Research on the prognostic value of adjusting intraperitoneal three-dimensional quality evaluation mode in laparoscopic cholecystectomy patients

BACKGROUND

Benign gallbladder diseases have become a high-prevalence condition not only in China but also worldwide. The main types of benign gallbladder diseases include gallbladder polyps, acute and chronic cholecystitis, and gallstones, with gallstones being the most common, accounting for over 70% of cases. Although the mortality rate of benign gallbladder diseases is low, they carry obvious potential risks. Studies have shown that an increased incidence of benign gallbladder diseases can increase the risk of cardiovascular diseases and gallbladder cancer, resulting in a substantial disease burden on patients and their families.

AIM

To assess the medical utility of the Configuration-Procedure-Consequence (CPC) three-dimensional quality evaluation model in modulating the prognosis of laparoscopic cholecystectomy patients.

METHODS

A total of 98 patients who underwent laparoscopic cholecystectomy in our hospital from February 2020 to January 2022 were selected as the subjects. According to the random number table method, they were divided into a study group and a control group, with 49 patients in each group. The control group received routine perioperative care, while the study group had the addition of the CPC three-dimensional quality evaluation. The postoperative recovery-related indicators (time to first flatus, time to oral intake, time to ambulation, hospital stay), stress indicators (cortisol and adrenaline levels), distinctions in anxiety and depression status, and the incidence of perioperative complications were compared.

RESULTS

The time to first flatus, time to oral intake, time to ambulation, and hospital stay of the study group patients were obviously lower than those of the control group patients, with statistical significance (P < 0.05). On the 1st day after admission, there were no obvious distinctions in cortisol and adrenaline levels in blood samples, as well as in the Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS) scores between the study group and the control group (P > 0.05). However, on the 3rd day after surgery, the cortisol and adrenaline levels, as well as SAS and SDS scores of the study group patients, were obviously lower than those of the control group patients (P < 0.05). The study group had 2 cases of incisional infection and 1 case of pulmonary infection, with a total incidence of complications of 6.12% (3/49), which was obviously lower than the 20.41% (10/49) in the control group (P < 0.05).

CONCLUSION

Implementing the CPC three-dimensional quality evaluation model for patients undergoing laparoscopic cholecystectomy can help accelerate their perioperative recovery process, alleviate perioperative stress symptoms, mitigate anxiety, depression, and other adverse emotions, and to some extent, reduce the incidence of perioperative complications.

Complete Common Bile Duct Injury after Laparoscopic Cholecystectomy in Situs Inversus Totalis: A Case Report, Review of the Literature and Illustrative Case Video

INTRODUCTION AND IMPORTANCE

Situs Inversus Totalis (SIT) is a rare condition characterized by the transposition of internal organs. Given the anatomical variations in SIT, surgeons must exercise extreme caution when performing laparoscopic cholecystectomy to avoid iatrogenic bile duct injury. Despite the high difficulty index associated with laparoscopic cholecystectomy in SIT, there is only one case report of common bile duct (CBD) injury in the English-language literature.

CASE PRESENTATION

A 41-year-old female patient, known to have Kartagener syndrome, underwent laparoscopic cholecystectomy for acute cholecystitis and was discharged home on post-operative day one. However, on post-operative day five, the patient presented to the emergency room with abdominal pain, fever, and jaundice. Laboratory tests revealed leukocytosis and hyperbilirubinemia. Radiological images revealed complete occlusion of the CBD. A delayed approach was chosen, and six weeks after her initial operation, a hepaticojejunostomy was performed.

CLINICAL DISCUSSION

Laparoscopic cholecystectomy is the standard operative procedure for gallbladder disease. The unique anatomy of SIT increases the risk of CBD injury during laparoscopic cholecystectomy. Surgeons are required to perform a mirror-image procedure and adhere to the basic principles of safe laparoscopic cholecystectomy in SIT. This is only the second reported case of CBD injury in SIT patients.

CONCLUSION

Laparoscopic cholecystectomy in SIT presents a significant challenge. In patients with SIT, preventing CBD injury is the best approach, and referral to an experienced hepato-pancreato-biliary (HPB) surgeon is recommended. A delayed approach to CBD injuries in SIT allows thorough planning and understanding of the complex anatomical variations in these patients.

