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Kowal S, Vendrov M, Vaz D, Mir ZM, Hanna NM, Zevin B. The Safety and Efficacy of Concurrent Laparoscopic Cholecystectomy during Minimally Invasive Roux-en-Y Gastric Bypass: A Systematic Review. Obes Surg 2024; 34:2650-2655. [PMID: 38767785 DOI: 10.1007/s11695-024-07270-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 04/26/2024] [Accepted: 05/08/2024] [Indexed: 05/22/2024]
Abstract
We conducted a systematic review to examine perioperative outcomes for adults undergoing minimally invasive Roux-en-Y gastric bypass (RYGB) with and without concurrent cholecystectomy (CCE). We reviewed the literature using OVID MEDLINE(R), Embase, Cochrane CENTRAL, Web of Science, and medRxiv and identified studies published between 1946 and May 2023. We identified a total of 2402 studies with 11 included in the final analysis (combined 149,356 patients). Studies suggested increased operative time associated with RYGB-CCE, with mixed results regarding length of stay and rates of bile duct injury. Presently available data is not robust enough to conclude whether minimally invasive RYGB with CCE harms or benefits patients compared to RYGB alone.
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Affiliation(s)
- Sloane Kowal
- School of Medicine, Queen's University, 80 Barrie Street, Kingston, ON, K7L 3N6, Canada
| | - Mitchell Vendrov
- Department of Medicine, Queen's University, Kingston, Ontario 76 Stuart St, Kingston, ON, K7L 2V7, Canada
| | - David Vaz
- School of Medicine, Queen's University, 80 Barrie Street, Kingston, ON, K7L 3N6, Canada
| | - Zuhaib M Mir
- Department of Surgery, Division of General Surgery, Dalhousie University, Halifax, Nova Scotia Room 8-848, 1278 Tower Road, Halifax, NS, B3H 2Y9, Canada
| | - Nader M Hanna
- Department of Surgery, Queen's University, Kingston, Ontario 76 Stuart St, Kingston, ON, K7L 2V7, Canada
| | - Boris Zevin
- Department of Surgery, Queen's University, Kingston, Ontario 76 Stuart St, Kingston, ON, K7L 2V7, Canada.
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2
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Shiihara M, Sudo Y, Matsushita N, Kubota T, Hibi Y, Osugi H, Inoue T. Preoperative difficulty assessment of interval laparoscopic cholecystectomy for gallstones. Surgery 2024; 175:1503-1507. [PMID: 38521628 DOI: 10.1016/j.surg.2024.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 12/29/2023] [Accepted: 02/14/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND Laparoscopic cholecystectomy is the gold standard treatment for benign gallbladder disease. However, few studies have reported the difficulty of interval cholecystectomy after cholecystitis because early cholecystectomy is recommended for acute cholecystitis. In this study, we evaluated the difficulties associated with interval cholecystectomy for cholecystitis with gallstones. METHODS We retrospectively analyzed patients with gallstones who underwent interval laparoscopic cholecystectomy for cholecystitis at our institution between January 2012 and December 2021. Patients were classified into laparoscopic total cholecystectomy and bailout procedure groups depending on whether they were converted to a bailout procedure, and their characteristics and outcomes were subsequently compared. Additionally, a logistic regression analysis of the preoperative factors contributing to bailout procedure conversion was performed. RESULTS Of the 269 participants, 39 converted to bailout procedure, and bile duct injury occurred in one case (0.4%). In patient characteristics comparison, patients in the bailout procedure group were significantly older, had more impacted stones, had higher post-treatment choledocholithiasis, had severe cholecystitis, and had a higher rate of percutaneous transhepatic gallbladder drainage. There were no differences in the bile duct injury or perioperative complications between the two groups. In logistic regression multivariate analysis of the factors contributing to the bailout procedure, post-treatment of choledocholithiasis (P < .001), impacted stone (P = .002), and age ≥71 (P = .007) were independent risk factors. CONCLUSION Impacted stones and choledocholithiasis are risk factors for conversion to bailout procedure and high difficulty in interval cholecystectomy. For such patients, interval cholecystectomy should be performed cautiously.
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Affiliation(s)
- Masahiro Shiihara
- Department of Surgery, Kamifukuoka General Hospital, Saitama, Japan.
| | - Yasuhiro Sudo
- Department of Surgery, Kamifukuoka General Hospital, Saitama, Japan
| | | | - Takeshi Kubota
- Department of Surgery, Kamifukuoka General Hospital, Saitama, Japan
| | - Yasuhiro Hibi
- Department of Surgery, Kamifukuoka General Hospital, Saitama, Japan
| | - Harushi Osugi
- Department of Surgery, Kamifukuoka General Hospital, Saitama, Japan
| | - Tatsuo Inoue
- Department of Surgery, Kamifukuoka General Hospital, Saitama, Japan
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Larose PC, Brisson BA, Sanchez A, Monteith G, Singh A, Zhang M. Near-infrared fluorescence cholangiography in dogs: A pilot study. Vet Surg 2024; 53:659-670. [PMID: 37537967 DOI: 10.1111/vsu.14007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 05/29/2023] [Accepted: 06/30/2023] [Indexed: 08/05/2023]
Abstract
OBJECTIVE To determine the effect of indocyanine green (ICG) dose and timing of administration on near-infrared fluorescence (NIRF) imaging of the normal canine biliary tree. STUDY DESIGN Preclinical prospective study. ANIMALS Eight purpose-bred beagles. METHODS The dogs were randomized to receive two of four intravenous ICG dose (low [L]:0.05 mg/kg or high [H]:0.25 mg/kg)/time (0 and 3 h prior to NIRF) combinations. NIRF images were collected every 10 min for 120 min. Target (cystic duct)-to-background (liver) ratios were calculated for all timepoints and compared. RESULTS ICG cholangiography was successful in all dogs. The contrast ratio was above 1 in the L0 group by 20 min and reached its peak at 100 min. In the H0 group, the ratio was above 1 by 60 min and reached its peak at 90 min. Contrast ratios above 2 (fluorescence twice as bright in the cystic duct compared to the liver) were maintained from 180 to 300 min for L3 and H3 and was achieved after 80 min for L0. CONCLUSION Low dose ICG provided better ratios early after injection compared to the high dose which remained highly concentrated in the liver tissue after injection. Both doses provided excellent visualization of the biliary tree at 3 h post injection, low dose ICG provided better ratios from 3 to 5 h post injection. Based on these results, 0.05 mg/kg of ICG administered at anesthetic premedication, or as early as 3 h prior to laparoscopic surgery should yield optimal fluorescence images. CLINICAL SIGNIFICANCE This study provides guidelines for NIRF cholangiography in clinically normal dogs.
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Affiliation(s)
- Philippe Chagnon Larose
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada
| | - Brigitte A Brisson
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada
| | - Andrea Sanchez
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada
| | - Gabrielle Monteith
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada
| | - Ameet Singh
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada
| | - Michael Zhang
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada
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Symeonidis S, Mantzoros I, Anestiadou E, Ioannidis O, Christidis P, Bitsianis S, Zapsalis K, Karastergiou T, Athanasiou D, Apostolidis S, Angelopoulos S. Biliary Anatomy Visualization and Surgeon Satisfaction Using Standard Cholangiography versus Indocyanine Green Fluorescent Cholangiography during Elective Laparoscopic Cholecystectomy: A Randomized Controlled Trial. J Clin Med 2024; 13:864. [PMID: 38337557 PMCID: PMC10856121 DOI: 10.3390/jcm13030864] [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: 12/26/2023] [Revised: 01/26/2024] [Accepted: 01/28/2024] [Indexed: 02/12/2024] Open
Abstract
Background: Intraoperative biliary anatomy recognition is crucial for safety during laparoscopic cholecystectomy, since iatrogenic bile duct injuries represent a fatal complication, occurring in up to 0.9% of patients. Indocyanine green fluorescence cholangiography (ICG-FC) is a safe and cost-effective procedure for achieving a critical view of safety and recognizing early biliary injuries. The aim of this study is to compare the perioperative outcomes, usefulness and safety of standard intraoperative cholangiography (IOC) with ICG-FC with intravenous ICG. Methods: Between 1 June 2021 and 31 December 2022, 160 patients undergoing elective LC were randomized into two equal groups: Group A (standard IOC) and group B (ICG-FC with intravenous ICG). Results: No significant difference was found between the two groups regarding demographics, surgery indication or surgery duration. No significant difference was found regarding the visualization of critical biliary structures. However, the surgeon satisfaction and cholangiography duration presented significant differences in favor of ICG-FC. Regarding the inflammatory response, a significant difference between the two groups was found only in postoperative WBC levels. Hepatic and renal function test results were not significantly different between the two groups on the first postoperative day, except for direct bilirubin. No statistically significant difference was noted regarding 30-day postoperative complications, while none of the complications noted included bile duct injury events. Conclusions: ICG-FC presents equivalent results to IOC regarding extrahepatic biliary visualization and postoperative complications. However, more studies need to be performed in order to standardize the optimal dose, timing and mode of administration.
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Affiliation(s)
- Savvas Symeonidis
- 4th Department of General Surgery, Aristotle University of Thessaloniki, General Hospital of Thessaloniki “G. Papanikolaou”, 54124 Thessaloniki, Greece; (S.S.); (I.M.); (E.A.); (P.C.); (S.B.); (K.Z.); (T.K.); (D.A.); (S.A.)
| | - Ioannis Mantzoros
- 4th Department of General Surgery, Aristotle University of Thessaloniki, General Hospital of Thessaloniki “G. Papanikolaou”, 54124 Thessaloniki, Greece; (S.S.); (I.M.); (E.A.); (P.C.); (S.B.); (K.Z.); (T.K.); (D.A.); (S.A.)
| | - Elissavet Anestiadou
- 4th Department of General Surgery, Aristotle University of Thessaloniki, General Hospital of Thessaloniki “G. Papanikolaou”, 54124 Thessaloniki, Greece; (S.S.); (I.M.); (E.A.); (P.C.); (S.B.); (K.Z.); (T.K.); (D.A.); (S.A.)
| | - Orestis Ioannidis
- 4th Department of General Surgery, Aristotle University of Thessaloniki, General Hospital of Thessaloniki “G. Papanikolaou”, 54124 Thessaloniki, Greece; (S.S.); (I.M.); (E.A.); (P.C.); (S.B.); (K.Z.); (T.K.); (D.A.); (S.A.)
| | - Panagiotis Christidis
- 4th Department of General Surgery, Aristotle University of Thessaloniki, General Hospital of Thessaloniki “G. Papanikolaou”, 54124 Thessaloniki, Greece; (S.S.); (I.M.); (E.A.); (P.C.); (S.B.); (K.Z.); (T.K.); (D.A.); (S.A.)
| | - Stefanos Bitsianis
- 4th Department of General Surgery, Aristotle University of Thessaloniki, General Hospital of Thessaloniki “G. Papanikolaou”, 54124 Thessaloniki, Greece; (S.S.); (I.M.); (E.A.); (P.C.); (S.B.); (K.Z.); (T.K.); (D.A.); (S.A.)
| | - Konstantinos Zapsalis
- 4th Department of General Surgery, Aristotle University of Thessaloniki, General Hospital of Thessaloniki “G. Papanikolaou”, 54124 Thessaloniki, Greece; (S.S.); (I.M.); (E.A.); (P.C.); (S.B.); (K.Z.); (T.K.); (D.A.); (S.A.)
| | - Trigona Karastergiou
- 4th Department of General Surgery, Aristotle University of Thessaloniki, General Hospital of Thessaloniki “G. Papanikolaou”, 54124 Thessaloniki, Greece; (S.S.); (I.M.); (E.A.); (P.C.); (S.B.); (K.Z.); (T.K.); (D.A.); (S.A.)
| | - Dimitra Athanasiou
- 4th Department of General Surgery, Aristotle University of Thessaloniki, General Hospital of Thessaloniki “G. Papanikolaou”, 54124 Thessaloniki, Greece; (S.S.); (I.M.); (E.A.); (P.C.); (S.B.); (K.Z.); (T.K.); (D.A.); (S.A.)
| | - Stylianos Apostolidis
- 1st Propaedeutic Department of Surgery, AHEPA University Hospital, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece;
| | - Stamatios Angelopoulos
- 4th Department of General Surgery, Aristotle University of Thessaloniki, General Hospital of Thessaloniki “G. Papanikolaou”, 54124 Thessaloniki, Greece; (S.S.); (I.M.); (E.A.); (P.C.); (S.B.); (K.Z.); (T.K.); (D.A.); (S.A.)
