic regression was used to examine the association between preoperatory factors and surgical complications.

RESULTS

Three hundred and nine consecutive patients were submitted to LC. There were 73.5% elective CL and 26.5% acute cholecystitis. The age ranged from 14 to 87 years, and 76.8% were female. The median body mass index was 26.7. Previous abdominal surgeries were present in 64%, and 26% were obese. The CVS was achieved in 79.9% of the patients, and there were no surgical complications in this group. The factors associated with nonachievement were acute cholecystitis (p=0.007), male sex (p=0.014), and previous surgeries (p=0.021). Three patients needed a subtotal cholecystectomy due to severe inflammation. There was no statistical correlation between the identification of CVS and surgical complications.

CONCLUSIONS

The CVS is achieved in most patients. Acute cholecystitis, male sex, and previous abdominal operations are associated with difficulties in obtaining CVS.

Indocyanine green in laparoscopic cholecystectomy: utility and correlation with a preoperative risk score

BACKGROUND

This study aims to compare the visualization of the cystic duct-common bile duct junction with indocyanine green (ICG) among 3 groups of patients divided according to the difficulty of elective laparoscopic cholecystectomy.

METHODS

Conducted at a single center, this non-randomized, prospective, observational study encompassed 168 patients who underwent elective laparoscopic cholecystectomy and were assessed with a preoperative risk score to predict difficult cholecystectomies, including clinical factors and radiological findings. Three groups were identified: low, moderate, and high risk. A dose of 0.25 mg of IV ICG was administered during anesthesia induction and the different objectives were evaluated.

RESULTS

The visualization of the cystic duct-common bile duct junction was achieved in 28 (100%), 113 (91.1%), and 10 (63%) patients in the low, moderate, and high-risk groups, respectively. The high-risk group had longer total operative time, higher conversion, more complications and longer hospital stay. In the surgeon's subjective assessment, ICG was considered useful in 36% of the low-risk group, 58% in the moderate-risk group, and 69% in the high-risk group. Additionally, there were no cases where ICG modified the surgeon's surgical approach in the low-risk group, compared to 11% in the moderate-risk group and 25% in the high-risk group (p < 0.01).

CONCLUSIONS

The results of this study confirm that in the case of difficult cholecystectomies, the visualization of the cystic duct-common bile duct junction is achieved in 63% of cases and prompts a modification of the surgical procedure in one out of four patients.

The Role of ICG-Guided Fluorescent Mode in Boosting the Learning Curve of Laparoscopic Cholecystectomy

Background: The most common therapy for gallstones is laparoscopic cholecystectomy (LC). How to help young residents avoid bile duct injuries (BDI) during surgery and grasp LC seems to be a paradox. Methods: We retrospectively reviewed 145 cases of LC operated by two residents under indocyanine green (ICG)-guided mode or normal LC procedures to illustrate the role of ICG mode in boosting the LC learning curve. The clinic data were analyzed by logistic regression, receiver operator curve tests, Cumulative Sum (CUSUM), and Risk-Adjusted Cumulative Sum (RA-CUSUM) analysis. Results: The operation failure rate is similar. However, operation time under ICG mode is shorter than that under normal mode. The peak at the 49th case represented the normal resident's complete mastery of the surgery, while the peak point of ICG mode appeared at the 36th case in the fitting curve. The most significant cumulative risk (peak point) of operation failure of LC was at the 35th case in ICG LC mode, while it appeared in the 49th in normal LC mode. Conclusions: Owing to the advantage of real-time imaging and the stable success rate of cholangiography, ICG-guided LC helps residents shorten the operation time, boost the learning curve, and manage to control the operation failure rate.

Critical View of Safety Dissection and Rouviere's Sulcus for Safe Laparoscopic Cholecystectomy: A Descriptive Study

Objective: To determine the importance of a critical view of safety (CVS) techniques and Rouviere's sulcus (RS) in laparoscopic cholecystectomy (LC) and its relation to biliary duct injuries (BDIs) and to determine the frequency and the type of RS. Design, Setting, and Participants: A descriptive study was carried out among 76 patients presenting to the surgery department of a tertiary care center in Nepal. The study population included all patients in the age group 16-80 years undergoing LC. Outcome Measures: The main outcome of interest was to calculate the percentage of BDIs along with the frequency and the type of RS. Results: A total of 76 patients were enrolled in the study, out of which 57(75%) were female patients with a male-to-female ratio of 1:3 and a mean age of 45.87 ± 15.33 years. Seventy-one (93.4%) patients were diagnosed with symptomatic gallstone disease. The CVS was achieved in 75 (98.7%) of the cases, whereas in 1 case, the CVS could not be achieved, and in the same patient routine LC was converted into open cholecystectomy owing to the difficult laparoscopic procedure. In 56 (73.7%) cases, RS was first visible to the operating surgeons after port installation, alignment, and adequate traction of the gallbladder; in 20 (26.3%) cases, RS was not originally apparent. Conclusion: According to the findings of this study and the literature's critical assessment of safety, this method will soon become a gold standard for dissecting gall bladder components. The technique needs to be extended further, especially for training purposes. Major difficulties can be avoided by identifying RS before cutting the cystic artery or duct during LC.

SAGES SAFE CHOLE program changes surgeons practice in France-results of the FCVD implementation of SAFE CHOLE in France

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.

SurgSmart: an artificial intelligent system for quality control in laparoscopic cholecystectomy: an observational study

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.

Critical View of Safety in Laparoscopic Cholecystectomy: A Systematic Review of Current Evidence and Future Perspectives

BACKGROUND

The Critical View of Safety (CVS) has been increasingly recognised as the standard method for identification of the cystic structures, to prevent vasculobiliary injuries during laparoscopic cholecystectomy, however, its adoption has been anything but universal. A significant proportion of surgeons has a poor understanding of the three requirements. To bridge this gap between theory and practice, we aimed to summarise the available evidence on CVS, emphasising on current debates and future perspectives.

METHOD

We systematically reviewed the literature (1995-2021), to identify studies reporting on the CVS. Eligible articles were classified according to methodology and key idea. A quantitative analysis was performed to evaluate effectiveness of the CVS in preventing bile duct injury (BDI).