Unilateral Right-Sided Ultrasound-Guided Erector Spinae Plane Block for Post-Laparoscopic Cholecystectomy Analgesia: A Randomized Control Trial

Background

Post-laparoscopic cholecystectomy (LC) pain control is still an issue postoperatively.

Objectives

We investigated the effectiveness of the unilateral right-side ultrasound-guided erector spinae plane block (ESPB) on post-LC pain intensity and opioid consumption.

Methods

This is a parallel-arm randomized control trial on 62 adult patients with an American Society of Anesthesiologists (ASA) physical status ≤ 2 who underwent LC. The patients were randomized into 2 groups (the block group [BG] and the control group [CG]; n = 31 per group). BG received a single-shot right-sided T7 ESPB with 20 mL of 0.2% ropivacaine at arrival time in the post-anesthesia care unit (PACU). CG) received no regional anesthesia. Both groups received patient-controlled intravenous fentanyl and rescue meperidine for analgesia. The primary outcome was the pain intensity determined using a Numerical Rating Scale (NRS) in the first 24 hours after surgery. Secondary outcomes included total fentanyl and meperidine consumption within 24 hours.

Results

Median pain scores were significantly higher in CG at rest and with coughing up to 12 hours after surgery compared with BG. Pain scores were higher in CG with a cough at 24 hours compared with BG (median 1 [interquartile range (IQR) 1, 2] vs. 1 [1, 0]; P = 0.0005). Total fentanyl consumption and meperidine consumption within 24 hours were significantly lower in BG compared with CG (median 60 µg [IQR 60, 90] vs 250 µg [90, 300]; P < 0.0001 and median 20 µg [IQR 10, 20] vs 25 [20, 25]; P = 0.002, respectively).

Conclusions

A single-shot, right-sided, unilateral ESPB decreases post-LC opioid consumption and pain.

Elective Laparoscopic Cholecystectomy as an Entrustable Professional Activity (EPA) for General Surgical Trainees in Australia

INTRODUCTION

To evaluate the operation time and surgical outcomes of elective laparoscopic cholecystectomy performed by surgical trainees at different levels of training at Eastern health and hence, to establish the efficacy and safety of elective laparoscopic cholecystectomy as an Entrustable Professional Activity for surgical trainees in general surgery.

OBJECTIVE

Elective laparoscopic cholecystectomies performed at our institution between January 2018 and January 2019 were included. Analyses were divided among three groups - consultants (C), fellows (F) and registrars (R). Standard technique with critical view of safety was used.

RESULTS

A total of 592 patients was included, with a mean age of 54 ± 63 years old. The average operation time was 84 ± 51 minutes. Surgical education and training (SET) 2 trainees took significantly longer when compared to their SET3 and above counterparts as a primary operator (SET2: 131 ± 32 min, Reference; SET3: 78 ± 21 min, p = 0.003; SET4: 80 ± 33 min, p = 0.004; SET5: 77 ± 28 min, p = 0.003; F: 93 ± 77 min, p = 0.036; C: 85 ± 59 min; p = 0.007). Consultant primary operators took an average of 15 minutes longer to complete the operation when assisted by a SET trainee compared to the non-SET registrars (p = 0.03). The overall complication rate was 3.2% and was not significantly different among all three groups (p = 0.17). No death was recorded during the study period. The readmission and return to theatre rates were 7.8% and 0.8% respectively and were not significantly different among the groups (p-values = 0.61 and 0.69). All conversion to open were performed by the consultant primary operator.

CONCLUSIONS

Elective laparoscopic cholecystectomy can be safely performed by surgical trainees at all SET levels when under appropriate supervision, although junior surgical trainees that is SET 2 took longer to complete the procedure. This operation seems to have a steep, but relatively short, learning curve and it may be broken down into various components. These components, with the addition of time, may be suitable as an Entrustable Professional Activity tool for assessing the competency of early SET trainees.

Effect of Oxycodone hydrochloride combined with Dexmedetomidine on quality of recovery and stress response after general anesthesia in patients who had Laparoscopic Cholecystectomy

Objective:

To explore the effect of oxycodone hydrochloride combined with dexmedetomidine on the recovery quality and stress response during anesthesia in patients undergoing laparoscopic cholecystectomy (LC).

