Laparoscopic subtotal cholecystectomy for difficult cases of acute cholecystitis: a simple technique using barbed sutures

Continuous suture closure using a LapraTy® suture clips is an effective method for reconstruction of cystic duct stump after laparoscopic subtotal cholecystectomy

Objective

Recently, number of laparoscopic subtotal cholecystectomy (LSC) has been increasing.

Summary background data

LSC is suitable as a treatment as it can avoid intraoperative bile duct injury and bleeding for difficult laparoscopic cholecystectomy. On the other hand, improper handling of remnant of GB can lead to postoperative bile leakage.

Methods

Here, we report our positive experience utilizing new technique of continuous suture closure and omental covering using Lapra Ty® suture clips on the remnant of GB.

Results

From January 2016 to July 2021, we experienced 30 cases of LSC for LC patients who had difficulty securing critical view of safety (CVS). In six of the 30 cases, we repaired remnant of GB using continuous suture closure and omental covering with Lapra Ty® suture clips. The median operating time was 136 min (range 112-199 ml), and amount of bleeding was 1 ml (range 1-100). There were no cases of postoperative bile leakage (postope. BL), remnant cystic duct stone, and abscess formation in abdomen.

Conclusion

we recommend this new suturing technique for closure of remnant of GB as it was very effective in preventing postope. BL after LSC.

Massive Hemothorax Caused by Removal of Percutaneous Transhepatic Abscess Drainage Tube for Bile Leak After Subtotal Cholecystectomy: A Case Report

A 59-year-old man with a past medical history of gallstones was diagnosed with acute cholecystitis and received antibiotic treatment. He was discharged after ten days of hospitalization and was due to undergo laparoscopic cholecystectomy. Three months later, however, he had to be readmitted due to a recurrence of acute cholecystitis. Subsequently, laparoscopic reconstituting subtotal cholecystectomy was performed because Inflammation of the gallbladder was severe. At the first postoperative outpatient visit, the patient reported obstructive jaundice, and computed tomography (CT) scan revealed fluid collection in the hepatic bed and a missed common bile duct stone. Percutaneous transhepatic abscess drainage (PTAD) was performed on admission, and endoscopic stone removal was attempted the following day but was challenging due to a periampullary diverticulum. During laparotomy for stone extraction, the patient experienced prolonged shock and CT showed bleeding from the liver and massive right hemothorax. After open chest drainage and hemostasis, transcatheter arterial embolization (TAE) was performed. Such a case has never been reported before, and the PTAD tube should be handled cautiously.

Navigation by modified and dynamic intraoperative cholangiography during laparoscopic subtotal cholecystectomy for difficult gallbladder

We used modified and dynamic intraoperative cholangiography (IOC) navigation during laparoscopic subtotal cholecystectomy for difficult gallbladders. We have defined an IOC that does not open the cystic duct as a modified IOC. Modified IOC methods include the percutaneous transhepatic gallbladder drainage (PTGBD) tube method, the infundibulum puncture method, and the infundibulum cannulation method. Case 1 was chronic cholecystitis after PTGBD for acute cholecystitis with pericholecystic abscess. In this case, modified IOC was performed via PTGBD, and biliary anatomy and incarcerated stone were confirmed. Case 2 was chronic cholecystitis after endoscopic sphincterotomy for cholecystocholedocholithiasis. In this case, modified IOC was performed via gallbladder puncture needle, and biliary anatomy and incision line were confirmed. The target point on the laparoscopic image was determined by moving the tip of the grasping forceps under modified IOC, which we call modified and dynamic IOC. We conclude that the navigation by the modified and dynamic IOC via PTGBD tube or puncture needle is useful to identify biliary anatomy, incarcerated gallbladder stone, and safe incision line during laparoscopic subtotal cholecystectomy .

Utility of Tokyo Guidelines 2018 in early laparoscopic cholecystectomy for mild and moderate acute calculus cholecystitis: A retrospective cohort study

Background

Tokyo Guidelines 2018 (TG18) proposed laparoscopic cholecystectomy (LC) for acute calculus cholecystitis (ACC) irrespective of the duration of symptoms. This retrospective study assessed the impact of utility of TG18 in early LC for ACC.

