Laparoscopic partial cholecystectomy: A safe and effective alternative surgical technique in "difficult cholecystectomies"

Laparoscopic Management of Cholecystoduodenal and Cholecystocolic Fistula: A Clinical Case Report

Biliary fistula is a rare (less than 8%) cholecystectomy complication, internal fistulae being the most common of them (mainly colonic and duodenal). However, the presence of two fistulas at the same time is extremely rare, with a small number of cases reported in the literature to date. Symptoms tend to be non-specific, leading to a difficult preoperative diagnosis. The standard treatment for bilioenteric fistulas is open cholecystectomy and subsequent closure of the fistula. Nonetheless, modern techniques including laparoscopic and endoscopic approaches have been reported lately for their treatment with favorable results. We present a case of concomitant cholecystoduodenal and cholecystocolic fistula successfully treated with subtotal cholecystectomy and primary closure of the fistulous tracts by laparoscopic approach in a female Hispanic patient.

Efficacy and Cost-Effectiveness of Laparoscopic Transversus Abdominis Plane (TAP) Block in Laparoscopic Cholecystectomy: A Comparison With the Non-TAP Group

BACKGROUND

Postoperative pain caused by laparoscopic cholecystectomy can be controlled by different methods. The study aimed to observe the efficacy of laparoscopic transversus abdominis plane (TAP) block in laparoscopic cholecystectomy and to analyze the cost-effectiveness of the procedure in comparison to the non-TAP method.

METHODS

 In this double-blinded randomized clinical trial, the subjects who had come for cholecystectomy were randomly divided into two groups (n = 43 in each group). Group A received laparoscopy-guided subcostal TAP block bilaterally (0.25% bupivacaine, 20 ml each) along with parenteral analgesics (100 mg tramadol injection in 100 ml normal saline IV) SOS as rescue analgesia, and group B received parenteral analgesics (injection paracetamol 1 gm IV) eight hourly and injection tramadol 100 mg in 100 ml normal saline IV SOS as rescue analgesia.

RESULT

 A bulge was visualized by the surgeon through a laparoscope as a signature view for confirming the placement of local anesthetic in TAP. Based on the Visual Analog Scale (VAS) for assessment of postoperative pain and the Numeric Rating Scale (NRS) for assessment of pain at 30 minutes, four hours, eight hours, 12 hours, and 24 hours postoperatively, patients of both groups were assessed. According to the VAS, the pain assessment was better in the TAP block group at 30 minutes post-surgery than in the non-TAP group. As a primary outcome, 37% of TAP block group cases were recovered without any rescue analgesia. VAS score revealed a significant difference in postoperative nausea and vomiting (PONV) among the TAP block and non-TAP groups. PONV at four hours, eight hours, and 12 hours showed significantly lesser incidences in the TAP group as compared to the non-TAP group (p-value: 0.015, 0.028, and 0.055, respectively).

CONCLUSION

 The cost-effectiveness of the TAP block method is 20 times lesser than the non-TAP method. Thus, a laparoscopic-guided TAP block could offer better postoperative analgesia at a low cost with a similar advantage to a USG-guided TAP block.

Laparoscopic subtotal reconstituting cholecystectomy in type II & III Mirizzi syndrome: Case series of 5 patients

BACKGROUND

Mirizzi syndrome Type II & III treatment is a true surgical challenge. The purpose was to determine whether the laparoscopic subtotal reconstituting cholecystectomy can be a safe and effective approach in our institution to treat Mirizzi Syndrome type II and III.

CASE PRESENTATION

We report a case series of 5 patients with Mirizzi syndrome type II and III who underwent laparoscopic subtotal reconstituting cholecystectomy.

DISCUSSION

We found only one patient had presurgical diagnosis, average surgical time of 218 min, average surgical bleeding of 230 ml and the mean hospital stay of 3.4 days; one patient presented low volume and auto limited biliary leak; no cases presented biliary injury, major complications, or reintervention.

CONCLUSIONS

Laparoscopic subtotal reconstituting cholecystectomy is a security and effective technique to treat type II and III Mirizzi syndrome in our context.

Subtotal cholecystectomy for difficult acute cholecystitis: how to finalize safely by laparoscopy-a systematic review

Background

Aim of this study was to clarify the best laparoscopic subtotal cholecystectomy (LSTC) technique for finalizing a difficult cholecystectomy.