Methods:

Ninety patients who had LC in Cangzhou Hospital of Integrated TCM-WM of Hebei from December 2016 to December 2019 were selected and divided into dexmedetomidine group (DEX group), oxycodone hydrochloride group (Q group), dexmedetomidine + oxycodone hydrochloride group (DQ group) by a random number table method, with 30 cases in each group. At the time before anesthesia induction (T0), and immediately (T1), 1 min (T2), 10 min (T3) and 30 minutes (T4) after extubation, the general vital signs of three groups were observed, and plasma cortisol (COR), epinephrine (E), norepinephrine (NE) and blood glucose (GLU) were measured. The spontaneous respiration recovery time, wake-up time, VAS score of each time period after extubation, extubation quality score, and adverse event rate were recorded.

Results:

The vital signs at each time point of extubation, recovery time of spontaneous respiration, wake-up time, and extubation quality of DQ group were better than those of DEX group and Q group (P<0.05). The incidence of agitation, VAS score at T2 and T3, plasma concentrations of Cor, E, NE and Glu at T1, T3 and T4 in DQ group were significantly lower than those in Q group and DEX group (P<0.05).

Conclusion:

Oxycodone hydrochloride combined with dexmedetomidine can improve the recovery quality and reduce stress response in patients with LC after anesthesia, and can be safely used in patients with LC.

ClipAssistNet: bringing real-time safety feedback to operating rooms

Purpose

Cholecystectomy is one of the most common laparoscopic procedures. A critical phase of laparoscopic cholecystectomy consists in clipping the cystic duct and artery before cutting them. Surgeons can improve the clipping safety by ensuring full visibility of the clipper, while enclosing the artery or the duct with the clip applier jaws. This can prevent unintentional interaction with neighboring tissues or clip misplacement. In this article, we present a novel real-time feedback to ensure safe visibility of the instrument during this critical phase. This feedback incites surgeons to keep the tip of their clip applier visible while operating.

Methods

We present a new dataset of 300 laparoscopic cholecystectomy videos with frame-wise annotation of clipper tip visibility. We further present ClipAssistNet, a neural network-based image classifier which detects the clipper tip visibility in single frames. ClipAssistNet ensembles predictions from 5 neural networks trained on different subsets of the dataset.

Results

Our model learns to classify the clipper tip visibility by detecting its presence in the image. Measured on a separate test set, ClipAssistNet classifies the clipper tip visibility with an AUROC of 0.9107, and 66.15% specificity at 95% sensitivity. Additionally, it can perform real-time inference (16 FPS) on an embedded computing board; this enables its deployment in operating room settings.

Conclusion

This work presents a new application of computer-assisted surgery for laparoscopic cholecystectomy, namely real-time feedback on adequate visibility of the clip applier. We believe this feedback can increase surgeons’ attentiveness when departing from safe visibility during the critical clipping of the cystic duct and artery.

Supplementary Information

The online version supplementary material available at 10.1007/s11548-021-02441-x.

Unilateral rhomboid intercostal and subserratus plane block application for analgesia after laparoscopic cholecystectomy surgery :a quasi-experimental study

Background

Interfascial plane block applications can be used for postoperative pain after laparoscopic surgery. We aimed to investigate the effect of ultrasound-guided unilateral rhomboid intercostal and subserratus plane (RISS) block after laparoscopic cholecystectomy operations on the amount of analgesic use.

Methods

50 patients underwent laparoscopic cholecystectomy were included in the quasi-experimental study. Patients meeting the criteria were analyzed in two groups as experimental group (RISS block with 20 ml %0.25 bupivacaine+intravenous patient-controlled analgesia (IV-PCA) tramadol ; n = 25) and group Control (IV-PCA tramadol; n = 25).The primary outcome was the total amount of tramadol used over 24 hours.Secondary outcomes included the side effects, additional analgesic use and postoperative pain (during rest and activity) was at the 2nd, 6th, 12th, and 24th hours using the NRS scores .