RESULTS

150 relevant articles were identified, focusing on six main points, (1) safety and effectiveness, (2) intraoperative documentation, (3) complementary imaging techniques, (4) bail-out alternatives, (5) adoption among surgeons, and (6) education and training. The quantitative analysis included 11 studies, with 10,938 cases. Overall, the CVS was achieved in 92.5%. Conversion rate was 4.8%. CVS-related BDI was 0.09% (0.05% technical errors and 0.04% misidentification errors).

CONCLUSION

Routine application of the CVS reduces BDI, but does not eliminate them altogether. Besides operative notes, the CVS should be documented by an imaging modality of sufficient quality. When the CVS cannot be safely established, the threshold for bail-out alternatives or complementary imaging should be low. Adoption by the surgical community worldwide shows great variability and focus should be placed on training through structured educational modules.

Subtotal Fenestrating Cholecystectomy: A Safe and Effective Approach to the Difficult Gallbladder

INTRODUCTION

Subtotal laparoscopic cholecystectomy (SUB) is an alternative to total laparoscopic cholecystectomy (TOT) when the critical view of safety (CVS) cannot be achieved. Little is known about the clinical factors and postoperative outcomes associated with SUB. The objective was to determine predictive factors and outcomes of SUB as compared to TOT.

METHODS

Clinical data from patients admitted from our emergency department to the acute care surgery service who underwent SUB or TOT by an acute care surgery surgeon for acute biliary disease (2017-2019) were reviewed. Wilcoxon rank-sum and Fisher's exact tests were used.

RESULTS

355 patients underwent cholecystectomy for acute cholecystitis; 28 were SUB (7.9%). SUB patients were more likely to be older (57 versus 43 y; P = 0.015), male (60.7% versus 39.3%; P < 0.001), have a history of cirrhosis or liver disease (14.3% versus 2.1%; P = 0.007), and have a higher Charlson-Comorbidity Index (1 versus 0, P = 0.041). SUB had greater leukocytosis (14.6 versus 10.9; P < 0.001), higher total bilirubin (0.9 versus 0.6; P = 0.021), and a higher Tokyo grade (2 versus 1; P < 0.001), and had operative findings including gallbladder decompression (82.1% versus 23.2%; P < 0.001) and inability to achieve the CVS (78.6% versus 3.4%; P < 0.001). SUB patients had an increased length of stay (4 versus 2 d; P < 0.001) and more 1-y readmissions. No major vascular injuries occurred in either group with one biliary injury in the TOT group.

CONCLUSIONS

SUB patients present with more significant markers of biliary disease and have more complicated intraoperative and postoperative courses. However, the lack of biliary or vascular injuries suggests that SUB may represent a safe alternative when the CVS cannot be achieved.

Three-port laparoscopic cholecystectomy is safe and efficient in the treatment of surgical biliary disease: a retrospective cohort study

Multiple studies have suggested that three-port laparoscopic cholecystectomy is both feasible and safe. However, this approach has failed to gain acceptance outside of clinical trials, leaving adopters of this approach vulnerable to medico-legal scrutiny. We hypothesized that the three-port approach to laparoscopic cholecystectomy (LC) is safe and efficient in experienced hands. All LC (including robotic) cases were performed on patients 18 years and older between November 2018 and March 2020. Operations utilizing three ports were compared to those performed using more than three ports. The primary outcomes measured were total operative time, conversion-to-open rate, and the complication rate. A two-sample test was performed to compare operative times, and a Fisher's exact test was used to compare conversion-to-open and complication rates. Linear regression models were used to account for the effect of confounders. 924 total LCs were performed by 30 surgeons in the study period (71 three-port, 853 four or more ports). The mean operative time was 10 min shorter in the three-port group in comparison (64.1 ± 1.4 min vs. 74.4 ± 1.8 min, p < 0.01), despite a threefold higher rate of intraoperative cholangiogram in these cases (23.0% vs. 7.9%, p < 0.001). There was no significant difference in either the conversion-to-open rate (1.6% vs. 5.1%, p = 0.35), or the overall complication rate (7.1% vs. 8.7%, p = 0.82). Operative time for LC performed through three ports was significantly less than those performed through the traditional four port approach, despite utilizing intraoperative cholangiogram nearly three times as often. There was no difference in the conversion-to open rate or complication rate. These results provide considerable evidence that three-port laparoscopic cholecystectomy is comparable to four-port laparoscopic cholecystectomy in operative duration, conversion-to-open rate, and complication rate.

Fat clearance in the hepatocystic triangle during laparoscopic cholecystectomy: Fact or fad? An NIRF-based study

INTRODUCTION

At present, the pre- and postdissection regions during laparoscopic cholecystectomy (LC) are uniformly described by the term "hepatocystic triangle" (HCT). It is unclear whether a distinction needs to be made. An observational study was undertaken to evaluate the predissection hepatocystic region (pre-HCR) and the postdissection hepatocystic region (post-HCR). Also, the dissection-related changes to the contents of the pre-HCR ("proper HCT") were evaluated.

METHODS

A retrospective review of a prospectively maintained database was done. The operative videos of patients who underwent fluorescence-guided surgery from December 2021 to February 2022 were reviewed. Patients with gallstone disease without complications (GSD) were included in the study. Exclusion criteria were acute cholecystitis, choledocholithiasis, biliary pancreatitis, biliary fistulas, and gallbladder wall thickening of ≥3 mm on ultrasonography.

RESULTS

Thirteen patients underwent LC for GSD using standard dissection methods. The boundaries of the pre-HCR were identified before dissection in all patients. The dissection resulted in a quadrangular space lateral to the "proper HCT" in all. The post-HCR contained the undissected "proper-HCT" and the quadrangular space in all. The post-HCR area was 4.4 times that of the pre-HCR (3.2-13.1). The peritoneum over the "proper HCT" was unbreached in all patients, and the target structures were delineated outside of it. A critical view of safety (CVS) was demonstrated outside of the "proper HCT" in all patients.

CONCLUSION

During near-infrared fluorescence-guided LC for GSD, there is no fat clearance in the "HCT." The hepatocystic region before and at the conclusion were distinctly different. The uniform usage of the term "HCT" does not convey this change.

An additional port in difficult laparoscopic cholecystectomy for surgical safety

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.

Critical view of safety in laparoscopic cholecystectomy: A prospective investigation from both cognitive and executive aspects

Background

The 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 Methods

We 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.