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Adrales G, Ardito F, Chowbey P, Morales-Conde S, Ferreres AR, Hensman C, Martin D, Matthaei H, Ramshaw B, Roberts JK, Schrem H, Sharma A, Tabiri S, Vibert E, Woods MS. A multi-national, video-based qualitative study to refine training guidelines for assigning an "unsafe" score in laparoscopic cholecystectomy critical view of safety. Surg Endosc 2024; 38:983-991. [PMID: 37973638 DOI: 10.1007/s00464-023-10528-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 10/12/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND The critical view of safety (CVS) was incorporated into a novel 6-item objective procedure-specific assessment for laparoscopic cholecystectomy (LC-CVS OPSA) to enhance focus on safe completion of surgical tasks and advance the American Board of Surgery's entrustable professional activities (EPAs) initiative. To enhance instrument development, a feasibility study was performed to elucidate expert surgeon perspectives regarding "safe" vs. "unsafe" practice. METHODS A multi-national consortium of 11 expert LC surgeons were asked to apply the LC-CVS OPSA to ten LC videos of varying surgical difficulty using a "safe" vs. "unsafe" scale. Raters were asked to provide written rationale for all "unsafe" ratings and invited to provide additional feedback regarding instrument clarity. A qualitative analysis was performed on written responses to extract major themes. RESULTS Of the 660 ratings, 238 were scored as "unsafe" with substantial variation in distribution across tasks and raters. Analysis of the comments revealed three major categories of "unsafe" ratings: (a) inability to achieve the critical view of safety (intended outcome), (b) safe task completion but less than optimal surgical technique, and (c) safe task completion but risk for potential future complication. Analysis of reviewer comments also identified the potential for safe surgical practice even when CVS was not achieved, either due to unusual anatomy or severe pathology preventing safe visualization. Based upon findings, modifications to the instructions to raters for the LC-CVS OPSA were incorporated to enhance instrument reliability. CONCLUSIONS A safety-based LC-CVS OPSA has the potential to significantly improve surgical training by incorporating CVS formally into learner assessment. This study documents the perspectives of expert biliary tract surgeons regarding clear identification and documentation of unsafe surgical practice for LC-CVS and enables the development of training materials to improve instrument reliability. Learnings from the study have been incorporated into rater instructions to enhance instrument reliability.
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Affiliation(s)
- Gina Adrales
- Division of Minimally Invasive Surgery, Minimally Invasive Surgical Training and Innovation Center (MISTIC), Johns Hopkins Hospital, 600 N. Wolfe St., Blalock 618, Baltimore, MD, 21287, USA.
| | - Francesco Ardito
- Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Catholic University, Rome, Italy
| | - Pradeep Chowbey
- Institute of Laparoscopic, Endoscopic and Bariatric Surgery, Max Super Specialty Hospital, Saket, New Delhi, India
| | - Salvador Morales-Conde
- Unit of Innovation in Minimally Invasive Surgery, University Hospital Virgen del Rocío, University of Sevilla, Seville, Spain
| | - Alberto R Ferreres
- Department of Surgery, University of Buenos Aires, Buenos Aires, Argentina
| | - Chrys Hensman
- Monash University Department of Surgery & Lap Surgery, Melbourne, Australia
| | - David Martin
- Division of Critical Care/Acute Care Surgery, University of Minnesota, Minneapolis, USA
| | - Hanno Matthaei
- Department of Surgery, University Medical Center Bonn, Bonn, Germany
| | - Bruce Ramshaw
- CQInsights PBC, Knoxville, TN, USA
- Caresyntax Corporation, Boston, USA
| | - J Keith Roberts
- Liver Transplant and HPB Surgery, University Hospitals Birmingham NHS Trust, Birmingham, UK
| | - Harald Schrem
- General, Visceral and Transplant Surgery, Medical University Graz, Graz, Austria
| | - Anil Sharma
- Institute of Laparoscopic, Endoscopic and Bariatric Surgery, Max Super Specialty Hospital, Saket, New Delhi, India
| | - Stephen Tabiri
- Tamale Teaching Hospital, University for Development Studies-School of Medicine and Health Sciences, Tamale, Ghana
| | - Eric Vibert
- Centre Hépato-Biliaire, Paul Brousse Hospital, AP-HP, Villejuif, France
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Bakhtiar Khan H, Shiraz A, Haseeb A, Hamayun S, Ali A, Zahid MJ, Alizai Q, Karim M, Rehman SU, Ali I. Scale and Safety: Analyzing the Association Between Intraoperative Difficulty and Achieving the Critical View of Safety in Laparoscopic Cholecystectomy. Cureus 2024; 16:e53408. [PMID: 38435198 PMCID: PMC10908434 DOI: 10.7759/cureus.53408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2024] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND Laparoscopic cholecystectomy (LC) is the preferred method for gallstone removal, but bile duct injuries remain a concern. Achieving the critical view of safety (CVS) is pivotal in preventing such injuries. The aim of this study was to compare the rates of difficult LC in those with CVS achieved compared to those with CVS not achieved. METHODS We performed a single-center prospective study on all patients with ultrasound-confirmed symptomatic gallstones. Patients were excluded if they refused to consent or if they underwent LC for indications other than gallstone disease. Patients were stratified into two groups as CVS not achieved and CVS achieved groups and compared for outcomes. Our primary outcome was the rate of intraoperative difficulty on the modified Nassar scale (MNS). Statistical analysis was performed using SPSS version 25.0 (IBM Corp., Armonk, NY). RESULTS We included 70 patients who underwent LC for gallstones (CVS not achieved = 24 and CVS achieved = 46). The mean (SD) age was 42.2 (12.3) years, and 73.5% were females. The mean (SD) weight in our study cohort was 74.1 (10.9) kg, and there was no difference between the two groups in terms of the baseline demographic characteristics, disease characteristics, and comorbid conditions (p > 0.05). On univariate analyses, achieving CVS was associated with lower rates of higher-grade operative difficulty on the MNS and lower rates of length of stay of more than one day. CONCLUSION Achieving CVS is associated with easy LC based on significantly lower Nassar scores. These findings highlight the role of the MNS in the successful identification of the operative difficulty of LC and its correlation with achieving CVS.
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Affiliation(s)
| | - Ahmad Shiraz
- General Surgery, Hayatabad Medical Complex Peshawar, Peshawar, PAK
| | - Abdul Haseeb
- General Surgery, Hayatabad Medical Complex Peshawar, Peshawar, PAK
| | - Sana Hamayun
- General Surgery, Hayatabad Medical Complex Peshawar, Peshawar, PAK
| | - Aiman Ali
- General Surgery, Hayatabad Medical Complex Peshawar, Peshawar, PAK
| | | | - Qaidar Alizai
- General Surgery, Hayatabad Medical Complex Peshawar, Peshawar, PAK
| | - Maryam Karim
- General Surgery, Rehman Medical Institute, Peshawar, PAK
| | - Sajid Ur Rehman
- General Surgery, Hayatabad Medical Complex Peshawar, Peshawar, PAK
| | - Irfan Ali
- General Surgery, Mardan Medical Complex, Mardan, PAK
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Shapira SS, Ehrlich Z, Koren P, Sroka G. Comparing a novel wide field of view laparoscope with conventional laparoscope while performing laparoscopic cholecystectomy. Surg Endosc 2023; 37:8910-8918. [PMID: 37735219 DOI: 10.1007/s00464-023-10393-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 08/13/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND The limited 70° field of view (FoV) used in standard laparoscopy necessitates maneuvering the laparoscope to view the ports, follow the surgical tools, and search for a target region. Complications related to events that take place outside the FoV are underreported. Recently, a novel laparoscopic system (SurroundScope, 270Surgical) was reported to dramatically expand the FoV from 70 to 270°. This study focuses on differences in performing laparoscopic cholecystectomy using the SurroundScope compared to the standard laparoscope. METHODS Forty-four laparoscopic surgeries were performed and video recorded. A subanalysis of 21 Cholecystectomies was performed and compared to 21 Cholecystectomies, performed with the standard laparoscope during the study period by the same surgeon. RESULTS No accidental or intraoperative adverse events occurred when using the SurroundScope. Subanalysis of 21 Cholecystectomies revealed shorter fog/smoke cleaning times using the SurroundScope compared to the standard scope (1.45 ± 5.08 sec vs. 54.95 ± 137.77 sec, p = 0.0454). Furthermore, operations performed with the SurroundScope had a shorter trocar placement duration (85.0 ± 40.9 sec vs. 111.3 ± 70.5 sec; p = 0.077), shorter time to achieve critical view of safety (9.5 ± 4.14 min vs. 15.8 ± 11.87 min; p = 0.015), and shorter procedure duration (31.9 ± 10.4 min vs. 42.9 ± 22 min; p = 0.025). In post-operative evaluations, the surgeon noted that tools could be continuously followed and ports were visible without camera manipulation. Also, the surgeon agreed that the procedure could be better planned due to the wide FoV and that surgical workflow was improved. Furthermore, the surgeon agreed that the procedure was safer using the SurroundScope. CONCLUSIONS Initial results demonstrate the advantages of the SurroundScope over standard laparoscopy. By expanding the FoV, visualization is improved, the procedure is more efficient, significantly shorter and most important, patient safety, per surgeons' testimonials is improved. Further investigation to quantify these benefits in a larger group of patients and among various surgical procedures should be considered.
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Affiliation(s)
| | - Zvi Ehrlich
- Department of Obstetrics and Gynaecology, Shaare Zedek Medical Centre, Hebrew University, Jerusalem, Israel
| | - Pazit Koren
- Department of Surgery, Bnai Zion Medical Center, Haifa, Israel
| | - Gideon Sroka
- Department of Surgery, Bnai Zion Medical Center, Haifa, Israel.
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Zhang J, Zhou S, Wang Y, Shi S, Wan C, Zhao H, Cai X, Ding H. Laparoscopic Image-Based Critical Action Recognition and Anticipation With Explainable Features. IEEE J Biomed Health Inform 2023; 27:5393-5404. [PMID: 37603480 DOI: 10.1109/jbhi.2023.3306818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Abstract
Surgical workflow analysis integrates perception, comprehension, and prediction of the surgical workflow, which helps real-time surgical support systems provide proper guidance and assistance for surgeons. This article promotes the idea of critical actions, which refer to the essential surgical actions that progress towards the fulfillment of the operation. Fine-grained workflow analysis involves recognizing current critical actions and previewing the moving tendency of instruments in the early stage of critical actions. Aiming at this, we propose a framework that incorporates operational experience to improve the robustness and interpretability of action recognition in in-vivo situations. High-dimensional images are mapped into an experience-based explainable feature space with low dimensions to achieve critical action recognition through a hierarchical classification structure. To forecast the instrument's motion tendency, we model the motion primitives in the polar coordinate system (PCS) to represent patterns of complex trajectories. Given the laparoscopy variance, the adaptive pattern recognition (APR) method, which adapts to uncertain trajectories by modifying model parameters, is designed to improve prediction accuracy. The in-vivo dataset validations show that our framework fulfilled the surgical awareness tasks with exceptional accuracy and real-time performance.