Results

Postoperative tramadol consumption at the 24 hours was significantly lower in the Group RISS than the Group Control (p<0.001). The resting NRS scores at the 2nd and 6th hours were statistically significantly low in the Grup RISS. The NRS scores during movement in Grup RISS were significantly low at the postoperative 2nd, 6th, and 12th hours.There was no statistically significant difference in the rate of side effects and additional analgesic use between the groups (p>0.05).

Conclusions

In conclusion, unilateral RISS block is an effective method for pain management after laparoscopic cholecystectomy and can be used as a part of multimodal analgesia.

Aggressive Laparoscopic Cholecystectomy in Accordance with the Tokyo Guideline 2018

Objectives:

The Tokyo Guidelines 2018 have been widely adopted since their publication. However, the few reports on clinical outcomes following laparoscopic cholecystectomy have not taken into account the severity of the acute cholecystitis and the patient’s general condition, as estimated by the Charlson comorbidity index. This study aimed to assess the relationships between severity, Charlson comorbidity index, and clinical outcomes subsequent to laparoscopic cholecystectomy.

Methods:

We extracted the retrospective data for 370 Japanese patients who underwent emergency or scheduled early laparoscopic cholecystectomy within 72 hours from onset between February 2015 and August 2018. We compared postoperative factors in relationship to severity (grade I versus grade II/III). Then, we made a similar comparison between those with low (< 4) and high Charlson comorbidity index (≥ 4).

Results:

According to the Tokyo guideline 2018 levels of severity, there were 282 (76.2%), 61 (16.5%), and 27 (7.3%) patients in grades I, II, and III, respectively. With regards to surgical outcomes, the mean operating time was 62.3 minutes and the mean blood loss was 24.4 mL. The mean hospital stay was 3.6 days, with no mortalities. Blood loss was the only factor affected by severity (20.9 mL versus 60.1 mL, P = 0.0164), and operating time was the only factor affected by high Charlson comorbidity index (53.4 versus 67.8 minutes, P = 0.0153).

Conclusion:

Our aggressive strategy is acceptable, and severity and Charlson comorbidity index are not critical factors suggesting the disqualification of early laparoscopic cholecystectomy in patients with any grade acute cholecystitis.

Bilateral versus unilateral erector spinae plane block for postoperative analgesia in laparoscopic cholecystectomy: a randomized controlled study

INTRODUCTION

Laparoscopic cholecystectomy (LC) is the common surgical intervention for benign biliary diseases. Postoperative pain after LC remains as an important problem, with two components: somatic and visceral. Trocar entry incisions lead to somatic pain, while peritoneal distension with diaphragm irritation leads to visceral pain. Following its description by Forero et al., the erector spinae plane (ESP) block acquired considerable popularity among clinicians. This led to the use of ESP block for postoperative pain management for various operations.

MATERIALS AND METHODS

This study was conducted between January and June 2019. Patients aged between 18 and 65 years with an American Society of Anesthesiologists (ASA) physical status I.ÇôII, scheduled for elective laparoscopic cholecystectomy were included in the study. All the patients received bilateral or unilateral ESP block at the T8 level preoperatively according to their groups.

RESULTS

There was no significant difference between the groups in terms NRS scores either at rest or while coughing at any time interval except for postoperative 6^th hour (p = 0.023). Morphine consumption was similar between the groups but was significantly lower in group B at 12 and 24 hours (p = 0.044 and p = 0.022, respectively). Twelve patients in group A and three patients in group B had shoulder pain and this difference was statistically significant (p = 0.011).

DISCUSSION

In conclusion, bilateral ESP block provided more effective analgesia than unilateral ESP block in patients undergoing elective LC. Bilateral ESP block reduced the amount of opioid consumption and the incidence of postoperative shoulder pain.