Results

We 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 &lt; 0.001), a misunderstanding of the 2nd (OR: 8.917, P &lt; 0.05) and 3rd (OR:8.206, P &lt; 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 &lt; 0.01) were associated with lower and higher achievements of the critical view of safety, respectively.

Conclusions

The 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.

[Modern principles of safety in laparoscopic cholecystectomy]

Laparoscopic cholecystectomy has many advantages over open surgery. Nevertheless, incidence of intraoperative bile duct injury is consistently higher for laparoscopic technique. This review is devoted to modern principles of identifying the anatomical elements in hepatoduodenal ligament and rules for safe tissue dissection in this area. The last ones mainly consist in formation of «critical view of safety» before clipping and transection of tubular structures. The key for «critical view of safety» is mobilization of fatty and fibrous tissues of hepatocystic triangle starting from the lower third of the gallbladder.

The critical view of safety and bile duct injuries in laparoscopic cholecystectomy: a photo evaluation study on 1532 patients

BACKGROUND

Laparoscopic cholecystectomy (LCC) carries a 0.3-1.8% risk of bile duct injury (BDI). This study investigated if intraoperative photo documentation of the critical view of safety (CVS) is related to lower rates of BDIs and postoperative complications in LCC.

METHODS

Surgeons were instructed to take photos of the view before clipping the cystic duct and artery. Two independent raters scored the photos 0-6 using predefined criteria for CVS. Mean scores of ≥4.5 were satisfactory.

RESULTS

The study consisted of 1532 patients undergoing LCC between April 2018 and October 2019. CVS was satisfactory in 354 (23.1%), unsatisfactory in 823 (53.7%), and photos were missing in 355 (23.2%) patients. Patients with satisfactory CVS had the lowest BDI rate compared with unsatisfactory CVS or missing photos (0.3% vs. 1.0% vs. 2.3%, p = 0.012). Four major BDIs (Strasberg D-E) occurred, but none in patients with satisfactory CVS. Patients with satisfactory CVS had the lowest postoperative complication rate compared with patients with unsatisfactory CVS or without photos (4.8% vs. 7.9 vs. 9.9%, p = 0.011). Of patients with acute cholecystitis, 15.7% had satisfactory CVS, whereas 26.8% without cholecystitis had satisfactory CVS (p < 0.001).

CONCLUSION

Intraoperative photo documentation of satisfactory CVS is associated with lower rates of BDIs and complications.

Development of a novel intraoperative difficulty score for minimally invasive cholecystectomy

BACKGROUND

The rate of biliary injuries from minimally invasive cholecystectomy has remained high for over two decades. To improve outcomes there are multiple bail-out methods described, including aborting the procedure, converting to open, or performing a sub-total cholecystectomy. However, the intraoperative difficulty threshold for when a bail-out method should be implemented is poorly understood.

METHODS

From 1/2014 to 2/2019 cholecystectomy videos were collected, de-identified, edited to include the 2-3 minutes when the gallbladder was first visualized, and accelerated. They were then rated on a 5-point difficulty scale. Inter-coder reliability was evaluated using Krippendorff's alpha and regression models were used to evaluate the scores ability to predict the need for a bail-out technique.

RESULTS

62 videos were analyzed with a median length after editing of 37.5 (29.0-43.3) seconds. A median time of 46.2 (38.3-53.4) seconds was required for grading. The bail-out rate was 42.9%. The inter-coder reliability between 2 surgeons and 8 non-clinical reviewers was 0.675 with an average difficulty score of 3.0 (SD = 1.01). Regression models showed that the scale was able to significantly predict conversion (β=0.56,p<.01).

CONCLUSION

This novel difficulty score was able to predict conversion to a bail-out technique early in the course of minimally invasive cholecystectomy.

MRI evaluation of bile duct injuries and other post-cholecystectomy complications

Laparoscopic cholecystectomy is one of the most common procedures performed each year and can be associated with various post-operative complications. Imaging is integral to diagnosis and management of patients with suspected cholecystectomy complications, and a thorough understanding of normal and abnormal biliary anatomy, risk factors for biliary injury, and the spectrum of adverse events is crucial for interpretation of imaging studies. Magnetic resonance cholangiography (MRC) enhanced with hepatobiliary contrast agent is useful in delineating biliary anatomy and pathology following cholecystectomy. In this article, we provide a protocol for contrast-enhanced MR imaging of the biliary tree. We also review the classification and imaging manifestations of post-cholecystectomy bile duct injuries in addition to other complications such as bilomas, retained/dropped gallstones, and vascular injuries.

One-stage fluoroscopy-guided laparoscopic transcystic papillary balloon dilation and laparoscopic cholecystectomy in patients with cholecystocholedocholithiasis who previously had undergone gastrectomy for gastric cancer

BACKGROUND

Patients with a history of gastrectomy have a higher incidence of cholecystocholedocholithiasis (CCL) and related morbidities than the general population. However, the management of common bile duct (CBD) stones with endoscopic retrograde cholangiopancreatography is challenging in patients after Roux-en-Y or Billroth II reconstruction because of the altered gastrointestinal anatomy. The aim of the current study was to evaluate the safety and efficacy of one-stage laparoscopic transcystic papillary balloon dilation and laparoscopic cholecystectomy (LTPBD+LC) in patients with previous gastrectomy for gastric cancer.

METHODS

This retrospective cohort study included five patients with CCL who had previously undergone gastrectomy. All five underwent LTPBD+LC between May 2015 and February 2020 at our institution. The primary end-point was complete clearance of the CBD stones.

RESULTS

Of the 311 patients who had undergone gastrectomy for gastric cancer from December 2009 to December 2018 at our institution, six (1.9%) were later diagnosed with CCL. Five of the six patients did not need emergency biliary drainage and underwent conservative therapy and subsequent elective LTPBD+LC. LTPBD+LC was successfully performed in all cases. None of the patients required conversion to open surgery. The rate of complete clearance of the CBD stones was 100%. The mean operative time of the entire procedure was 126 minutes (range, 102-144 minutes), and the mean blood loss was 12.4 mL (range, 1-50 mL). There were no major perioperative complications, and the mean length of postoperative hospital stay was 4.2 days (range, 3-7 days).

CONCLUSION

One-stage LTPBD+LC may be a feasible procedure for patients with CCL who have previously undergone gastrectomy for gastric cancer.