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9
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Iftikhar M, Shah M, Ullah Z, Shakoor HA, Ullah S. Achieving Critical View of Safety via a New Technique: The Triple One (111) Technique. Cureus 2023; 15:e44098. [PMID: 37750143 PMCID: PMC10518118 DOI: 10.7759/cureus.44098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND Misidentification of anatomical structures is one of the most common causes of bile duct injury following laparoscopic cholecystectomy. Achieving Critical View of Safety (CVS) is a standard step in conducting safe cholecystectomy all over the world. In our institute, we achieve CVS via a unique technique called Triple One or 111 and find it very helpful and easy to achieve CVS. Moreover, the rate of conversion has also decreased while achieving CVS via this technique. The unique aspect of the Triple One technique is that by following this method, even new laparoscopic surgeons can achieve CVS very easily in difficult cases and, hence, it decreases the chances of vasculobiliary injury (VBI). OBJECTIVE This study aimed to determine how effective the Triple One technique is in achieving CVS as well as in lessening the chances of VBI. MATERIAL AND METHODS A total of 545 patients were admitted through the outpatient department, ranging in age from 30 to 70 years, with a mean of 50 years. The study comprised patients with American Society of Anaesthesiologists (ASA) I & II, acute and chronic cholecystitis, and symptomatic cholelithiasis. The study excluded patients with co-morbidities, prior abdominal procedures, and suspected complications. On the second postoperative day, all patients received their discharge papers and on the seventh postoperative day, follow-up was completed. RESULTS Successful gallbladder extraction using the Triple One technique was achieved in 540 (99%) cases. The other five (1%) cases converted to open cholecystectomy because of the difficult gallbladder anatomy and extensive scarring. No VBI or bile duct injury was noted. No mortality was recorded during the study period. CONCLUSION By incorporating CVS using the Triple One technique into our policies and curriculum, we may encourage safe cholecystectomy practices and prevent bile duct injuries.
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Affiliation(s)
- Muhammad Iftikhar
- General Surgery Department, Hayatabad Medical Complex Peshawar, Peshawar, PAK
| | - Muhammad Shah
- General Surgery Department, Hayatabad Medical Complex Peshawar, Peshawar, PAK
| | - Zia Ullah
- Anatomy Department, Peshawar Institute of Medical Sciences, Peshawar, PAK
| | | | - Shahid Ullah
- General Surgery Department, Hayatabad Medical Complex Peshawar, Peshawar, PAK
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10
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Gupta R, Khanduri A, Singh A, Tyagi H, Varshney R, Rawal N, Daspal U, Singh SK, Morey P, Pokharia P. Defining Critical View of Safety During Laparoscopic Cholecystectomy: The Preoperative Predictors of Failure. Cureus 2023; 15:e37464. [PMID: 37187662 PMCID: PMC10181886 DOI: 10.7759/cureus.37464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2023] [Indexed: 05/17/2023] Open
Abstract
Background Defining critical view of safety (CVS) is one of the most crucial steps during laparoscopic cholecystectomy (LC). This study aimed to determine the preoperative predictors of failure to achieve CVS during LC. Methods All patients undergoing LC from December 2020 to July 2022 were prospectively included. Results There were 180 females and 93 males. CVS was achieved during LC in 238 (87.2%) patients. Conversion to open surgery was performed for 11 patients. Bile leak occurred in three patients which resolved spontaneously. No patient developed bile duct injury. On univariate analysis, age, male sex, American Society of Anaesthesiologists (ASA) grading, Murphy's sign, emergency surgery, neutrophil percentage, lymphocyte percentage, gallbladder wall thickness > 3mm, and impacted gallstone on abdominal ultrasound were predictors of failure to achieve CVS. On multivariate analysis, neutrophil and lymphocyte percentages were independent predictors of failure to achieve CVS. Patients in whom CVS could not be achieved had significantly longer operative time, higher blood loss, complications, and hospital stays. Discussion Inability to achieve CVS during LC can be predicted preoperatively using various parameters including neutrophil and lymphocyte percentages. Such cases must be operated by senior surgeons or referred to experienced general or hepatobiliary surgeons for cholecystectomy to avoid bile duct injury. The proposed algorithm can help in intraoperative decision-making in difficult cases.
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Affiliation(s)
- Rahul Gupta
- Gastrointestinal Surgery, Synergy Institute of Medical Sciences, Dehradun, IND
| | - Archana Khanduri
- Gastrointestinal Surgery, Synergy Institute of Medical Sciences, Dehradun, IND
| | - Arvind Singh
- Gastroenterology, Synergy Institute of Medical Sciences, Dehradun, IND
| | - Harshdeep Tyagi
- Anaesthesiology, Synergy Institute of Medical Sciences, Dehradun, IND
| | - Rahul Varshney
- Anesthesia and Critical Care, Synergy Institute of Medical Sciences, Dehradun, IND
| | - Nagendra Rawal
- Anaesthesiology, Synergy Institute of Medical Sciences, Dehradun, IND
| | - Ujjwal Daspal
- Anaesthesiology, Synergy Institute of Medical Sciences, Dehradun, IND
| | - Sudhir K Singh
- Anaesthesiology, Synergy Institute of Medical Sciences, Dehradun, IND
| | - Parikshit Morey
- Radiology, Synergy Institute of Medical Sciences, Dehradun, IND
| | - Pradip Pokharia
- Radiology, Synergy Institute of Medical Sciences, Dehradun, IND
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11
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Elser H, Bergquist JR, Li AY, Visser BC. Determinants, Costs, and Consequences of Common Bile Duct Injury Requiring Operative Repair Among Privately Insured Individuals in the United States, 2003-2020. ANNALS OF SURGERY OPEN 2023; 4:e238. [PMID: 37600869 PMCID: PMC10431520 DOI: 10.1097/as9.0000000000000238] [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: 07/19/2022] [Accepted: 12/30/2022] [Indexed: 02/05/2023] Open
Abstract
Objective Characterize the determinants, all-cause mortality risk, and healthcare costs associated with common bile duct injury (CBDI) following cholecystectomy in a contemporary patient population. Background Retrospective cohort study using nationwide patient-level commercial and Medicare Advantage claims data, 2003-2019. Beneficiaries ≥18 years who underwent cholecystectomy were identified using Current Procedure Terminology (CPT) codes. CBDI was defined by a second surgical procedure for repair within one year of cholecystectomy. Methods We estimated the association of common surgical indications and comorbidities with risk of CBDI using logistic regression; the association between CBDI and all-cause mortality using Cox proportional hazards regression; and calculated average healthcare costs associated with CBDI repair. Results Among 769,782 individuals with cholecystectomy, we identified 894 with CBDI (0.1%). CBDI was inversely associated with biliary colic (odds ratio [OR] = 0.82; 95% confidence interval [CI]: 0.71-0.94) and obesity (OR = 0.70, 95% CI: 0.59-0.84), but positively associated with pancreas disease (OR = 2.16, 95% CI: 1.92-2.43) and chronic liver disease (OR = 1.25, 95% CI: 1.05-1.49). In fully adjusted Cox models, CBDI was associated with increased all-cause mortality risk (hazard ratio = 1.57, 95% CI: 1.38-1.79). The same-day CBDI repair was associated with the lowest mean overall costs, with the highest mean overall costs for repair within 1 to 3 months. Conclusions In this retrospective cohort study, calculated rates of CBDI are substantially lower than in prior large studies, perhaps reflecting quality-improvement initiatives over the past two decades. Yet, CBDI remains associated with increased all-cause mortality risks and significant healthcare costs. Patient-level characteristics may be important determinants of CBDI and warrant ongoing examination in future research.
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Affiliation(s)
- Holly Elser
- From the Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - John R. Bergquist
- Department of General Surgery, Stanford University School of Medicine, Stanford, CA
| | - Amy Y. Li
- Department of General Surgery, Stanford University School of Medicine, Stanford, CA
| | - Brendan C. Visser
- Department of General Surgery, Stanford University School of Medicine, Stanford, CA
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12
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Lee BJH, Yap QV, Low JK, Chan YH, Shelat VG. Cholecystectomy for asymptomatic gallstones: Markov decision tree analysis. World J Clin Cases 2022; 10:10399-10412. [PMID: 36312509 PMCID: PMC9602237 DOI: 10.12998/wjcc.v10.i29.10399] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 05/13/2022] [Accepted: 09/01/2022] [Indexed: 02/05/2023] Open
Abstract
Gallstones are a common public health problem, especially in developed countries. There are an increasing number of patients who are diagnosed with gallstones due to increasing awareness and liberal use of imaging, with 22.6%-80% of gallstone patients being asymptomatic at the time of diagnosis. Despite being asymptomatic, this group of patients are still at life-long risk of developing symptoms and complications such as acute cholangitis and acute biliary pancreatitis. Hence, while early prophylactic cholecystectomy may have some benefits in selected groups of patients, the current standard practice is to recommend cholecystectomy only after symptoms or complications occur. After reviewing the current evidence about the natural course of asymptomatic gallstones, complications of cholecystectomy, quality of life outcomes, and economic outcomes, we recommend that the option of cholecystectomy should be discussed with all asymptomatic gallstone patients. Disclosure of material information is essential for patients to make an informed choice for prophylactic cholecystectomy. It is for the patient to decide on watchful waiting or prophylactic cholecystectomy, and not for the medical community to make a blanket policy of watchful waiting for asymptomatic gallstone patients. For patients with high-risk profiles, it is clinically justifiable to advocate cholecystectomy to minimize the likelihood of morbidity due to complications.
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Affiliation(s)
- Brian Juin Hsien Lee
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore S308232, Singapore
| | - Qai Ven Yap
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore S117597, Singapore
| | - Jee Keem Low
- Department of General Surgery, Tan Tock Seng Hospital, Singapore S308433, Singapore
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore S117597, Singapore
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore S308433, Singapore
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13
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Sewefy AM, Elsageer EM, Kayed T, Mohammed MM, Taha Zaazou MM, Hamza HM. Nasobiliary guided laparoscopic cholecystectomy following endoscopic retrograde cholangiopancreatography, randomized controlled trial. Surgeon 2022:S1479-666X(22)00101-9. [PMID: 35953433 DOI: 10.1016/j.surge.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 06/18/2022] [Accepted: 06/28/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC) is the most common management of gallstones combined with common bile duct (CBD) stones. This study aims to evaluate the impact of routine insertion of nasobiliary catheter during ERCP in cases of difficult LC. PATIENTS & METHODS From total 110 patients who underwent ERCP followed by LC in the period from April 2019 to April 2020, nasobiliary (NB) catheter was inserted during ERCP in 55 patients after CBD clearance (NB group). In the other 55 patients, only CBD clearance was done (Control group). In the NB group, dynamic trans-nasobiliary intraoperative cholangiography (TN-IOC) was done during dissection of Calot's triangle. At the end of the procedure, trans-nasobiliay methylene blue (MB) test was done to detect any missed biliary injury. The primary outcome to be analyzed was the incidence and severity of bile duct injury (BDI), secondary outcomes were the operative time, conversion to open surgery, and hospital stay. RESULTS Of the 110 patients, 57 patients (51.8%) were males and 53 (48.2%) were females. Median age was 55 years. One case of biliary leak was reported in the NB group (1.8%), while 2 cases (3.6%) were reported in the Control group. The average operative time in the NB group was 115 min versus 128 min in the Control group (P value < 0.001). No cases were converted to open cholecystectomy in the NB group (0%) with 5 cases (9.1%) converted to open in the Control group. The average postoperative hospital stay was 2 ± 0.1 days in the NB group versus 3.6 ± 5.3 days in the Control group (P value = 0.037). CONCLUSION Routine insertion of nasobiliary tube during ERCP, in patients with combined gallbladder and CBD stones, is a simple, safe and dynamic method for IOC. This maneuver does not statistically decrease the incidence of BDI but can diagnose, minimize and treat BDI with shorter operative time and hospital stay.