Polymeric locking clips [Hem-o-lok] versus Metallic clips in elective Laparoscopic Cholecystectomy: A Retrospective study of 1496 patients

Background Laparoscopic cholecystectomy is one of the most commonly performed operation. Various methods for securing the cystic artery and cystic duct are described in literature. We aim to compare intra-operative and early post-operative outcomes of laparoscopic cholecystectomy using polymeric locking Hem-o-lok clips versus metallic ligaclips . Patients and Methods Retrospective study of prospectively maintained single institutional data including all consecutive patients who underwent elective laparoscopic cholecystectomy from 2013 to 2018. Patients in whom metallic ligaclips were used were grouped as Group I and those with Hem-o-Lok were grouped as Group II. The early post-operative outcomes of the two groups were compared. Results Total 1496 patients were included in the study; 836 patients in Group I and 660 in Group II. Study included 29.1% males and 70.9% females with mean age of 43.6 years. Hem-o-lok clip was better in securing wide cystic duct compared to metallic clips. Metallic clip failed to secure 8 out of 44 wide cystic duct compared to 0 out 70 with Hem-o-lok clips (p=0.002). The post-operative outcomes of both groups were comparable. There were no cystic duct leak, post- operative bleeding or major bile duct injuries in either group. Conclusion Use of Hem-o-lok clip is safe in laparoscopic cholecystectomy due to ease of application and security. Hem-o-lok is more useful in patients with thick and wide cystic duct which are difficult to secure with metallic clips with low risk of leak. Key words: Laparoscopic Cholecystectomy, Hem-o-lok clip, Metallic clip, Wide cystic duct.

Evaluation of Liver Function Tests and Serum Bilirubin Levels After Laparoscopic Cholecystectomy

Introduction

Laparoscopic cholecystectomy has been known as one of the most important prevalent and minimally invasive surgeries in medicine.

Aim

The aim here was to investigate the changes in liver enzymes and bilirubin levels after laparoscopic cholecystectomy in patients diagnosed with chronic cholecystitis.

Methods

This cross-sectional study was conducted at Poursina Hospital (Rasht, Iran) and 128 patients who met both inclusion and exclusion criteria were enrolled for further investigations. After collecting the patients' bio-demographic information, levels of serum alkaline phosphatase, lactate dehydrogenase, alanine aminotransferase, aspartate aminotransferase, and bilirubin were checked before laparoscopic cholecystectomy and 24 (post-op 1) and 48 (post-op 2) h after laparoscopic cholecystectomy.

Results

No significant difference was found in the serum levels of ALP in post-op 1 and 2 compared both to each other and to the baseline (P>0.05). Regarding AST and ALT, there was a significant increase in post-op 1 and 2 compared to their baseline values (P<0.05). However, the difference between post-op 1 and post-op 2 was not significant for these outcomes. Compared to baseline levels, LDH had a significant increase after post-op 2 (P=0.001); but not after post-op 1 (P >0.05). Moreover, total bilirubin levels showed significant increases at post-op 1 and post-op 2 from the baseline and also in comparison with each other (P < 0.05).

Conclusion

Our results demonstrated a transient increase in liver function tests and bilirubin after laparoscopic cholecystectomy.

Short term outcomes of three dimensional versus two-dimensional laparoscopic cholecystectomy

Objective:

To compare the short-term outcomes of three dimensional (3D) versus two dimensional (2D) laparoscopic procedures used for cholecystectomy.

Methods:

This study was conducted at minimally invasive surgery center of Liaquat University of Medical Health and Sciences (LUMHS) Jamshoro Pakistan, between 15^th May 2017 to 16^th December 2017 after taking informed consent. All patients were diagnosed cases of cholelithiasis without any complications. Patients having risk factors for inability to get access to gall bladder via laparoscope and in whom the chances of conversion to open cholecystectomy were greater were not included as part of study. One group of patients underwent cholecystectomy under 3D laparoscopy while other group underwent 2D laparoscopy. Surgeons included in the study were all well-trained. The short-term outcome noted were intraoperative and postoperative complications, conversion to open, operative time, mortality and hospital stay. Visual strain and headache for the surgeon in three D laparoscopic cholecystectomy.

Results:

A total of one hundred forty patients were included in the study. Group-A consists of sixty two females and eleven males whereas Group-B comprised of fifty eight females and fifteen males. Eight percent of patients in Group-A whereas in Group-B two percent had gallbladder rupture. Fifteen percent of patients in Group-A whereas 5.4% from Group-B had bleeding from liver bed. One patient from Group-A had CBD (Common Bile Duct) injury. Post-operatively two (2.73%) patients from Group-A had port site bleeding. Six (8.21%) patients had port site infection in Group-A.

Conclusion:

Three dimensional was found to have low incidence of intra-operative and post-operative complications compared to 2D laparoscopic cholecystectomy.