Importance of Rouviere's sulcus in laparoscopic cholecystectomy

Background:

Rouviere's sulcus is a 2–5 cm fissure on the liver between the right lobe and caudate process. The benefit of finding the Rouviere's sulcus during laparoscopic cholecystectomy is supported by the fact that the cystic duct and artery lay anterosuperior to the sulcus, and the common bile duct (CBD) lays below the level of the Rouviere's sulcus. Hence, it can serve as an extrabiliary anatomical reference point during laparoscopic cholecystectomy to identify the location of CBD.

Materials and Methods:

This prospective observational study was carried out on 99 patients during a period of 1 year. During laparoscopic cholecystectomy, Rouviere's sulcus was identified after retracting the fundus of the gallbladder toward the right shoulder. Its morphology in terms of open type, close type, or scar-like shapes was recorded, and if the CBD outline could be visualized, then its relation with the Rouviere's sulcus was noted.

Results:

Among all 99 study patients, Rouviere's sulcus could be identified in 63 cases (63.63%), whereas it could not be seen in 36 cases (36.36%) (P < 0.007). It was of open type in 68.25% (43 cases), close type in 25.39% (16 cases), and scar like in 6.35% (4 cases) (P < 0.0001). The Rouviere's sulcus was found to be above the level of CBD line in 50 patients (79.36%) and at the same level in 11 patients (17.46%), and in two patients, (5.97%) CBD line could not be visualized.

Conclusion:

Identification of Rouviere's sulcus during laparoscopic cholecystectomy can serve as an additional reference point to avoid major bile duct injury. In the era of laparoscopy, it can be better visualized after creating the pneumoperitoneum and retracting the fundus of the gallbladder.

The “critical view of safety (CVS)” cannot be applied—What to do? Strategies to avoid bile duct injuries

Laparoscopic cholecystectomy has become the standard procedure worldwide since the early 1990s for those patients whose gallbladder has to be removed as part of their underlying disease (NIH Consensus Statement 1992). The most common complication is iatrogenic bile duct injury, which has not improved significantly since the introduction of open laparoscopic cholecystectomy as compared with open cholecystectomy. The intraoperative injuries are mostly the result of a misinterpretation of anatomical structures due to severe inflammation or topographical variations. In order to minimize this risk, a number of improved operative techniques and behavioral measures have been formulated. Here, we present methodological and operative possibilities as well as techniques that in unclear situations can help to minimize the risk of intraoperative injuries of the biliary tract and the accompanying vascular system.

Safe Cholecystectomy Multi-society Practice Guideline and State of the Art Consensus Conference on Prevention of Bile Duct Injury During Cholecystectomy

BACKGROUND

BDI is the most common serious complication of laparoscopic cholecystectomy. To address this problem, a multi-society consensus conference was held to develop evidenced-based recommendations for safe cholecystectomy and prevention of BDI.

METHODS

Literature reviews were conducted for 18 key questions across 6 broad topics around cholecystectomy directed by a steering group and subject experts from 5 surgical societies (Society of Gastrointestinal and Endoscopic Surgeons, Americas Hepato-Pancreato-Biliary Association, International Hepato-Pancreato-Biliary Association, Society for Surgery of the Alimentary Tract, and European Association for Endoscopic Surgery). Evidence-based recommendations were formulated using the grading of recommendations assessment, development, and evaluation methodology. When evidence-based recommendations could not be made, expert opinion was documented. A number of recommendations for future research were also documented. Recommendations were presented at a consensus meeting in October 2018 and were voted on by an international panel of 25 experts with greater than 80% agreement considered consensus.

RESULTS

Consensus was reached on 17 of 18 questions by the guideline development group and expert panel with high concordance from audience participation. Most recommendations were conditional due to low certainty of evidence. Strong recommendations were made for (1) use of intraoperative biliary imaging for uncertainty of anatomy or suspicion of biliary injury; and (2) referral of patients with confirmed or suspected BDI to an experienced surgeon/multispecialty hepatobiliary team.

CONCLUSIONS

These consensus recommendations should provide guidance to surgeons, training programs, hospitals, and professional societies for strategies that have the potential to reduce BDIs and positively impact patient outcomes. Development of clinical and educational research initiatives based on these recommendations may drive further improvement in the quality of surgical care for patients undergoing cholecystectomy.

A practical new strategy to prevent bile duct injury during laparoscopic cholecystectomy. A single-center experience with 5539 cases

Purpose

Bile duct injury (BDI) is a catastrophic complication of cholecystectomy, and misidentification of the cystic anatomy is considered to be the main cause. Although several techniques have been developed to prevent BDI, such as the “critical view of safety”, the infundibular technique, the rates remain higher during laparoscopic cholecystectomy (LC) than during open surgery. We, here, propose a practical new strategy for ductal identification, that can help to prevent laparoscopic bile duct injury.

Methods

A retrospective study of 5539 patients who underwent LC from March 2007 to February 2019 at a single institution was conducted. The gallbladder infundibulum was classified by its position located on an imaginary clock with the gallbladder neck as the center point of the dial, 3-o’clock position as cranial, 6-o’clock as dorsal, 9-o’clock as caudal, and 12-o’clock as ventral, as well as the axial position. Patient demographics, pathologic variables and infundibulum classification were evaluated. Detailed analysis of ductal identification based on gallbladder infundibulum position was performed in this study. All infundibulum positions were recorded by intraoperative laparoscopic video or photographic images.

Results

All the patients successfully underwent LC during the study period. No conversion or serious complications such as biliary injury occurred. Gallbladders with infundibulum of 3-o’clock position, 6-o’clock position, 9-o’clock position, 12-o’clock position, axial position were 12.3%, 23.4%, 28.0%, 4.2%, and 32.1%, respectively. The 3-o’clock and 12-o’clock position were pitfalls that might cause biliary injury.

Conclusion

The gallbladder infundibulum as a navigator is useful for ductal identification to reduce BDI and improve the safety of LC.

Safe cholecystectomy multi-society practice guideline and state-of-the-art consensus conference on prevention of bile duct injury during cholecystectomy

BACKGROUND

Bile duct injury (BDI) is the most common serious complication of laparoscopic cholecystectomy. To address this problem, a multi-society consensus conference was held to develop evidenced-based recommendations for safe cholecystectomy and prevention of BDI.