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Affiliation(s)
- Alaa M Sewefy
- Department of General Surgery, Faculty of Medicine, Minia University, Egypt
| | - Emad M Elsageer
- Department of General Surgery, Faculty of Medicine, Minia University, Egypt
| | - Taha Kayed
- Department of General Surgery, Faculty of Medicine, Minia University, Egypt
| | | | - Mohamed M Taha Zaazou
- Department of General Surgery, Faculty of Medicine, Misr University for Science and Technology, Egypt
| | - Hosam M Hamza
- Department of General Surgery, Faculty of Medicine, Minia University, Egypt.
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14
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Khalid H, Khan NA, Aziz MA. What is the critical view of safety in laparoscopic cholecystectomy? - Correspondence. Int J Surg 2022; 104:106728. [PMID: 35753655 DOI: 10.1016/j.ijsu.2022.106728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/24/2022] [Accepted: 06/08/2022] [Indexed: 10/17/2022]
Affiliation(s)
- Hina Khalid
- Dow University of Health Sciences, Dow International Medical College, Karachi, Pakistan.
| | - Naveed Ali Khan
- Department of Surgery, Dow University of Health Sciences, Dow International Medical College, Karachi, Pakistan.
| | - Munira Abdul Aziz
- Department of Surgery, Dow University of Health Sciences, Dow International Medical College, Karachi, Pakistan.
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15
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Dekonenko C, Holcomb GW. Laparoscopic Cholecystectomy in Children. J Laparoendosc Adv Surg Tech A 2021; 31:1180-1184. [PMID: 34382817 DOI: 10.1089/lap.2021.0397] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The incidence of gallbladder disease in children is rising due to an increase in the development of nonhemolytic cholelithiasis in this age group. Laparoscopic cholecystectomy is the gold standard for treatment for gallbladder disease in adults and, with the technique's widespread adoption, it has now become the mainstay of treatment for gallbladder disease in children as well. Complications are infrequent and is now often performed as an outpatient surgery. Although the standard approach is through a 4-port technique, it can also be performed using a single-site technique. We describe our thoughts on laparoscopic cholecystectomy in children with a focus on the standard approach.
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Affiliation(s)
- Charlene Dekonenko
- Department of Surgery, Vanderbilt University School of Medicine, Children's Mercy Hospital, Kansas City, Missouri, USA
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16
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Kılıç ŞS, Özden Ö, Çolak ST. Comparative analysis of reliability and clinical effects of the critical view of safety approach used in laparoscopic cholecystectomy in the pediatric population. Pediatr Surg Int 2021; 37:737-743. [PMID: 33586011 DOI: 10.1007/s00383-021-04869-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/31/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE With the increase in indications for cholecystectomy in children, the frequency of laparoscopic cholecystectomy procedures and related problems has increased. The Critical View of Safety (CVS) is the target-specific method for identifying the cystic duct during laparoscopic cholecystectomy to prevent common bile duct injury. We hypothesize that the use of CVS is reliable in the pediatric population. METHODS Data of 91 patients under 18 years of age who underwent elective laparoscopic cholecystectomy were retrospectively analyzed. Patients were divided into two groups depending on whether CVS was applied. The descriptive characteristics and complications of the two groups were compared. RESULTS CVS was applied to 41 patients. When the groups were compared in terms of operation time, postoperative length of stay, idiopathic gallbladder perforation, dropping stone, and presence of surgical site infection, no statistical significant difference was found. However, the time to start oral feeding was shorter in CVS group (p = 0.01). CONCLUSION We believe CVS is a reliable method to ensure safe cystic channel identification in the pediatric population. New studies are warranted on the effectiveness of CVS for safely performing laparoscopic cholecystectomy in children, as the procedure is being performed more frequently in the pediatric population.
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Affiliation(s)
- Şeref Selçuk Kılıç
- Department of Pediatric Surgery, Faculty of Medicine, Çukurova University, Sarıcam, ABD 01330, Adana, Turkey.
| | - Önder Özden
- Department of Pediatric Surgery, Faculty of Medicine, Çukurova University, Sarıcam, ABD 01330, Adana, Turkey
| | - Selcan Türker Çolak
- Department of Pediatric Surgery, Faculty of Medicine, Çukurova University, Sarıcam, ABD 01330, Adana, Turkey
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17
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Grossi JVM, Lee B, Belyansky I, Carbonell AM, Cavazzola LT, Novitsky YW, Ballecer CD. Critical view of robotic-assisted transverse abdominal release (r-TAR). Hernia 2021; 25:1715-1725. [PMID: 33797679 DOI: 10.1007/s10029-021-02391-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 03/08/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Establishing straightforward and reproducible steps to describe the technique performed with the aid of the robotic system for complex hernia surgery is key for good outcomes. Even using the description of open surgery as a parameter for performing the robotic technique, it is important to stress the particularities of this access. To describe the steps to perform robotic-assisted TAR (r-TAR) in a standardized technique, with a critical and safe view of all the anatomical structures. DESCRIPTION OF THE TECHNIQUE We defined 8 landmarks for the critical view of safety in r-TAR which include: (1) patient position, trocar and docking; (2) posterior rectus sheath mobilization; (3) transversus abdominis release (TAR)-Top-down technique; (4) transversus abdominis release (TAR)-bottom-up technique and mesh insertion; (5) contralateral trocar insertion and redocking, 6) posterior sheath closure; (7) final mesh positioning; and (8) anterior defect closure and drains. DISCUSSION Complex hernia surgery using a robotic-assisted posterior component separation requires well-established steps so the procedure can be reproducible and achieve better results.
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Affiliation(s)
- J V M Grossi
- Department of Surgery, Moinhos de Vento Hospital, Porto Alegre, Brazil.
| | - B Lee
- Creighton University School of Medicine-Phoenix, Phoenix, USA
| | - I Belyansky
- Department of Surgery, Anne Arundel Medical Center, 2000 Medical Parkway, Belcher, Pavilion, Suite106, Annapolis, MD, 21401, USA
| | - A M Carbonell
- Department of Surgery, Division of Minimal Access and Bariatric Surgery, Greenville Health System, University of South Carolina School of Medicine, Greenville, SC, USA
| | - L T Cavazzola
- Department of Surgery, Clinicas de Porto Alegre Hospital, Porto Alegre, Brazil
| | | | - C D Ballecer
- Creighton University School of Medicine-Phoenix, Phoenix, USA
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18
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Nassar AHM, Ng HJ, Wysocki AP, Khan KS, Gil IC. Achieving the critical view of safety in the difficult laparoscopic cholecystectomy: a prospective study of predictors of failure. Surg Endosc 2020; 35:6039-6047. [PMID: 33067645 PMCID: PMC8523408 DOI: 10.1007/s00464-020-08093-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 10/03/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Bile duct injury rates for laparoscopic cholecystectomy (LC) remain higher than during open cholecystectomy. The "culture of safety" concept is based on demonstrating the critical view of safety (CVS) and/or correctly interpreting intraoperative cholangiography (IOC). However, the CVS may not always be achievable due to difficult anatomy or pathology. Safety may be enhanced if surgeons assess difficulties objectively, recognise instances where a CVS is unachievable and be familiar with recovery strategies. AIMS AND METHODS A prospective study was conducted to evaluate the achievability of the CVS during all consecutive LC performed over four years. The primary aim was to study the association between the inability to obtain the CVS and an objective measure of operative difficulty. The secondary aim was to identify preoperative and operative predictors indicating the use of alternate strategies to complete the operation safely. RESULTS The study included 1060 consecutive LC. The median age was 53 years, male to female ratio was 1:2.1 and 54.9% were emergency admissions. CVS was obtained in 84.2%, the majority being difficulty grade I or II (70.7%). Displaying the CVS failed in 167 LC (15.8%): including 55.6% of all difficulty grade IV LC and 92.3% of difficulty grade V. There were no biliary injuries or conversions. CONCLUSION All three components of the critical view of safety could not be demonstrated in one out of 6 consecutive laparoscopic cholecystectomies. Preoperative factors and operative difficulty grading can predict cases where the CVS may not be achievable. Adapting instrument selection and alternate dissection strategies would then need to be considered.
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Affiliation(s)
- Ahmad H M Nassar
- University Hospital Monklands, Airdrie, Lanarkshire, ML6 0JSb, Scotland.
| | - Hwei J Ng
- NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Arkadiusz Peter Wysocki
- Logan Hospital, Corner Meadowbrook and Loganlea Roads, Meadowbrook, Logan City, QLD, 4133, Australia
| | | | - Ines C Gil
- Centro Hospitalar de Leiria, Leiria, Portugal
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19
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Safe Cholecystectomy Multi-society Practice Guideline and State of the Art Consensus Conference on Prevention of Bile Duct Injury During Cholecystectomy. Ann Surg 2020; 272:3-23. [PMID: 32404658 DOI: 10.1097/sla.0000000000003791] [Citation(s) in RCA: 102] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
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.
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20
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Safe cholecystectomy multi-society practice guideline and state-of-the-art consensus conference on prevention of bile duct injury during cholecystectomy. Surg Endosc 2020; 34:2827-2855. [PMID: 32399938 DOI: 10.1007/s00464-020-07568-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 04/10/2020] [Indexed: 12/11/2022]
Abstract
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.
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21
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Tokuyasu T, Iwashita Y, Matsunobu Y, Kamiyama T, Ishikake M, Sakaguchi S, Ebe K, Tada K, Endo Y, Etoh T, Nakashima M, Inomata M. Development of an artificial intelligence system using deep learning to indicate anatomical landmarks during laparoscopic cholecystectomy. Surg Endosc 2020; 35:1651-1658. [PMID: 32306111 PMCID: PMC7940266 DOI: 10.1007/s00464-020-07548-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 04/04/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND The occurrence of bile duct injury (BDI) during laparoscopic cholecystectomy (LC) is an important medical issue. Expert surgeons prevent intraoperative BDI by identifying four landmarks. The present study aimed to develop a system that outlines these landmarks on endoscopic images in real time. METHODS An intraoperative landmark indication system was constructed using YOLOv3, which is an algorithm for object detection based on deep learning. The training datasets comprised approximately 2000 endoscopic images of the region of Calot's triangle in the gallbladder neck obtained from 76 videos of LC. The YOLOv3 learning model with the training datasets was applied to 23 videos of LC that were not used in training, to evaluate the estimation accuracy of the system to identify four landmarks: the cystic duct, common bile duct, lower edge of the left medial liver segment, and Rouviere's sulcus. Additionally, we constructed a prototype and used it in a verification experiment in an operation for a patient with cholelithiasis. RESULTS The YOLOv3 learning model was quantitatively and subjectively evaluated in this study. The average precision values for each landmark were as follows: common bile duct: 0.320, cystic duct: 0.074, lower edge of the left medial liver segment: 0.314, and Rouviere's sulcus: 0.101. The two expert surgeons involved in the annotation confirmed consensus regarding valid indications for each landmark in 22 of the 23 LC videos. In the verification experiment, the use of the intraoperative landmark indication system made the surgical team more aware of the landmarks. CONCLUSIONS Intraoperative landmark indication successfully identified four landmarks during LC, which may help to reduce the incidence of BDI, and thus, increase the safety of LC. The novel system proposed in the present study may prevent BDI during LC in clinical practice.