Patients and methods

A review was performed (1987–2021) searching "difficulty cholecystectomy" AND/OR "subtotal cholecystectomy". The LSTC techniques considered were as follows: type A, leaving posterior wall attached to the liver and the remainder of the gallbladder stump open; type B, like type A but with the stump closed; type C, resection of both the anterior and posterior gallbladder walls and the stump closed; type D, like type C but with the stump open. Morbidity (including mortality) was analysed with Dindo–Clavien classification.

Results

Nineteen articles were included. Of the 13,340 patients screened, 678 (8.2%) had cholecystectomy finalized by LSTC: 346 patients (51.0%) had type A LSTC, 134 patients (19.8%) had type B LSTC, 198 patients (29.2%) had type C LSTC, and 198 patients (0%) had type D LSTC. Bile leakage was found in 83 patients (12.2%), and recorded in 58 patients (69.9%) treated by type A. Twenty-three patients (3.4%) developed a subhepatic collection, 19 of whom (82.6%) were treated by type A. Other complications were reported in 72 patients (10.6%). The Dindo–Clavien classification was four for grade I, 27 for grade II, 126 for grade IIIa, 18 for grade IIIb, zero for grade IV and three for grade V.

Conclusion

In the case of LSTC, closure of the gallbladder stump represents the best method to avoid complications. Careful exploration of the gallbladder stump is mandatory, washing the abdominal cavity and leaving drainage.

Re-interventions and re-admissions in a 13-year series following use of laparoscopic subtotal cholecystectomy

Background:

Laparoscopic subtotal cholecystectomy (LSTC) without cystic duct ligation is an alternative to conversion to open surgery in a difficult cholecystectomy, thus avoiding a potentially hazardous dissection in Calot's triangle. The long-term outcomes of this procedure are not well reported. The aim of this study is to assess the rates of re-presentation, re-admissions, endoscopic interventions and completion cholecystectomy in patients who have undergone LSTC.

Methods:

Details of all patients undergoing cholecystectomy over a 13-year period (2003–2015) were entered on a prospective database. Further information on subsequent hospital attendances, biliary imaging, endoscopic interventions and re-operations following the index LSTC was collected retrospectively from hospital database.

Results:

Overall, 2313 patients underwent laparoscopic cholecystectomy. Eighty-five patients (3.7%) underwent LSTC and the rest had standard laparoscopic cholecystectomy. A controlled bile leak was observed in 16 (19%) patients post-operatively, of which 3 resolved spontaneously. The remaining 13 were managed with an early endoscopic retrograde cholangiopancreatography (ERCP) and biliary stent. Twenty-seven patients (32%), who underwent LSTC, were re-investigated for the upper abdominal symptoms. The time range for re-investigation was 21 days–124 months. Eight patients underwent ERCP post-discharge, for suspected bile duct stones on radiological imaging. Two patients required open completion cholecystectomy for symptomatic stones in the gallbladder remnant.

Conclusion:

LSTC is a feasible and safe alternative to open surgery with acceptable long-term consequences and re-interventions.

Laparoscopic-guided transversus abdominis plane block versus trocar site local anesthetic infiltration in gynecologic laparoscopy

Background

Relieving postoperative pain and prompt resumption of physical activity are of the utmost importance for the patients and surgeons. Infiltration of local anesthetic is frequently used methods of pain control postoperatively. Laparoscopically delivered transversus abdominis plane block is a new modification of ultrasound-guided transversus abdominis plane block.

This study was conducted to compare the efficacy of laparoscopic-guided transversus abdominis plane block with trocar site local anesthetic infiltration for pain control after gynecologic laparoscopy.

Results

No statistically significant difference between the two groups in mean visual analogue scale at 1, 18, and 24 h (P = 0.34, P = 0.41, and P = 0.61, respectively), while the mean visual analogue scale was significantly lower in the laparoscopic-guided transversus abdominis plane block group than in the trocar site local anesthetic infiltration group at 3, 6, and 12 h (P = 0.049, P = 0.011, and P = 0.042, respectively). No statistically significant difference was observed in the cumulative narcotics consumed at 3 h (P = 0.52); however, women with transversus abdominis plane block have consumed significantly less amount of narcotics than women with trocar site infiltration at 6, 12, and 24 h (P = 0.04, P = 0.038, and P = 0.031 respectively). Patient satisfaction was significantly higher in the laparoscopic-guided transversus abdominis plane block group (P = 0.035).