METHODS

Literature reviews were conducted for 18 key questions across six broad topics around cholecystectomy directed by a steering group and subject experts from five surgical societies (SAGES, AHPBA IHPBA, SSAT, and EAES). Evidence-based recommendations were formulated using the GRADE methodology. When evidence-based recommendations could not be made, expert opinion was documented. A number of recommendations for future research were also documented. Recommendations were presented at a consensus meeting in October 2018 and were voted on by an international panel of 25 experts with greater than 80% agreement considered consensus.

RESULTS

Consensus was reached on 17 of 18 questions by the Guideline Development Group (GDG) and expert panel with high concordance from audience participation. Most recommendations were conditional due to low certainty of evidence. Strong recommendations were made for (1) use of intraoperative biliary imaging for uncertainty of anatomy or suspicion of biliary injury; and (2) referral of patients with confirmed or suspected BDI to an experienced surgeon/multispecialty hepatobiliary team.

CONCLUSION

These consensus recommendations should provide guidance to surgeons, training programs, hospitals, and professional societies for strategies that have the potential to reduce BDIs and positively impact patient outcomes. Development of clinical and educational research initiatives based on these recommendations may drive further improvement in the quality of surgical care for patients undergoing cholecystectomy.

Retrograde tracing along "cystic duct" method to prevent biliary misidentification injury in laparoscopic cholecystectomy

Bile duct injury remains the most serious complication of laparoscopic cholecystectomy (LC), the main cause was misidentification of cystic duct (CD). The aim of this study was to evaluate the effectiveness and security of retrograde tracing along "cystic duct" (RTACD) method for the prevention of biliary misidentification injury in LC. The conception of RTACD method was first described and then illustrated by simulation dissection with extrahepatic biliary structure charts. A total of 840 patients undergoing LC were selected. After the "CD" was separated during operation, its authenticity was identified by RTACD method according to its course and origin. The "CD" can be clipped/divided only when it was identified to be true CD. Among 840 patients, the initially separated "CD" was identified as actual CD in 831 cases, common hepatic (bile) duct in six cases, accessory right posterior sectoral duct in two cases, and right haptic duct in one case. LCs were successfully finished in 837 patients, and converted to open cholecystectomy in three cases. The average operation time was 64.23 min (range 25-225 min), and the average blood loss was 8.07 ml (range 2-200 ml). No biliary misidentification injury was found. All patients recovered smoothly. No jaundice or abdominal pain was noted in the patients during 1-19 months follow-up. RTACD method is a safe and effective new technique of preventing biliary misidentification injury.

A three-step conceptual roadmap for avoiding bile duct injury in laparoscopic cholecystectomy: an invited perspective review

Bile duct injuries are the most common serious complication of cholecystectomy. Avoidance of bile duct injury is a key aim of biliary surgery. The purpose of this paper is to describe laparoscopic cholecystectomy from the viewpoint of three conceptual goals. Three conceptual goals of cholecystectomy are: (1) getting secure anatomical identification of key structures; (2) making the right decision not to perform a total cholecystectomy when conditions are too dangerous to get secure identification - the "inflection point"; and (3) finishing the operation safely when secure anatomical identification of cystic structures is not possible. The Critical View of Safety (CVS) has been shown to be a good way of getting secure anatomical identification. Conceptually, CVS is a method of target identification, the targets being the two cystic structures. Sometimes, anatomic identification is not possible because the risk of biliary injury is judged to be too great. Then a decision is made to abandon the attempt to do a complete cholecystectomy - and instead to "bail-out". This "inflection point" is defined as the moment at which the decision is made to halt the attempt to perform a total cholecystectomy laparoscopically and to finish the operation by a different method. Currently the best bail-out procedure seems to be subtotal fenestrating cholecystectomy. Application of conceptual goals of cholecystectomy can help the surgeon to avoid biliary injury.

Safe laparoscopic cholecystectomy: A systematic review of bile duct injury prevention

BACKGROUND

Since the introduction of laparoscopic cholecystectomy (LC), a substantial increase in bile duct injury (BDI) incidence was noted. Multiple methods to prevent this complication have been developed and investigated. The most suitable method however is subject to debate. In this systematic review, the different modalities to aid in the safe performance of LC and prevent BDI are delineated.

MATERIALS AND METHODS

A systematic search for articles describing methods for the prevention of BDI in LC was conducted using EMBASE, Medline, Web of science, Cochrane CENTRAL and Google scholar databases from inception to 11 June 2018.

RESULTS

90 studies were included in this systematic review. Overall, BDI preventive techniques can be categorized as dedicated surgical approaches (Critical View of Safety (CVS), fundus first, partial laparoscopic cholecystectomy), supporting imaging techniques (intraoperative radiologic cholangiography, intraoperative ultrasonography, fluorescence imaging) and others. Dedicated surgical approaches demonstrate promising results, yet limited research is provided. Intraoperative radiologic cholangiography and ultrasonography demonstrate beneficial effects in BDI prevention, however the available evidence is low. Fluorescence imaging is in its infancy, yet this technique is demonstrated to be feasible and larger trials are in preparation.

CONCLUSION

Given the low sample sizes and suboptimal study designs of the studies available, it is not possible to recommend a preferred method to prevent BDI. Surgeons should primarily focus on proper dissection techniques, of which CVS is most suitable. Additionally, recognition of hazardous circumstances and knowledge of alternative techniques is critical to complete surgery with minimal risk of injury to the patient.

Optimal timing of preoperative indocyanine green administration for fluorescent cholangiography during laparoscopic cholecystectomy using the PINPOINT® Endoscopic Fluorescence Imaging System

INTRODUCTION

The PINPOINT® Endoscopic Fluorescence Imaging System (Novadaq, Mississauga, Canada) allows surgeons to visualize the bile ducts during laparoscopic cholecystectomy. Surgeons can continue operation while confirming the bile ducts' fluorescence with a bright-field/color image. However, strong fluorescence of the liver can interfere with the surgery. Here, we investigated the optimal timing of indocyanine green administration to allow fluorescent cholangiography to be performed without interference from the liver fluorescence.