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Affiliation(s)
- Tatsushi Tokuyasu
- Faculty of Information Engineering, Department of Information and Systems Engineering, Fukuoka Institute of Technology, 3-30-1 Wajiro-higashi, Higashi-ku, Fukuoka-City, Fukuoka, 811-0295, Japan.
| | - Yukio Iwashita
- Faculty of Medicine, Department of Gastroenterological and Pediatric Surgery, Oita University, 1-1 Idaigaoka, Hasama-machi, Yufu-City, Oita, 879-5593, Japan
| | - Yusuke Matsunobu
- Faculty of Information Engineering, Department of Information and Systems Engineering, Fukuoka Institute of Technology, 3-30-1 Wajiro-higashi, Higashi-ku, Fukuoka-City, Fukuoka, 811-0295, Japan
| | - Toshiya Kamiyama
- Customer Solutions Development, Platform Technology, Olympus Technologies Asia, Olympus Corporation, 2-3 Kuboyama-cho, Hachioji-City, Tokyo, 192-8512, Japan
| | - Makoto Ishikake
- Customer Solutions Development, Platform Technology, Olympus Technologies Asia, Olympus Corporation, 2-3 Kuboyama-cho, Hachioji-City, Tokyo, 192-8512, Japan
| | - Seiichiro Sakaguchi
- Customer Solutions Development, Platform Technology, Olympus Technologies Asia, Olympus Corporation, 2-3 Kuboyama-cho, Hachioji-City, Tokyo, 192-8512, Japan
| | - Kohei Ebe
- Customer Solutions Development, Platform Technology, Olympus Technologies Asia, Olympus Corporation, 2-3 Kuboyama-cho, Hachioji-City, Tokyo, 192-8512, Japan
| | - Kazuhiro Tada
- Faculty of Medicine, Department of Gastroenterological and Pediatric Surgery, Oita University, 1-1 Idaigaoka, Hasama-machi, Yufu-City, Oita, 879-5593, Japan
| | - Yuichi Endo
- Faculty of Medicine, Department of Gastroenterological and Pediatric Surgery, Oita University, 1-1 Idaigaoka, Hasama-machi, Yufu-City, Oita, 879-5593, Japan
| | - Tsuyoshi Etoh
- Faculty of Medicine, Department of Gastroenterological and Pediatric Surgery, Oita University, 1-1 Idaigaoka, Hasama-machi, Yufu-City, Oita, 879-5593, Japan
| | - Makoto Nakashima
- Faculty of Science and Technology, Division of Computer Science and Intelligent Systems, Oita University, 700 Dannoharu, Oita-City, Oita, 870-1192, Japan
| | - Masafumi Inomata
- Faculty of Medicine, Department of Gastroenterological and Pediatric Surgery, Oita University, 1-1 Idaigaoka, Hasama-machi, Yufu-City, Oita, 879-5593, Japan
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22
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Gunawardena N, Matscheko M, Anzengruber B, Ferscha A, Schobesberger M, Shamiyeh A, Klugsberger B, Solleder P. The Effect of Expertise on Gaze Behaviour in Laparoscopic Cholecystectomy. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2020; 2019:7123-7127. [PMID: 31947478 DOI: 10.1109/embc.2019.8857612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Laparoscopic skills vary with experience and training of surgeons. The complexity of laparoscopic surgeries affects the cognitive resources of surgeons significantly and leads to many biliary injuries during surgeries. Assuming that experts are more focused, we investigated how the skill level of surgeons during live surgery is reflected through eye metrics. Throughout the study, we used five eye movement metrics classified under saccadic, fixations and pupillary metrics. Forty-two laparoscopic surgeries have been conducted with four surgeons belonging to three expertise levels (novice, semi-expert and expert) from which thirty-eight surgeries were considered in the study. With the use of mean, standard deviation and ANOVA test we found three reliable metrics which we can use to differentiate the skill levels during live surgeries.
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Bamber JR, Stephens TJ, Cromwell DA, Duncan E, Martin GP, Quiney NF, Abercrombie JF, Beckingham IJ. Effectiveness of a quality improvement collaborative in reducing time to surgery for patients requiring emergency cholecystectomy. BJS Open 2019; 3:802-811. [PMID: 31832587 PMCID: PMC6887703 DOI: 10.1002/bjs5.50221] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 08/01/2019] [Indexed: 12/21/2022] Open
Abstract
Background Acute gallstone disease is a high-volume emergency general surgery presentation with wide variations in the quality of care provided across the UK. This controlled cohort evaluation assessed whether participation in a quality improvement collaborative approach reduced time to surgery for patients with acute gallstone disease to fewer than 8 days from presentation, in line with national guidance. Methods Patients admitted to hospital with acute biliary conditions in England and Wales between 1 April 2014 and 31 December 2017 were identified from Hospital Episode Statistics data. Time series of quarterly activity were produced for the Cholecystectomy Quality Improvement Collaborative (Chole-QuIC) and all other acute National Health Service hospitals (control group). A negative binomial regression model was used to compare the proportion of patients having surgery within 8 days in the baseline and intervention periods. Results Of 13 sites invited to join Chole-QuIC, 12 participated throughout the collaborative, which ran from October 2016 to January 2018. Of 7944 admissions, 1160 patients had a cholecystectomy within 8 days of admission, a significant improvement (P < 0·050) from baseline performance. This represented a relative change of 1·56 (95 per cent c.i. 1·38 to 1·75), compared with 1·08 for the control group. At the individual site level, eight of the 12 Chole-QuIC sites showed a significant improvement (P < 0·050), with four sites increasing their 8-day surgery rate to over 20 per cent of all emergency admissions, well above the mean of 15·3 per cent for control hospitals. Conclusion A surgeon-led quality improvement collaborative approach improved care for patients requiring emergency cholecystectomy.
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Affiliation(s)
- J. R. Bamber
- Practicality ConsultingQueen Mary University of LondonLondonUK
| | - T. J. Stephens
- William Harvey Research InstituteQueen Mary University of LondonLondonUK
| | - D. A. Cromwell
- Department of Health Services Research and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | - E. Duncan
- Department of Professional StandardsRoyal College of Surgeons of EnglandLondonUK
| | - G. P. Martin
- The Healthcare Improvement Studies (THIS) InstituteUniversity of CambridgeCambridgeUK
| | - N. F. Quiney
- Department of AnaesthesiaRoyal Surrey County HospitalGuildfordUK
| | | | - I. J. Beckingham
- Hepatobiliary and Pancreatic SurgeryQueen's Medical CentreNottinghamUK
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Erridge S, Payne CJ, Sodergren M. Novel clip applicator for minimally invasive surgery. Surg Endosc 2019; 33:2710-2718. [PMID: 31227900 PMCID: PMC6647405 DOI: 10.1007/s00464-019-06860-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 05/18/2019] [Indexed: 11/30/2022]
Abstract
Background Ligation clips are used ubiquitously throughout minimally invasive surgery for apposition of tissues. Their size limits their application beyond ligation of small tubular structures. A novel clip and clip applicator that allows for broad-area clamping and rotation has been developed by our team. The primary aim of this study is to provide preliminary data assessing tensile strength of the clip across apposed segments of bowel. Methods A comparative study evaluating the maximum load (N) held across two apposed tissues by (a) our novel broad-area clip and (b) a conventional commercial clip was performed. Two sections of porcine bowel were clamped together and the maximum load (N) was measured using a tensile strength material testing machine. A preliminary experiment comparing staple line leak pressures in a porcine model ± clip enforcement of staple line was also conducted. p < 0.05 determined statistical significance. Results Twenty-four samples (intervention = 15; control = 9) of porcine bowel annealed by surgical clips were tested. The mean maximum force withheld by the bowel and staples was greater for our novel clip design (2.043 ± 0.831 N) than the control clip (1.080 ± 0.466 N, p = 0.004). Ten staple line (intervention = 5; control = 5) pressures of porcine bowel were measured. There was no statistically significant difference between the leak pressures with clip reinforcement (84.8 mmHg; range 71.8–109.8 mmHg), or without (54.1 mmHg; range 26.3–98.9 mmHg). Conclusion These preliminary results suggest that our novel clip is able to withstand higher tensile force across tissues compared to a leading commercial clip. A small preliminary trial of effect on leak pressures demonstrated no statistical significance; however, increasing reliability of staple line deformation may be a clinically important finding. Whilst further iteration of product design and clinical testing is required, this product may occupy an important clinical niche through staple line reinforcement, enterotomy closure and other applications.
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Affiliation(s)
- Simon Erridge
- Department of Surgery & Cancer, Imperial College London, London, UK
| | - Christopher J Payne
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, USA
| | - Mikael Sodergren
- Academic Surgical Unit, Division of Surgery, Department of Surgery & Cancer, Imperial College London, 10th Floor QEQM, St Mary's Hospital, South Wharf Road, London, W2 1NY, UK.
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25
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Luciano MP, Namgoong JM, Nani RR, Nam SH, Lee C, Shin IH, Schnermann MJ, Cha J. A Biliary Tract-Specific Near-Infrared Fluorescent Dye for Image-Guided Hepatobiliary Surgery. Mol Pharm 2019; 16:3253-3260. [PMID: 31244218 DOI: 10.1021/acs.molpharmaceut.9b00453] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Despite advances, visual inspection, palpation, and intraoperative ultrasound remain the most utilized tools during surgery today. A particularly challenging issue is the identification of the biliary system due to its complex architecture partially embedded within the liver. Fluorescence guided surgical interventions, particularly using near-infrared (NIR) wavelengths, are an emerging approach for the real-time assessment of the hepatobiliary system. However, existing fluorophores, such as the FDA-approved indocyanine green (ICG), have significant limitations for rapid and selective visualization of bile duct anatomy. Here we report a novel NIR fluorophore, BL (Bile Label)-760, which is exclusively metabolized by the liver providing high signal in the biliary system shortly after intravenous administration. This molecule was identified by first screening a small set of known heptamethine cyanines including clinically utilized agents. After finding that none of these were well-suited, we then designed and tested a small series of novel dyes within a prescribed polarity range. We validated the molecule that emerged from these efforts, BL-760, through animal studies using both rodent and swine models employing a clinically applicable imaging system. In contrast to ICG, BL-760 fluorescence revealed a high target-to-background ratio (TBR) of the cystic duct relative to liver parenchyma 5 min after intravenous injection. During hepatic resection surgery, intrahepatic ducts were clearly highlighted, and bile leakage was easily detected. In conclusion, BL-760 has highly promising properties for intraoperative navigation during hepatobiliary surgery.
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Affiliation(s)
- Michael P Luciano
- Chemical Biology Laboratory, Center for Cancer Research , National Cancer Institute , 376 Boyles Street , Frederick , Maryland 21702 , United States
| | - Jung-Man Namgoong
- Sheikh Zayed Institute for Pediatric Surgical Innovation , Children's National Health System , 111 Michigan Avenue Northwest , Washington , D.C. 20010 , United States.,Department of Surgery , University of Ulsan College of Medicine , Asan Medical Center, 88 Olympic-ro, 43-gil , Songpa-gu, Seoul 138-736 , South Korea
| | - Roger R Nani
- Chemical Biology Laboratory, Center for Cancer Research , National Cancer Institute , 376 Boyles Street , Frederick , Maryland 21702 , United States
| | - So-Hyun Nam
- Sheikh Zayed Institute for Pediatric Surgical Innovation , Children's National Health System , 111 Michigan Avenue Northwest , Washington , D.C. 20010 , United States.,Department of Surgery , Dong-A University College of Medicine , 26 Daesingongwon-Ro , Seo-Gu, Busan 49201 , South Korea
| | - Choonghee Lee
- InTheSmart Co , Center for Medical Innovation Bld , 71 Daehak-ro , Jongro-gu, Seoul , South Korea
| | - Il Hyung Shin
- InTheSmart Co , Center for Medical Innovation Bld , 71 Daehak-ro , Jongro-gu, Seoul , South Korea
| | - Martin J Schnermann
- Chemical Biology Laboratory, Center for Cancer Research , National Cancer Institute , 376 Boyles Street , Frederick , Maryland 21702 , United States
| | - Jaepyeong Cha
- Chemical Biology Laboratory, Center for Cancer Research , National Cancer Institute , 376 Boyles Street , Frederick , Maryland 21702 , United States.,Department of Pediatrics , George Washington University School of Medicine and Health Sciences , 2300 Eye Street Northwest , Washington , D.C. 20052 , United States
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Chaouch MA, Jerraya H, Dougaz MW, Nouira R, Dziri C. A Systematic Review of Laparoscopic Cholecystectomy in Situs Inversus. J INVEST SURG 2019; 34:324-333. [DOI: 10.1080/08941939.2019.1622822] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
| | - Hichem Jerraya
- Department of General Surgery B, Charles Nicolle Hospital, Tunis, Tunisia
| | | | - Ramzi Nouira
- Department of General Surgery B, Charles Nicolle Hospital, Tunis, Tunisia
| | - Chadli Dziri
- Department of General Surgery B, Charles Nicolle Hospital, Tunis, Tunisia
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Laparoscopic cholecystectomy with infundibulum cystic artery first technique: A record-based case series. INTERNATIONAL JOURNAL OF SURGERY OPEN 2019. [DOI: 10.1016/j.ijso.2019.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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28
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Safe laparoscopic cholecystectomy: A systematic review of bile duct injury prevention. Int J Surg 2018; 60:164-172. [PMID: 30439536 DOI: 10.1016/j.ijsu.2018.11.006] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 10/14/2018] [Accepted: 11/04/2018] [Indexed: 12/13/2022]
Abstract
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.