Methods

From 2018 to 2020, 66 patients with mild (grade I) and moderate (grade II) ACC who underwent early surgery were studied. Subgroup analyses were based on timing of surgery and operation time.

Results

A total of 32 and 34 patients were operated within and beyond 7 days since ACC onset. More patients with grade II ACC were in the beyond 7 days group (P < 0.05). More patients with enlarged gallbladder were in the within 7 days group (P < 0.05). The duration of symptoms to admission, symptoms to LC, and operation time were longer in the beyond 7 days group (P < 0.05). There were no significant differences regarding intraoperative blood loss, conversion to bail-out procedures, complication rate, hospital stay, and cost between the two groups (P > 0.05). Longer operation time was significantly associated with duration of symptoms to admission, symptoms to LC, and conversion to laparoscopic subtotal cholecystectomy (LSC) (P < 0.05).

Conclusion

In a subset of carefully selected patients, applying TG18 in early LC for mild and moderate ACC results in acceptable clinical outcomes. Standardized safe steps and conversion to LSC in difficult cases are important.

Successful procedure with additional omentopexy to suture closure of gallbladder stump in laparoscopic subtotal cholecystectomy

Laparoscopic subtotal cholecystectomy, a bailout surgery for cholecystitis, can result in postoperative bile leakage, so surgical ingenuity is required. An 88-year-old woman had pain at the right hypochondrium. Abdominal computed tomography showed swelling of the gallbladder and thickness of the gallbladder wall, leading to diagnosis of mild acute cholecystitis. Percutaneous transhepatic gallbladder drainage was performed to alleviate cholecystitis because the patient was taking antiplatelet medicine. Laparoscopic cholecystectomy was then performed within 72 hours from the onset. The gallbladder was operatively found to be strongly fibrotic, so the procedure was switched to laparoscopic subtotal cystectomy, dissecting the gallbladder at the infundibulum-cystic duct level. The gallbladder stump was closed with barbed suture and omentopexy was added due to fragility. There was no significant postoperative bile leakage. Additional omentopexy to stump closure in laparoscopic subtotal cholecystectomy was thought to be useful in prevention of postoperative bile leakage.

Laparoscopic bailout surgery effective procedure for patients with difficult laparoscopic cholecystectomy

TG18 recommends bailout surgery (BOS) for difficult laparoscopic cholecystectomy. However, there is not a clear criterion on the decision process on whether to continue laparoscopic BOS or open BOS, and optimal procedure for treatment for the remnant cystic bile duct also awaits discussion. We comparted with open BOS and laparoscopic BOS, and compared with suture close and clipping or ligating of remnant cystic duct. We have accrued 57 patients underwent BOS during study period. Seventeen cases underwent laparoscopic BOS, and 38 cases underwent open BOS. There were 22 patients were accrued in suture closing and 35 patients were accrued in clipping or ligating. Open BOS experienced high levels of CRP, WBC, NLR, and CAR, and was associated with significantly longer hospitalization, operating time, and amount of bleeding. Suture close was higher in patients with preoperative endoscopic lithotripsy (EL). BOS can be sufficiently performed under laparoscopy. Patients underwent preoperative EL tended to be higher necessity to suture close of cystic duct.

A comparison of barbed continuous suture versus conventional interrupted suture for fascial closure in total hip arthroplasty

A barbed suture is a self-anchoring knotless suture hypothesized to shorten suture time and reduce the tension point of the wound. The purpose of this study was to compare the barbed suture and the interrupted suture for fascial closure in total hip arthroplasty. We retrospectively reviewed patients who underwent total hip arthroplasty from March 2014 to June 2020. We evaluated 324 cases among 274 patients consisting of 188 males and 86 females. We collected the following data: demographics, time for wound closure, the number of threads used, hemoglobin level, surgical site pain, and wound complications. Variables were analyzed for their association with closure time using multiple regression analyses between the barbed suture (the SFX group) and the interrupted suture (the Vicryl group). Mean closure time was 5.8 min lower and the mean number of sutures used was 2.2 lower in the SFX group versus the Vicryl group (P < 0.01 and < 0.01, respectively). There were no statistical intergroup differences in the mean largest hemoglobin drop, the incidence of transfusion, surgical site pain, and the incidence of wound complications. The use of barbed sutures for fascial closure in total hip arthroplasty effectively reduces the surgical time without increasing wound complications.