METHODS

A total of 72 patients who underwent laparoscopic cholecystectomy were included in this study. The timing of indocyanine green administration was set immediately before surgery and at 3, 6, 9, 12, 15, 18, and 24 h before surgery. The luminance intensity ratios of gallbladder/liver, cystic duct/liver, and common bile duct/liver were measured using the ImageJ software (National Institutes of Health, Bethesda, USA). Visibility of the gallbladder and bile ducts was classified into three categories (grades A, B, and C) based on the degree of visibility in contrast to the liver.

RESULTS

The luminance intensity ratio for the gallbladder/liver, cystic duct/liver, and common bile duct/liver was ≥1 in the 15-, 18-, and 24-h groups. The proportion of cases in which evaluators classified the visibility of the gallbladder and bile ducts as grade A (best visibility) reached a peak in the 15-h group and decreased thereafter.

CONCLUSIONS

In the present study, the optimal timing of indocyanine green administration for fluorescent cholangiography during laparoscopic cholecystectomy using the PINPOINT Endoscopic Fluorescence Imaging System was 15 h before surgery.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Outcome trends and safety measures after 30 years of laparoscopic cholecystectomy: a systematic review and pooled data analysis

BACKGROUND

Laparoscopic cholecystectomy (LC), one of the most commonly performed surgical procedures, remains associated with significant major morbidity including bile leak and bile duct injury (BDI). The effect of changes in practice over time, and of interventions to improve patient safety, on morbidity rates is not well understood. The aim of this review was to describe current incidence rates and trends for BDI and other complications during and after LC, and to identify risk factors and preventative measures associated with morbidity and BDI.

METHODS

PubMed, MEDLINE, and Web of Science database searches and data extraction were conducted for studies which reported individual complications and complication rates following laparoscopic cholecystectomy in a representative population. Outcomes data were pooled. Meta-regression analysis was performed to assess factors associated with conversion, morbidity, and BDI rates.

RESULTS

One hundred and fifty-one studies reporting outcomes for 505,292 patients were included in the final quantitative synthesis. Overall morbidity, BDI, and mortality rates were 1.6-5.3%, 0.32-0.52%, and 0.08-0.14%, respectively. Reported BDI rates reduced over time (1994-1999: 0.69(0.52-0.84)% versus 2010-2015 0.22(0.02-0.40)%, p = 0.011). Meta-regression analysis suggested higher conversion rates in developed versus developing countries (4.7 vs. 3.4%), though a greater degree of reporting bias was present in these studies, with no other significant associations identified.

CONCLUSIONS

Overall, trends suggest a reduction in BDI over time with unchanged morbidity and mortality rates. However, data and reporting are heterogenous. Establishment of international outcomes registries should be considered.

[Non-functioning gallbladder as a risk factor for bile ducts injury during laparoscopic cholecystectomy]

AIM

To analyze the effect of gallbladder's morpho-functional changes as a risk factor for injury of extrahepatic bile ducts during cholecystectomy.

MATERIAL AND METHODS

Laparoscopic cholecystectomy was performed in 20 564 patients. There were 147 64 (71.8%) patients with chronic gallbladder inflammation and 5800 (28.2%) - with acute process. It was performed a retrospective analysis of the incidence and causes of intraoperative trauma of extrahepatic bile ducts and bile outflow. Two groups of comparison were distinguished: acute calculous cholecystitis and chronic inflammation.

RESULTS

There were 93 (0.04%) complications followed by bile outflow (55 (0.94%) in the 1^st group and 38 (0.25%) in the 2^nd group). Marginal injury of the ducts was interoperatively detected in 5 patients of group 1 and 3 patients of 2 groups. In postoperative period it was found in 6 patients of the 1^st group due to electric trauma of common bile duct. Complete transection of common bile duct occurred in 10 (8.8%) cases, while chronic calculous cholecystitis was observed in 8 of them. At the same time, in 6 patients these were surgical interventions in scleroatrophic gallbladder. As a results, we determined the forms of non-functioning gallbladder with morphofunctional changes which promote trauma of extrahepatic bile ducts.

CONCLUSION

Long-term non-functioning gallbladder leads to cicatricial and adhesive processes in its wall and surrounding tissues that significantly complicates cholecystectomy and increases the risk of bile ducts trauma. Scleroatrophic gallbladder is the most dangerous which occurs in 4.1% of patients with chronic calculous cholecystitis. Further trials are advisable to develop optimal therapeutic and diagnostic tactics for various forms of long-term non-functioning gallbladder.

IRCAD recommendation on safe laparoscopic cholecystectomy

An expert recommendation conference was conducted to identify factors associated with adverse events during laparoscopic cholecystectomy (LC) with the goal of deriving expert recommendations for the reduction of biliary and vascular injury. Nineteen hepato-pancreato-biliary (HPB) surgeons from high-volume surgery centers in six countries comprised the Research Institute Against Cancer of the Digestive System (IRCAD) Recommendations Group. Systematic search of PubMed, Cochrane, and Embase was conducted. Using nominal group technique, structured group meetings were held to identify key items for safer LC. Consensus was achieved when 80% of respondents ranked an item as 1 or 2 (Likert scale 1-4). Seventy-one IRCAD HPB course participants assessed the expert recommendations which were compared to responses of 37 general surgery course participants. The IRCAD recommendations were structured in seven statements. The key topics included exposure of the operative field, appropriate use of energy device and establishment of the critical view of safety (CVS), systematic preoperative imaging, cholangiogram and alternative techniques, role of partial and dome-down (fundus-first) cholecystectomy. Highest consensus was achieved on the importance of the CVS as well as dome-down technique and partial cholecystectomy as alternative techniques. The put forward IRCAD recommendations may help to promote safe surgical practice of LC and initiate specific training to avoid adverse events.

The Difficult Gallbladder: A Safe Approach to a Dangerous Problem

Laparoscopic cholecystectomy is a common surgical procedure, and remains the gold standard for the management of benign gallbladder and biliary disease. While this procedure can be technically straightforward, it can also represent one of the most challenging operations facing surgeons. This dichotomy of a routine operation performed so commonly that poses such a hidden risk of severe complications, such as bile duct injury, must keep surgeons steadfast in the pursuit of safety. The "difficult gallbladder" requires strict adherence to the Culture of Safety in Cholecystectomy, which promotes safety first and assists surgeons in managing or avoiding difficult operative situations. This review will discuss the management of the difficult gallbladder and propose the use of subtotal fenestrating cholecystectomy as a definitive option during this dangerous situation.