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Zarin M, Khan MA, Khan MA, Shah SAM. Critical view of safety faster and safer technique during laparoscopic cholecystectomy? Pak J Med Sci 2018; 34:574-577. [PMID: 30034418 PMCID: PMC6041509 DOI: 10.12669/pjms.343.14309] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objective: Incidence of Bile Duct Injuries (BDI) during Laparoscopic Cholecystectomy (LC) is reported to be higher as compared to Open Cholecystectomy. Studies have shown varying degree of success in reducing BDI by using Critical View of Safety (CVS) technique before clipping and cutting any structure. In this study, we will see whether CVS technique is faster and safer compared to conventional infundibular technique. Methods: This comparative study was conducted on patients who presented to Surgical Out-Patient-Department (OPD) of Khyber Teaching Hospital from July 2015 to June 2016. Total of 438 patients were divided into two groups. Group-A in which LC was done using infundibular while in Group-B, CVS technique was utilized. Two groups were compared for operating time and BDI. Results: The operative time was significantly reduced for LC using CVS technique (50 mins vs. 73 mins). Minor leaks were comparable (0.5% vs. 0.9%) but there was a significant difference in major LEAKS between the two techniques (0.5% vs. 1.4%). Conclusion: Although the “critical view of safety” requires more dissection as compared to infundibular technique, but once learnt and mastered, it is faster and safer identification technique during laparoscopic cholecystectomy.
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Affiliation(s)
- Mohammad Zarin
- Mohammad Zarin, FCPS. Department of Surgery, MTI, Khyber Teaching Hospital, Peshawar, Pakistan
| | - Muhammad Asim Khan
- Muhammad Asim Khan, MBBS. Department of Surgery, MTI, Khyber Teaching Hospital, Peshawar, Pakistan
| | - Maryam Alam Khan
- Maryam Alam Khan, FCPS. Queen Elizabeth Hospital, Birmingham, UK
| | - Syed Asad Maroof Shah
- Syed Asad Maroof Shah, FCPS. Department of Surgery, MTI, Khyber Teaching Hospital, Peshawar, Pakistan
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30
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Giménez ME, Houghton EJ, Zeledón ME, Palermo M, Acquafresca P, Finger C, Serra E. THE CRITICAL VIEW OF SAFETY PREVENTS THE APPEARANCE OF BILIARY INJURIES? ANALYSIS OF A SURVEY. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2018; 31:e1380. [PMID: 29972408 PMCID: PMC6044193 DOI: 10.1590/0102-672020180001e1380] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 03/22/2018] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
| | - Eduardo Javier Houghton
- Mini-Invasive Surgery, Hospital Bernardino Rivadavia, University of Buenos Aires, Staff DAICIM Foundation
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31
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Alius C, Oprescu S, Balalau C, Nica AE. Indocyanine green enhanced surgery; principle, clinical applications and future research directions. JOURNAL OF CLINICAL AND INVESTIGATIVE SURGERY 2018. [DOI: 10.25083/2559.5555/31.18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Over the past decade a new emergent technology has become very popular in all fields of surgery using Indocyanine green and near infrared fluorescent optical systems. This revolutionary approach overlaps conventional and near infrared images to produce highly informative intraoperative images on the anatomy and physiology of various tissues. Near infrared fluorescence is employed for perioperative angiography in vascular mapping, assessment of anastomoses, location of sentinel lymph nodes and delineation of biliary tree anatomy, highlighting tumours and metastatic deposits, improving surgical techniques and for many other uses. A lot of researchers have reported better surgical outcomes and technique innovations facilitated by this novel technology which although in its early stages, it lights up great interest worldwide. This article reviews the principle of the method, the properties of the fluorescent dye, the main clinical applications and discusses future research directions.
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32
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Assessment of lateral to medial dissection of Calot’s triangle in laparoscopic cholecystectomy: A case-control study. JOURNAL OF SURGERY AND MEDICINE 2018. [DOI: 10.28982/josam.388093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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33
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Rajnish K, Sureshkumar S, Ali MS, Vijayakumar C, Sudharsanan S, Palanivel C. Harmonic Scalpel-Assisted Laparoscopic Cholecystectomy vs. Conventional Laparoscopic Cholecystectomy - A Non-randomized Control Trial. Cureus 2018; 10:e2084. [PMID: 29560297 PMCID: PMC5856421 DOI: 10.7759/cureus.2084] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Introduction Laparoscopic cholecystectomy (LC) is the most commonly done, minimally invasive surgical procedure. Routinely used electrocautery produces more smoke, which masks the operating field, thereby prolongs the surgery and posing an increased risk of gallbladder (GB) perforation. The titanium clips used for clipping the cystic artery and cystic duct have a risk of slippage, which may lead to bleeding, and an increased risk for bile leakage. In addition, it may act as a nidus for stone formation. Advanced energy sources, such as the harmonic scalpel, though expensive, may provide the advantage of shorter operating time by reducing smoke, bloodless dissection in the GB bed, lower risk of bleeding from the cystic artery due to secure vessel sealing, and avoiding the use of a larger number of titanium clips. However, evidence to substantiate this advantage is limited. Aim To compare the operating time and perioperative complications between conventional laparoscopic cholecystectomy (CLC) and harmonic scalpel assisted laparoscopic cholecystectomy (HLC). Methodology All consecutive patients who underwent elective LC were included. Patients with acute infection, impaired liver function tests, concomitant common bile duct calculi, chronic liver disease/cirrhosis, suspected GB carcinoma, and pregnant women were excluded from the study. Patients were allocated into two groups. In the CLC group, both the cystic duct and the cystic artery were divided after conventional titanium clip application and electrocautery was used for thermal energy. In the HLC group, the cystic duct was clipped with a titanium clip and the rest of the procedure was carried out using Harmonic Ace (Ethicon, New Jersey, United States) and Harmonic Hook (Ethicon, New Jersey, United States). Outcome parameters analyzed were operating time in minutes, post-operative pain using visual analogue scale (VAS) scoring, frequency and route of analgesic requirement after 24 hours, and intraoperative complications, including bleeding, bile duct injury, GB perforation, and surgical site infection (SSI) in the postoperative period, per the Centers for Disease Control (CDC) criteria. Results Both the groups were comparable with respect to age, gender, body mass index (BMI), and the presence of comorbidity and an indication of cholecystectomy. The duration of surgery did not significantly differ between the groups (67.3 vs. 64.3 mins; p = 0.30). Other parameters, such as analgesic required on postoperative Day 1 (3.2 vs. 3; p = 0.67), VAS scores on Day 0 (4.55 vs. 4.65; p = 0.59), VAS scores on Day 1 (2.3 vs. 2.2; p = 0.84), superficial SSI (15% vs. 10%; p = 0.63), intraoperative GB perforation (30% vs. 20%; p = 0.71), and intraperitoneal drain (30% vs. 20%; p = 0.71) did not significantly differ between the groups. Conclusion HLC has no significant advantage over CLC with respect to operating time, postoperative pain, and perioperative complications.
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Affiliation(s)
- Kumar Rajnish
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Sathasivam Sureshkumar
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | | | - Chellappa Vijayakumar
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Sundaramurthi Sudharsanan
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Chinnakali Palanivel
- Preventive Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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Wakabayashi G, Iwashita Y, Hibi T, Takada T, Strasberg SM, Asbun HJ, Endo I, Umezawa A, Asai K, Suzuki K, Mori Y, Okamoto K, Pitt HA, Han HS, Hwang TL, Yoon YS, Yoon DS, Choi IS, Huang WSW, Giménez ME, Garden OJ, Gouma DJ, Belli G, Dervenis C, Jagannath P, Chan ACW, Lau WY, Liu KH, Su CH, Misawa T, Nakamura M, Horiguchi A, Tagaya N, Fujioka S, Higuchi R, Shikata S, Noguchi Y, Ukai T, Yokoe M, Cherqui D, Honda G, Sugioka A, de Santibañes E, Supe AN, Tokumura H, Kimura T, Yoshida M, Mayumi T, Kitano S, Inomata M, Hirata K, Sumiyama Y, Inui K, Yamamoto M. Tokyo Guidelines 2018: surgical management of acute cholecystitis: safe steps in laparoscopic cholecystectomy for acute cholecystitis (with videos). JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2018; 25:73-86. [PMID: 29095575 DOI: 10.1002/jhbp.517] [Citation(s) in RCA: 239] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In some cases, laparoscopic cholecystectomy (LC) may be difficult to perform in patients with acute cholecystitis (AC) with severe inflammation and fibrosis. The Tokyo Guidelines 2018 (TG18) expand the indications for LC under difficult conditions for each level of severity of AC. As a result of expanding the indications for LC to treat AC, it is absolutely necessary to avoid any increase in bile duct injury (BDI), particularly vasculo-biliary injury (VBI), which is known to occur at a certain rate in LC. Since the Tokyo Guidelines 2013 (TG13), an attempt has been made to assess intraoperative findings as objective indicators of surgical difficulty; based on expert consensus on these difficulty indicators, bail-out procedures (including conversion to open cholecystectomy) have been indicated for cases in which LC for AC is difficult to perform. A bail-out procedure should be chosen if, when the Calot's triangle is appropriately retracted and used as a landmark, a critical view of safety (CVS) cannot be achieved because of the presence of nondissectable scarring or severe fibrosis. We propose standardized safe steps for LC to treat AC. To achieve a CVS, it is vital to dissect at a location above (on the ventral side of) the imaginary line connecting the base of the left medial section (Segment 4) and the roof of Rouvière's sulcus and to fulfill the three criteria of CVS before dividing any structures. Achieving a CVS prevents the misidentification of the cystic duct and the common bile duct, which are most commonly confused. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.