Risk Factors of Postoperative Complications in Laparoscopic Cholecystectomy for Acute Cholecystitis

Introduction:

There are often cases with postoperative complications after laparoscopic cholecystectomy (LC), resulting in severe consequences. This study aimed to identify potential risk factors of postoperative complications in cases of LC for acute cholecystitis.

Materials and Methods:

A total of 423 patients with cholecystitis underwent LC. We divided the patients into two groups: group without postoperative complications (Group A) and group with postoperative complications (Group B). Pre-operative findings, surgical findings, and the methods for evaluating the risk of peri-operative complications were compared between the two groups with a univariate analysis. Independent risk factors of postoperative complications were then evaluated in a multivariate analysis with the factors shown to be statistically significant in the univariate analysis.

Results:

A Physiological and Operative severity Score for enUmeration of Mortality and morbidity (POSSUM) of ≥ 48.3 and moderate or severe cholecystitis were independent risk factors of postoperative complications in LC.

Conclusions:

This study indicated that POSSUM morbidity and moderate or severe cholecystitis were potential risk factors of postoperative complications. The pre-operative management of the general condition and cholecystitis using antibiotics, infusion, percutaneous transhepatic gallbladder drainage, and other approaches may be significant for the prevention of postoperative complications. Once the POSSUM morbidity reaches the threshold after LC, postoperative management becomes difficult, so strict control of the general condition should be performed.

Surgical team workload comparison for 4-port and single-port laparoscopic cholecystectomy procedures

Advanced minimally invasive procedures may cause postural constraints and increased workload and stress for providers. This study compared workload and stress across surgical team roles for 48 laparoscopic cholecystectomies (4-port vs single-port) using a task load index (NASA-TLX), a procedural difficulty question, and salivary stress hormones. Statistical analyses were performed based on the presence intra-cluster correlation within team roles, at α=0.05. The single-port technique resulted in an 89% increase in physical workload for the surgeon and 63% increase for the assistant (both p<0.05). The surgeon had significantly higher salivary stress hormones during single-port surgeries. The degree of procedural difficulty was positively correlated between the surgeon and most roles: resident (r=0.67), assistant (r=0.81), and technician (r=0.81). There was a statistically significant positive correlation between the surgeon and assistant for all selfreported workload measures (p<0.05). The single-port technique requires further improvement to balance surgical team workload for optimal patient safety and satisfaction.

The Effect of Preoperative Zintoma Capsule on Postoperative Nausea and Vomiting After Laparoscopic Cholecystectomy

Background

Postoperative nausea and vomiting (PONV), as one of the complications after laparoscopic cholecystectomy, occurs in over 40% - 77% of cases. Considering the numerous complications of synthetic drugs, there is a growing tendency towards the use of herbal medicines due to their unique features. Ginger root is one of the herbal compounds effective on nausea and vomiting.

Objectives

The aim of this study was to evaluate the effect of preoperative Zintoma capsules on PONV after laparoscopic cholecystectomy.

Methods

In this quasi-experimental study, 130 eligible patients were randomly assigned to intervention (n = 65) and control (n = 65) groups using the four-block method. The intervention group received two capsules of 500 mg and one of 250 mg Zintoma. The control group received three placebo capsules. The severity of patients' PONV was recorded at 0, 2, 6, 12, and 24 hours after surgery using a checklist and a standard VAS instrument. Data were analyzed using t-test, Chi-square test, and LSD Post Hoc test (ANOVA) in SPSS 19.

Results

The severity of PONV and vomiting was significantly different between the two groups (P = 0.001) at the above time points. The mean severity of nausea (by VAS) changed in the intervention group from 7.92 ± 1.28 to 0.33 ± 0.67 and in the control group from 8.00 ± 1.20 to 2.11 ± 1.55. The postoperative vomiting was less frequent in the group receiving the Zintoma capsules. The postoperative use of chemical anti-vomiting and nausea drugs was significantly lower in the intervention group than in the placebo group (P = 0.001).

Conclusions

Zintoma capsules can be used as a supportive treatment in the prevention of nausea and vomiting by reducing the incidence rate of PONV.