Importance of critical view of safety in laparoscopic cholecystectomy: a survey of 120 serial patients, with no incidence of complications

Backgrounds/Aims

To determine the importance of critical view of safety techniques in laparoscopic cholecystectomy.

Methods

A total of 120 patients were included in the study, between January 2015 to March 2016. Hydrodissection was performed for cases presenting with severe adhesions or cholecystitis. A critical view of safety was performed for all patients undergoing the procedure for isolation of cystic duct and cystic artery with cystic plate dissection. Demographic characteristics of the patients, as well as intraoperative and postoperative minor or major complications were recorded.

Results

A total of 81 (67.5%) female and 39 (32.5%) male patients succesfully underwent surgeries following the critical view of safety and hydrodissection technique. Acute/chronic cholecystitis, or severe adhesions in the surgical field, were detected in 34 (28.3%) patients. There were no intraoperative or postoperative biliary complications. Wound infection was detected in 5 (4.1%) patients. All patients were discharged on either the first, second or third postoperative day.

Conclusions

Biliary duct injury during laparoscopic cholecystectomy is an important complication. In this study, we show that the critical view of safety and hydrodissection techniquesminimizes the bile duct injury during laparoscopic cholecystectomy, including in difficult cases.

Increasing resident utilization and recognition of the critical view of safety during laparoscopic cholecystectomy: a pilot study from an academic medical center

BACKGROUND

Laparoscopic cholecystectomy (LC) is a commonly performed surgical procedure; however, it is associated with an increased rate of bile duct injury (BDI) when compared to the open approach. The critical view of safety (CVS) provides a secure method of ductal identification to help avoid BDI. CVS is not universally utilized by practicing surgeons and/or taught to surgical residents. We aimed to pilot a safe cholecystectomy curriculum to demonstrate that educational interventions could improve resident adherence to and recognition of the CVS during LC.

METHODS

Forty-three general surgery residents at Thomas Jefferson University Hospital were prospectively studied. Fifty-one consecutive LC cases were recorded during the pre-intervention period, while the residents were blinded to the outcome measured (CVS score). As an intervention, a comprehensive lecture on safe cholecystectomy was given to all residents. Fifty consecutive LC cases were recorded post-intervention, while the residents were empowered to "time-out" and document the CVS with a doublet photograph. Two independent surgeons scored the videos and photographs using a 6-point scale. Residents were surveyed pre- and post-intervention to determine objective knowledge and self-reported comfort using a 5-point Likert scale.

RESULTS

In the 18-week study period, 101 consecutive LCs were adequately captured and included (51 pre-intervention, 50 post-intervention). Patient demographics and clinical data were similar. The mean CVS score improved from 2.3 to 4.3 (p < 0.001). The number of videos with CVS score >4 increased from 15.7 to 52 % (p < 0.001). There was strong inter-observer agreement between reviewers. The pre- and post-intervention questionnaire response rates were 90.7 and 83.7 %, respectively. A greater number of residents correctly identified all criteria of the CVS post-intervention (41-93 %, p < 0.001) and offered appropriate bailout techniques (77-94 %, p < 0.001). Residents strongly agreed that the CVS education should be included in general surgery residency curriculum (mean Likert score = 4.71, SD = 0.54). Residents also agreed that they are more comfortable with their LC skills after the intervention (4.27, σ = 0.83).

CONCLUSION

The combination of focused education along with intraoperative time-out significantly improved CVS scores and knowledge during LC in our institution.

Open-access technique and "critical view of safety" as the safest way to perform laparoscopic cholecystectomy

BACKGROUND

The 2 main challenges of laparoscopic cholecystectomy are primary peritoneal access and safe identification, ligation, and division of the cystic duct and cystic artery.

PATIENTS AND METHODS

This is a 13-year period retrospective study from January 2000 to December 2012. All the operations were performed by 1 surgeon and all the data were collected from the hospitals archive. A total of 929 laparoscopic cholecystectomies were performed for symptomatic cholelithiasis. The first author was involved in all the operations either by performing or assisting in them. The open access (OA) technique was used in all cases for the creation of pneumoperitoneum. After establishing the pneumoperitoneum, the "critical view of safety" (CVS) technique was used to ligate and divide the cystic duct and cystic artery. When the OA was not possible or CVS was not feasible, the operation was converted to open.

RESULTS

Successful establishment of pneumoperitoneum with OA was possible in 911 of 929 (98.06%) patients and CVS was achieved in 873 patients (95.82%). In 18 patients the operation was converted to open because of dense adhesions not permitting the establishment of the pneumoperitoneum. No intraoperative or postoperative complications occurred in these patients. No bile duct injury occurred in this series. Postoperative complications were recorded in 19 patients (2.04%). Five patients had bleeding from port sites, 12 patients had wound infection at the umbilical incision, and 2 patients developed subhepatic collections, which were drained percutaneously under computed tomographic guidance.

CONCLUSIONS

In this series of laparoscopic cholecystectomies, we used the "open access" technique to create pneumoperitoneum and we obtained the "critical view of safety" for the identification of the cystic duct. Our results show that this approach is the safest way to perform and teach laparoscopic cholecystectomy.

Current practices in biliary surgery: Do we practice what we teach?

INTRODUCTION

Since the widespread adoption of laparoscopic techniques in biliary surgery, the incidence of bile duct injures (BDI) has not significantly declined despite increased operative experience and recognition of the critical view of safety (CVS) method for anatomic identification. We hypothesized that operative approaches in clinical practice may vary from well-described technical recommendations. The objective of this study was to access how practicing surgeons commonly identify anatomy during laparoscopic cholecystectomy (LC).

METHODS

We performed a cohort study assessing practices in biliary surgery among current practicing surgeons. Surgeons belonging to the Midwest Surgical Association and the Society of American Gastrointestinal and Endoscopic Surgeons were surveyed. Items surveyed include preferred methods for cystic duct identification, recognition of the CVS, and use of intraoperative imaging.

RESULTS

In total, 374 of 849 surgeons responded. The CVS was not correctly identified by 75 % of surgeons descriptively and by 21 % of surgeons visually. 56 % of surgeons practiced the infundibular method for identification of the cystic duct; 27 % practiced the CVS method. Intraoperative cholangiography was used by 16 % and laparoscopic ultrasound by <1 %.