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Affiliation(s)
- Go Wakabayashi
- Department of Surgery, Ageo Central General Hospital, Saitama, Japan
| | - Yukio Iwashita
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Taizo Hibi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Tadahiro Takada
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Steven M Strasberg
- Section of Hepato-Pancreato-Biliary Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Horacio J Asbun
- Department of Surgery, Mayo Clinic College of Medicine, Jacksonville, FL, USA
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Kanagawa, Japan
| | - Akiko Umezawa
- Minimally Invasive Surgery Center, Yotsuya Medical Cube, Tokyo, Japan
| | - Koji Asai
- Department of Surgery, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Kenji Suzuki
- Department of Surgery, Fujinomiya City General Hospital, Shizuoka, Japan
| | - Yasuhisa Mori
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Fukuoka, Japan
| | - Henry A Pitt
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Ho-Seong Han
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Tsann-Long Hwang
- Division of General Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Dong-Sup Yoon
- Department of Surgery, Yonsei University Gangnam Severance Hospital, Seoul, Korea
| | - In-Seok Choi
- Department of Surgery, Konyang University Hospital, Daejeon, Korea
| | | | - Mariano Eduardo Giménez
- Chair of General Surgery and Minimal Invasive Surgery "Taquini" University of Buenos Aires, DAICIM Foundation, Buenos Aires, Argentina
| | - O James Garden
- Clinical Surgery, University of Edinburgh, Edinburgh, UK
| | - Dirk J Gouma
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Giulio Belli
- Department of General and HPB Surgery, Loreto Nuovo Hospital, Naples, Italy
| | | | - Palepu Jagannath
- Department of Surgical Oncology, Lilavati Hospital and Research Centre, Mumbai, India
| | - Angus C W Chan
- Department of Surgery, Surgery Centre, Hong Kong Sanatorium and Hospital, Hong Kong
| | - Wan Yee Lau
- Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Keng-Hao Liu
- Division of General Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Cheng-Hsi Su
- Department of Surgery, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Takeyuki Misawa
- Department of Surgery, The Jikei University Kashiwa Hospital, Chiba, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akihiko Horiguchi
- Department of Gastroenterological Surgery, Fujita Health University School of Medicine, Aichi, Japan
| | - Nobumi Tagaya
- Department of Surgery, Dokkyo Medical University Koshigaya Hospital, Saitma, Japan
| | - Shuichi Fujioka
- Department of Surgery, The Jikei University Kashiwa Hospital, Chiba, Japan
| | - Ryota Higuchi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | | | - Yoshinori Noguchi
- Department of General Internal Medicine, Japanese Red Cross Nagoya Daini Hospital, Aichi, Japan
| | - Tomohiko Ukai
- Department of Family Medicine, Mie Prefectural Ichishi Hospital, Mie, Japan
| | - Masamichi Yokoe
- Department of General Internal Medicine, Japanese Red Cross Nagoya Daini Hospital, Aichi, Japan
| | - Daniel Cherqui
- Hepatobiliary Center, Paul Brousse Hospital, Villejuif, France
| | - Goro Honda
- Department of Surgery, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Atsushi Sugioka
- Department of Surgery, Fujita Health University School of Medicine, Aichi, Japan
| | - Eduardo de Santibañes
- Department of Surgery, Hospital Italiano, University of Buenos Aires, Buenos Aires, Argentina
| | - Avinash Nivritti Supe
- Department of Surgical Gastroenterology, Seth G S Medical College and K E M Hospital, Mumbai, India
| | | | - Taizo Kimura
- Department of Surgery, Fujinomiya City General Hospital, Shizuoka, Japan
| | - Masahiro Yoshida
- Department of Hemodialysis and Surgery, Ichikawa Hospital, International University of Health and Welfare, Chiba, Japan.,Department of EBM and Guidelines, Japan Council for Quality Health Care, Tokyo, Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine University of Occupational and Environmental Health, Fukuoka, Japan
| | | | - Masafumi Inomata
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Koichi Hirata
- Department of Surgery, JR Sapporo Hospital, Hokkaido, Japan
| | | | - Kazuo Inui
- Department of Gastroenterology, Second Teaching Hospital, Fujita Health University, Aichi, Japan
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Retroinfundibular laparoscopic cholecystectomy versus standard laparoscopic cholecystectomy in difficult cases. Int J Surg 2017; 43:75-80. [PMID: 28552812 DOI: 10.1016/j.ijsu.2017.05.044] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Revised: 05/12/2017] [Accepted: 05/21/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Laparoscopic cholecystectomy becomes the gold standard surgical procedure for treating gallstones. Standard laparoscopic cholecystectomy (SLC) requires proper dissection of Calot's triangle to achieve the critical view of safety. This may be difficult in certain conditions, resulting in higher incidence of bile duct injury and conversion to open. We aimed to compare the outcomes of laparoscopic cholecystectomy by retroinfundibular (RI) approach to that of SLC, in difficult cases. PATIENTS AND METHODS This study is prospective cohort study, in which 60 patients were operated by SLC and 65 patients by laparoscopic cholecystectomy by RI approach. RESULTS From the total 125 cases, 95 (76%) patients were male and 30 (24%) were female. The mean age was 59.5 ± 5.5 years. The mean operative time in SLC group was 128 ± 17 min VS. 114 ± 10 min in RI group. Conversion to open occurred in 10% in SLC group VS. 1.5% in RI group. Biliary injury occurred in 3.3% in SLC group VS. 0% in RI group. The mean hospital stay in SLC was 3.7 ± 5.3 days VS. 2.1 ± 0.3 days in RI group. CONCLUSION In difficult cholecystectomy, RI approach is feasible and safe alternative to SLC.
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Boogerd LSF, Handgraaf HJM, Huurman VAL, Lam HD, Mieog JSD, van der Made WJ, van de Velde CJH, Vahrmeijer AL. The Best Approach for Laparoscopic Fluorescence Cholangiography: Overview of the Literature and Optimization of Dose and Dosing Time. Surg Innov 2017; 24:386-396. [PMID: 28457194 PMCID: PMC5505227 DOI: 10.1177/1553350617702311] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Fluorescence cholangiography using indocyanine green (ICG) can enhance orientation of bile duct anatomy during laparoscopic cholecystectomy. To ensure clear discrimination between bile ducts and liver, the fluorescence ratio between both should be sufficient. This ratio is influenced by the ICG dose and timing of fluorescence imaging. We first systematically identified all strategies for fluorescence cholangiography. Second, we aimed to optimize the dose of ICG and dosing time in a prospective clinical trial. METHODS PubMed was searched for clinical trials studying fluorescence cholangiography. Furthermore, 28 patients planned to undergo laparoscopic cholecystectomy were divided into 7 groups, receiving different intravenous doses (5 or 10 mg ICG) at different time points (0.5, 2, 4, 6, or 24 hours prior to surgery). RESULTS The systematic review revealed 27 trials including 1057 patients. The majority of studies used 2.5 mg administered within 1 hour before imaging. Imaging 3 to 24 hours after ICG administration was never studied. The clinical trial demonstrated that the highest bile duct-to-liver ratio was achieved 3 to 7 hours after administration of 5 mg and 5 to 25 hours after administration of 10 mg ICG. Up to 3 hours after administration of 5 mg and up to 5 hours after administration of 10 mg ICG, the liver was equally or more fluorescent than the cystic duct, resulting in a ratio ≤1.0. CONCLUSION This study shows for the first time that the interval between ICG administration and intraoperative fluorescence cholangiography should be extended. Administering 5 mg ICG at least 3 hours before imaging is easy to implement in everyday clinical practice and results in bile duct-to-liver ratios >1.0.
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Affiliation(s)
| | | | | | - Hwai-Ding Lam
- 1 Leiden University Medical Center, Leiden, Netherlands
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Kaya B, Fersahoglu MM, Kilic F, Onur E, Memisoglu K. Importance of critical view of safety in laparoscopic cholecystectomy: a survey of 120 serial patients, with no incidence of complications. Ann Hepatobiliary Pancreat Surg 2017; 21:17-20. [PMID: 28317041 PMCID: PMC5353907 DOI: 10.14701/ahbps.2017.21.1.17] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 08/21/2016] [Accepted: 09/26/2016] [Indexed: 01/05/2023] Open
Abstract
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.
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Affiliation(s)
- Bulent Kaya
- Department of General Surgery, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Mahir Fersahoglu
- Department of General Surgery, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Fatih Kilic
- Department of General Surgery, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Ender Onur
- Department of General Surgery, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Kemal Memisoglu
- Department of General Surgery, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
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van den Bos J, Schols RM, Luyer MD, van Dam RM, Vahrmeijer AL, Meijerink WJ, Gobardhan PD, van Dam GM, Bouvy ND, Stassen LPS. Near-infrared fluorescence cholangiography assisted laparoscopic cholecystectomy versus conventional laparoscopic cholecystectomy (FALCON trial): study protocol for a multicentre randomised controlled trial. BMJ Open 2016; 6:e011668. [PMID: 27566635 PMCID: PMC5013353 DOI: 10.1136/bmjopen-2016-011668] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Misidentification of the extrahepatic bile duct anatomy during laparoscopic cholecystectomy (LC) is the main cause of bile duct injury. Easier intraoperative recognition of the biliary anatomy may be accomplished by using near-infrared fluorescence (NIRF) imaging after an intravenous injection of indocyanine green (ICG). Promising results were reported for successful intraoperative identification of the extrahepatic bile ducts compared to conventional laparoscopic imaging. However, routine use of ICG fluorescence laparoscopy has not gained wide clinical acceptance yet due to a lack of high-quality clinical data. Therefore, this multicentre randomised clinical study was designed to assess the potential added value of the NIRF imaging technique during LC. METHODS AND ANALYSIS A multicentre, randomised controlled clinical trial will be carried out to assess the use of NIRF imaging in LC. In total, 308 patients scheduled for an elective LC will be included. These patients will be randomised into a NIRF imaging laparoscopic cholecystectomy (NIRF-LC) group and a conventional laparoscopic cholecystectomy (CLC) group. The primary end point is time to 'critical view of safety' (CVS). Secondary end points are 'time to identification of the cystic duct (CD), of the common bile duct, the transition of CD in the gallbladder and the transition of the cystic artery in the gallbladder, these all during dissection of CVS'; 'total surgical time'; 'intraoperative bile leakage from the gallbladder or cystic duct'; 'bile duct injury'; 'postoperative length of stay', 'complications due to the injected ICG'; 'conversion to open cholecystectomy'; 'postoperative complications (until 90 days postoperatively)' and 'cost-minimisation'. ETHICS AND DISSEMINATION The protocol has been approved by the Medical Ethical Committee of Maastricht University Medical Center/Maastricht University; the trial has been registered at ClinicalTrials.gov. The findings of this study will be disseminated widely through peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER NCT02558556.
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Affiliation(s)
- Jacqueline van den Bos
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Rutger M Schols
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Misha D Luyer
- Department of Surgery, Catharina Ziekenhuis, Eindhoven, The Netherlands
| | - Ronald M van Dam
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | | | | | - Gooitzen M van Dam
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Nicole D Bouvy
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Laurents P S Stassen
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
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Increasing resident utilization and recognition of the critical view of safety during laparoscopic cholecystectomy: a pilot study from an academic medical center. Surg Endosc 2016; 31:1627-1635. [PMID: 27495348 DOI: 10.1007/s00464-016-5150-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 07/21/2016] [Indexed: 12/25/2022]
Abstract
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.
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How often do surgeons obtain the critical view of safety during laparoscopic cholecystectomy? Surg Endosc 2016; 31:142-146. [PMID: 27142437 DOI: 10.1007/s00464-016-4943-5] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 04/15/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND The reported incidence (0.16-1.5 %) of bile duct injury (BDI) during laparoscopic cholecystectomy (LC) is higher than during open cholecystectomy and has not decreased over time despite increasing experience with the procedure. The "critical view of safety" (CVS) technique may help to prevent BDI when certain criteria are met prior to division of any structures. This study aimed to evaluate the adherence of practicing surgeons to the CVS criteria during LC and the impact of a training intervention on CVS identification. METHODS LC procedures of general surgeons were video-recorded. De-identified recordings were reviewed by a blinded observer and rated on a 6-point scale using the previously published CVS criteria. A coaching program was conducted, and participating surgeons were re-assessed in the same manner. RESULTS The observer assessed ten LC videos, each involving a different surgeon. The CVS was adequately achieved by two surgeons (20 %). The remaining eight surgeons (80 %) did not obtain adequate CVS prior to division of any structures, despite two surgeons dictating that they did; the mean score of this group was 1.75. After training, five participating surgeons (50 %) scored > 4, and the mean increased from 1.75 (baseline) to 3.75 (p < 0.05). CONCLUSIONS The CVS criteria were not routinely used by the majority of participating surgeons. Further, one-fourth of those who claimed to obtain the CVS did so inadequately. All surgeons who participated in training showed improvement during their post-assessment. Our findings suggest that education of practicing surgeons in the application of the CVS during LC can result in increased implementation and quality of the CVS. Pending studies with larger samples, our findings may partly explain the sustained BDI incidence despite increased experience with LC. Our study also supports the value of direct observation of surgical practices and subsequent training for quality improvement.