Conclusion

Laparoscopic-guided transversus abdominis plane block is more effective in reduction of both pain scores in the early postoperative period and the cumulative narcotics consumption than trocar site local anesthetic infiltration in gynecologic laparoscopy.

Trial registration

Clinical Trials.gov NCT02973451

Damage-control laparoscopic partial cholecystectomy with an endoscopic linear stapler

OBJECTIVE

Several damage-control procedures have been described in the literature in case of severe Calot's triangle inflammation and fibrosis. In this report, we describe patients who underwent laparoscopic partial cholecystectomy using an endoscopic linear stapler.

MATERIALS AND METHODS

Five patients with acute cholecystitis underwent laparoscopic partial cholecystectomy in our clinic between January - December 2011. All patients had severe fibrosis and inflammation of Calot's triangle. The anterior and posterior walls of the gallbladder were totally resected if possible. The gallbladder was transected at its neck or Hartmann's pouch, leaving a remnant gallbladder pouch behind.

RESULTS

Five patients had laparoscopic partial cholecystectomy with an endoscopic linear stapler. The main symptom of all patients on admission to the emergency room was abdominal pain. The mean time for the surgical procedure was 140 minutes (range, 120-180 minutes). Inflammation and fibrosis of Calot's triangle was detected in all patients during surgery and a phlegmonous gallbladder was detected in one patient. Surgical drains were used in all patients and no biliary leakage was detected. Remnant common bile duct calculi were detected in one patient and this patient underwent endoscopic retrograde cholangiopancreatography one month after surgery.

CONCLUSIONS

When a reliable view of Calot's triangle cannot be obtained due to severe inflammation and fibrosis during laparoscopy, laparoscopic partial cholecystectomy seems to be a safe and feasible alternative to open surgery with an acceptable morbidity rate.

Efficacy of laparoscopic transversus abdominis plane block for elective laparoscopic cholecystectomy in elderly patients

Transversus abdominis plane (TAP) block technique seems to offer one of the most efficient methods for a local pain control. Our aim is to demonstrate the effectiveness and safety of TAP block for post-operative pain control under laparoscopic vision in elderly patients during laparoscopic cholecystectomy. The patients aged more than 65 years old, who had cholecystectomy due to symptomatic cholelithiasis, were retrospectively evaluated. The patients that were operated under general anesthesia + laparoscopic TAP block and those who were operated only under only general anesthesia were compared according to their' age and gender, comorbidities, American Society of Anesthesiologists scores, visual analog scale (VAS) for pain and length of stay in the hospital. Median (±interquartile range) values of post-operative 24th-hour-VAS for pain was found consecutively 2 (±1-3) in TAP block + group and 3 (±2-5) in TAP block - group. The median post-operative 24th-hour-VAS value in overall patients was three. Patients' VAS values were higher in the TAP block - group with a statistically significant difference (p = 0.001). Furthermore, no statistically significant difference was found for other parameters in two groups. The laparoscopic-guided TAP block can easily be performed and has potential for lower visceral injury risk and shorter operational time. Efficacy, safety and other advantages (analgesic requirements, etc.) make it an ideal abdominal field block in elderly patients.

Efficacy of laparoscopic transversus abdominis plane block for elective laparoscopic cholecystectomy in elderly patients

Transversus abdominis plane (TAP) block technique seems to offer one of the most efficient methods for a local pain control. Our aim is to demonstrate the effectiveness and safety of TAP block for post-operative pain control under laparoscopic vision in elderly patients during laparoscopic cholecystectomy. The patients aged more than 65 years old, who had cholecystectomy due to symptomatic cholelithiasis, were retrospectively evaluated. The patients that were operated under general anesthesia + laparoscopic TAP block and those who were operated only under only general anesthesia were compared according to their' age and gender, comorbidities, American Society of Anesthesiologists scores, visual analog scale (VAS) for pain and length of stay in the hospital. Median (±interquartile range) values of post-operative 24th-hour-VAS for pain was found consecutively 2 (±1-3) in TAP block + group and 3 (±2-5) in TAP block - group. The median post-operative 24th-hour-VAS value in overall patients was three. Patients' VAS values were higher in the TAP block - group with a statistically significant difference (p = 0.001). Furthermore, no statistically significant difference was found for other parameters in two groups. The laparoscopic-guided TAP block can easily be performed and has potential for lower visceral injury risk and shorter operational time. Efficacy, safety and other advantages (analgesic requirements, etc.) make it an ideal abdominal field block in elderly patients.