CONCLUSION

A majority of surgeons preferably do not use the CVS method of identification during LC. A large percentage of practicing surgeons are unable to describe or visually identify the CVS. These results suggest an urgent need to reexamine the tenets of how LC is being taught and disseminated and present a clear target for improvement to reduce BDI.

Cracking the Code: The Unexpected Challenge of Identifying Major Bile Duct Injuries

The reported rate of major bile duct injury (BDI) after cholecystectomy is 0.2 to 0.5 per cent. We evaluated the accuracy of coding major BDIs integrating both Current Procedural Terminology (CPT) and ICD-9 coding. A retrospective review was conducted for more than 3.5 million members of a large managed health-care organization from January 2007 to December 2013. A total of 56,194 cholecystectomies were captured over this 6-year period. Major BDIs were defined as unintended transection of a major bile duct, Bismuth-Strasberg classification E1-E5, and requiring biliary reconstruction within one year of cholecystectomy. Based on two published study methods (CPT 47760, 47765, 47780 and ICD-9 code 998.2), 173 possible BDIs were identified. Only 13 (7.5%) were confirmed to have a major BDI. The remaining 160 cases were minor complications or were unrelated to cholecystectomy. This reflects an overall BDI rate of 0.02 per cent, an order of magnitude less than commonly published rates. There is a lack of consistent methodology to identify major bile duct injuries. This calls into question the accuracy of published rates. We suspect that some major injuries were not captured. We recommend a universal clinical registry and specific ICD codes to accurately identify this serious complication.

Strategies to decrease bile duct injuries during laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy (LC) has been performed clinically for more than 20 years. However, the incidence of bile duct injury (BDI) remains high despite attempts to prevent and reduce it. The aim of this study was to use an intraoperative unfavorable factors ratings system to identify unfavorable intraoperative factors and evaluate the effectiveness of application of the system in reducing BDI during LC.

PATIENTS AND METHODS

Between January 2009 and December 2010, 780 patients who underwent LC were reviewed retrospectively, including 384 LC patients without graded treatment of intraoperative unfavorable factors (GTIUF) during 2009 and 396 LC patients with routine GTIUF during 2010.

RESULTS

BDI was decreased significantly after routine GTIUF (5 cases without GTIUF versus 0 cases with routine GTIUF; P=.029). There was no significant difference in postoperative morbidity and mortality between the two groups. The mean operation duration of the routine GTIUF group was prolonged significantly (P<.0001). Laparoscopic cholecystitis grading, GTIUF, and doctor's experience were important factors affecting the duration of operation (P<.0001, P<.0001, and P<.0001, respectively).

CONCLUSIONS

GTIUF is an effective method that emphasizes identification of the course of the extrahepatic bile duct and reduces the occurrence of BDI, especially for inexperienced operators.

Laparoscopic cholecystectomy: consensus conference-based guidelines

INTRODUCTION

Laparoscopic cholecystectomy (LC) is the gold standard technique for gallbladder diseases in both acute and elective surgery. Nevertheless, reports from national surveys still seem to represent some doubts regarding its diffusion. There is neither a wide consensus on its indications nor on its possible related morbidity. On the other hand, more than 25 years have passed since the introduction of LC, and we have all witnessed the exponential growth of knowledge, skill and technology that has followed it. In 1995, the EAES published its consensus statement on laparoscopic cholecystectomy in which seven main questions were answered, according to the available evidence. During the following 20 years, there have been several additional guidelines on LC, mainly focused on some particular aspect, such as emergency or concomitant biliary tract surgery.

METHODS

In 2012, several Italian surgical societies decided to revisit the clinical recommendations for the role of laparoscopy in the treatment of gallbladder diseases in adults, to update and supplement the existing guidelines with recommendations that reflect what is known and what constitutes good practice concerning LC.

A gallbladder with the "hidden cystic duct": A brief overview of various surgical techniques of the Calot's triangle dissection

We present a case of a middle-aged female who attended for a routine laparoscopic cholecystectomy as a day case surgery. At operation, she was found to have a distended gallbladder with an unusually prominent distal portion. This has made the dissection of the Calot's triangle challenging. As a result, the "critical view of safety" technique was applied. This allowed for the clear Calot's triangle visualization and identification of the cystic duct and artery. This case highlights that the knowledge of various ways of the cystic duct dissection is essential to every surgeon. Furthermore, this helps to adjust the dissection approach on an individual case bases ensuring avoidance of the common bile duct injuries.

A 'critical view' on a classical pitfall in laparoscopic cholecystectomy!

INTRODUCTION

Laparoscopic cholecystectomy is the most common laparoscopic surgery performed by general surgeons. Although being a routine procedure, classical pitfalls shall be regarded, as misperception of intraoperative anatomy is one of the leading causes of bile duct injuries. The "critical view of safety" in laparoscopic cholecystectomy serves the unequivocal identification of the cystic duct before transection. The aim of this manuscript is to discuss classical pitfalls and bile duct injury avoiding strategies in laparoscopic cholecystectomy, by presenting an interesting case report.

PRESENTATION OF CASE

A 71-year-old patient, who previously suffered from a biliary pancreatitis underwent laparoscopic cholecystectomy after ERCP with stone extraction. The intraoperative situs showed a shrunken gallbladder. After placement of four trocars, the gall bladder was grasped in the usual way at the fundus and pulled in the right upper abdomen. Following the dissection of the triangle of Calot, a "critical view of safety" was established. As dissection continued, it however soon became clear that instead of the cystic duct, the common bile duct had been dissected. In order to create an overview, the gallbladder was thereafter mobilized fundus first and further preparation resumed carefully to expose the cystic duct and the common bile duct. Consecutively the operation could be completed in the usual way.

DISCUSSION

Despite permanent increase in learning curves and new approaches in laparoscopic techniques, bile duct injuries still remain twice as frequent as in the conventional open approach. In the case presented, transection of the common bile duct was prevented through critical examination of the present anatomy. The "critical view of safety" certainly offers not a full protection to avoid biliary lesions, but may lead to a significant risk minimization when consistently implemented.

CONCLUSION

A sufficient mobilization of the gallbladder from its bed is essential in performing a critical view in laparoscopic cholecystectomy.