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Open-access technique and "critical view of safety" as the safest way to perform laparoscopic cholecystectomy. Surg Laparosc Endosc Percutan Tech 2016; 25:119-24. [PMID: 24752164 DOI: 10.1097/sle.0000000000000055] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
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.
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Lee JH, Han G, Kim YJ, Jung MS, Choi D. A Technique for Simultaneous Cholecystectomy During Bariatric Surgery. JSLS 2015; 19:JSLS.2015.00072. [PMID: 26648677 PMCID: PMC4653580 DOI: 10.4293/jsls.2015.00072] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background and Objectives: Cholecystectomy performed during bariatric surgery is technically demanding. Herein is described a technique we term the Glissonian approach along with an evaluation of its effectiveness and safety. Methods: From April 1, 2009, through February 28, 2014, laparoscopic cholecystectomy was performed during laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) in 38 patients with proven cholecystopathy on diagnostic imaging. Perioperative outcomes were compared between the patients operated on with the Glissonian approach and those who underwent conventional laparoscopic cholecystectomy. Results: The Glissonian approach was adopted in 13 patients—11 during LRYGB and 2 during LSG—and the conventional operation was performed on 16 patients during LRYGB and 9 during LSG. Mean body mass indexes were 40.1 kg/m2 in the Glissonian-approach group and 37.6 kg/m2 in the conventional group. Laparoscopic cholecystectomy by the Glissonian approach saved a mean operative time of 7 minutes compared with the operative time of the conventional operation. No surgical complications related to cholecystectomy were noted in either group. Conclusion: This simple technique can be performed safely in morbidly obese patients, with low resultant morbidity and acceptable operation times.
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Affiliation(s)
- Ju-Hee Lee
- Department of Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - Guru Han
- Department of Surgery, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Yong Jin Kim
- Department of Surgery, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Min-Sung Jung
- Department of Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - Dongho Choi
- Department of Surgery, Hanyang University College of Medicine, Seoul, Korea
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Agresta F, Campanile FC, Vettoretto N, Silecchia G, Bergamini C, Maida P, Lombari P, Narilli P, Marchi D, Carrara A, Esposito MG, Fiume S, Miranda G, Barlera S, Davoli M. Laparoscopic cholecystectomy: consensus conference-based guidelines. Langenbecks Arch Surg 2015; 400:429-53. [PMID: 25850631 DOI: 10.1007/s00423-015-1300-4] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 03/24/2015] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Ferdinando Agresta
- Department of Surgery, Presidio Ospedaliero di Adria (RO), Adria, RO, Italy,
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Kaczynski J, Hilton J. A gallbladder with the "hidden cystic duct": A brief overview of various surgical techniques of the Calot's triangle dissection. Interv Med Appl Sci 2015; 7:42-5. [PMID: 25838927 DOI: 10.1556/imas.7.2015.1.4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 11/24/2014] [Accepted: 12/08/2014] [Indexed: 01/05/2023] Open
Abstract
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.
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Affiliation(s)
- Jakub Kaczynski
- ABM University Health Board, Department of Vascular Surgery, Morriston Hospital Swansea United Kingdom
| | - Joanna Hilton
- ABM University Health Board, Department of Vascular Surgery, Morriston Hospital Swansea United Kingdom
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Ferzli G, Timoney M, Nazir S, Swedler D, Fingerhut A. Importance of the Node of Calot in Gallbladder Neck Dissection: An Important Landmark in the Standardized Approach to the Laparoscopic Cholecystectomy. J Laparoendosc Adv Surg Tech A 2015; 25:28-32. [DOI: 10.1089/lap.2014.0195] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
| | | | | | | | - Abe Fingerhut
- Section of Surgical Research, Department of Surgery, Medical University of Graz, Graz, Austria
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Dziodzio T, Weiss S, Sucher R, Pratschke J, Biebl M. A 'critical view' on a classical pitfall in laparoscopic cholecystectomy! Int J Surg Case Rep 2014; 5:1218-21. [PMID: 25437680 PMCID: PMC4275857 DOI: 10.1016/j.ijscr.2014.11.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 11/07/2014] [Indexed: 12/24/2022] Open
Abstract
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.
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Affiliation(s)
- Tomasz Dziodzio
- Department of General, Visceral and Transplant Surgery, Charité, Berlin, Germany.
| | - Sascha Weiss
- Department of Visceral-, Transplant-, and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - Robert Sucher
- Department of General, Visceral and Transplant Surgery, Charité, Berlin, Germany
| | - Johann Pratschke
- Department of General, Visceral and Transplant Surgery, Charité, Berlin, Germany
| | - Matthias Biebl
- Department of General, Visceral and Transplant Surgery, Charité, Berlin, Germany
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Osayi SN, Wendling MR, Drosdeck JM, Chaudhry UI, Perry KA, Noria SF, Mikami DJ, Needleman BJ, Muscarella P, Abdel-Rasoul M, Renton DB, Melvin WS, Hazey JW, Narula VK. Near-infrared fluorescent cholangiography facilitates identification of biliary anatomy during laparoscopic cholecystectomy. Surg Endosc 2014; 29:368-75. [PMID: 24986018 DOI: 10.1007/s00464-014-3677-5] [Citation(s) in RCA: 101] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 06/09/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND Intraoperative cholangiography (IOC) is the current gold standard for biliary imaging during laparoscopic cholecystectomy (LC). However, utilization of IOC remains low. Near-infrared fluorescence cholangiography (NIRF-C) is a novel, noninvasive method for real-time, intraoperative biliary mapping. Our aims were to assess the safety and efficacy of NIRF-C for identification of biliary anatomy during LC. METHODS Patients were administered indocyanine green (ICG) prior to surgery. NIRF-C was used to identify extrahepatic biliary structures before and after partial and complete dissection of Calot's triangle. Routine IOC was performed in each case. Identification of biliary structures using NIRF-C and IOC, and time required to complete each procedure were collected. RESULTS Eighty-two patients underwent elective LC with NIRF-C and IOC. Mean age and body mass index (BMI) were 42.6 ± 13.7 years and 31.5 ± 8.2 kg/m(2), respectively. ICG was administered 73.8 ± 26.4 min prior to incision. NIRF-C was significantly faster than IOC (1.9 ± 1.7 vs. 11.8 ± 5.3 min, p < 0.001). IOC was unobtainable in 20 (24.4 %) patients while NIRF-C did not visualize biliary structures in 4 (4.9 %) patients. After complete dissection, the rates of visualization of the cystic duct, common bile duct, and common hepatic duct using NIRF-C were 95.1, 76.8, and 69.5 %, respectively, compared to 72.0, 75.6, and 74.3 % for IOC. In 20 patients where IOC could not be obtained, NIRF-C successfully identified biliary structures in 80 % of the cases. Higher BMI was not a deterrent to visualization of anatomy with NIRF-C. No adverse events were observed with NIRF-C. CONCLUSIONS NIRF-C is a safe and effective alternative to IOC for imaging extrahepatic biliary structures during LC. This technique should be evaluated further under a variety of acute and chronic gallbladder inflammatory conditions to determine its usefulness in biliary ductal identification.
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Affiliation(s)
- Sylvester N Osayi
- Division of General and Gastrointestinal Surgery, Center for Minimally Invasive Surgery, The Ohio State University Wexner Medical Center, 558 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
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Routine cholangiography during rigid-hybrid transvaginal natural orifice transluminal endoscopic cholecystectomy. Surg Endosc 2013; 28:910-7. [PMID: 24141474 DOI: 10.1007/s00464-013-3246-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Accepted: 09/04/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Transvaginal rigid-hybrid transluminal endoscopic cholecystectomy (tvCCE) has become a routine procedure in some laparoscopic departments in recent years. Although intraoperative cholangiography is an important adjunct to cholecystectomy, its feasibility and safety in tvCCE have not been demonstrated to date. METHODS Patients undergoing tvCCE between April and October 2012 were included in this study. An intraoperative cholangiogram was obtained routinely for all the patients. Patient characteristics, operation data, feasibility, and duration of the cholangiography as well as the postoperative course were recorded prospectively. RESULTS For 32 (97 %) of the 33 patients enrolled in this study, intraoperative cholangiography could be performed successfully. The median duration of cholangiography was 6 min (interquartile range, 4-7 min). Common bile duct stones were detected in three patients (10 %). Laparoscopic bile duct revision with the aid of one additional port was successful in two of these patients. One patient needed postoperative endoscopic retrograde cholangiopancreatography due to the impossibility of extracting an impacted prepapillary concrement. One operation was converted to a four-port laparoscopic cholecystectomy. One additional port was used in 11 patients (33 %) and two additional ports in three patients (9 %). Three intraoperative minor complications (9 %) and one postoperative minor complication (3 %) occurred. CONCLUSIONS Intraoperative cholangiography during tvCCE is feasible, safe, and easy to perform. The need for intraoperative cholangiography no longer represents a contraindication for tvCCE.
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Zhu A, Yuan C, Piao D, Jiang T, Jiang H. Gravity line strategy may reduce risks of intraoperative injury during laparoscopic surgery. Surg Endosc 2013; 27:4478-84. [PMID: 23892760 DOI: 10.1007/s00464-013-3093-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Accepted: 06/28/2013] [Indexed: 01/05/2023]
Abstract
BACKGROUND "Tilt" of surgical view was commonly shown on the monitor due to unintentional rotation of camera along its long axis by camera driver. Surgeons may be influenced on identification of anatomical structures by the tilt vision. We aimed to analyze the surgical records and videos of laparoscopic surgery, and to reveal the correlation between intraoperative complications and tilt view. METHODS A series of 425 consecutive patients who received laparoscopic low anterior resection and abdominoperineal resection were studied, and 398 surgery videos were reviewed. Still pictures showing intraoperative injury were selected. A method was established to measure tilt angle in the still pictures according to the reference line based on several anatomic landmarks. The patients were grouped with two methods according to different study purposes. Incidence of intraoperative complication and tilt angle were calculated, and statistical analysis was performed. RESULTS The incidence of intraoperative complications was 8.3%. Tilt of the surgical field at different degrees (<15°, 15°-30° and >30°) was found in a relatively high rate in these surgery videos (31.4%). Compared with controls, comparatively bigger tilt angles were found in all cases of complication group. It is interesting to note that intraoperative complications happened more often when the tilt angle was in the range of 15°-30° (72.7%) than >30° (18.2%). We also noted a high incidence of complication (72.7%), while tilt angle was over 15° (26%) in the first 100 cases; comparatively a steady declining low rate of complication occurrence (5-7%) and also tilt angle over 15° (9-11%) were noted in the later 298 cases. CONCLUSIONS Rotation of camera is common during laparoscopic procedures. The tilt view increased the risk of laparoscopic procedures. Tilt angle at 15-30° is the most dangerous rotation for laparoscopic surgeries. Therefore, we propose the "Gravity Line Strategy" principle as one of the basic operating criteria to correct the tilt angle.
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Affiliation(s)
- Anlong Zhu
- Department of General Surgery, First Affiliated Hospital of Harbin Medical University, Harbin, Hei Long Jiang, China,
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When Will Video-assisted and Robotic-assisted Endoscopy Replace Almost All Open Surgeries? J Minim Invasive Gynecol 2012; 19:238-43. [DOI: 10.1016/j.jmig.2011.12.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Accepted: 12/23/2011] [Indexed: 11/19/2022]
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