A Preliminary Examination of the Comparative Efficacy of Intravenous vs Oral Acetaminophen in the Treatment of Perioperative Pain

Objective

The management of postoperative pain is a major health care issue. While the cost of intravenous acetaminophen (IVA) is significantly greater than its oral acetaminophen (OA) counterpart, less is known regarding comparative effectiveness of these routes. The purpose of this study was to determine whether perioperative IVA is equivalent in reducing postoperative pain compared with perioperative OA for laparoscopic cholecystectomy (LapChole).

Design

Double-blinded, prospective, randomized placebo-controlled trial.

Setting

Womack Army Medical Center, Fort Bragg, North Carolina.

Subjects

Adults (age > 18 years) active duty military, veterans, and beneficiaries receiving a laparoscopic cholecystectomy.

Methods

This study was conducted at Womack Army Medical Center (WAMC), Fort Bragg, North Carolina, between January 2013 and June 2015. Sixty-seven subjects with symptomatic cholelithiasis were randomly assigned to receive two doses (1,000 mg each) of either IVA or OA. A numerical rating scale (NRS) score of pain was obtained preoperatively and every six hours for 24 hours postoperation. The primary objective was to assess whether treatment groups had significantly different 24-hour postoperative sum of pain intensity differences (SPID24) using an analysis of covariance test.

Results

Sixty subjects completed the study and were included in the analysis. Treatment groups did not differ in SPID24, even when controlling for age, gender, and preoperative pain levels (F(1,55) = 0.39, P = 0.54, partial η2 = 0.007), nor did 24-hour opioid consumption when controlling for age, gender, and operation time (F(1, 46) = 0.47, P = 0.50, partial η2 = 0.01). Furthermore, treatment groups were equally as likely to report average postoperative NRS scores of 4 or higher (β = 0.24, Exp(B) = 1.28, P = 0.68).

Conclusions

The results show no evidence of differences between IVA or OA in pain or opioid consumption among a sample of patients undergoing LapChole. Due to low sample size, these descriptive findings warrant larger studies, which may have a significant economic impact.

Surgery Reduces Risk of Complications Even in High-Risk Veterans After Endoscopic Therapy for Biliary Stone Disease

BACKGROUND

In otherwise healthy patients, randomized trials have shown reduced mortality with cholecystectomy (CCY) when compared to non-operative management after endoscopic retrograde cholangiopancreatography (ERCP) for biliary stone disease. These findings may not apply to veterans with multiple comorbidities, who have an increased risk of postoperative complications.

AIMS

Our study assessed the benefit of CCY among veterans with multiple comorbidities.

METHODS

Medical records of patients undergoing ERCP for biliary stone-related diseases from July 2008 to December 2016 were reviewed. Among patients who did not undergo CCY, risk of postoperative complications or death with CCY was estimated using the American College of Surgeons National Surgery Quality Improvement Program risk calculator. Charlson comorbidity index (CCI) and American Society of Anesthesiologists classification system (ASA) were used to assess patient's functional status. The primary outcome was incidence of recurrent biliary events or death with non-operative management, compared to estimated risk of serious postoperative complications or death with CCY.

RESULTS

A total of 152 patients met inclusion criteria, 81 of whom did not undergo CCY. Patients managed non-operatively were older and less medically fit than patients who underwent CCY. Biliary complications recurred in 23 patients managed non-operatively, including 3 deaths due to cholangitis. Among patients with CCI ≥ 3 and ASA ≥ 3 who were managed non-operatively (n = 43), the risk of serious biliary events was significantly higher than estimated risk of serious postoperative complications with laparoscopic CCY (26 vs 5%, p < 0.001).

CONCLUSION

Our study suggests that non-operative management is associated with a higher risk of complications than laparoscopic CCY, even among veterans with significant comorbidities.

Hepatic or Cystic Artery Pseudoaneurysms Following a Laparoscopic Cholecystectomy: Literature review of aetiopathogenesis, presentation, diagnosis and management

Pseudoaneurysms (PSAs) of the hepatic and/or cystic artery are a rare complication following a laparoscopic cholecystectomy (LC). Generally, PSA cases present with haemobilia several weeks following the procedure. Transarterial embolisation (TAE) is considered the optimal management approach. We report a 70-year-old woman who presented to the Sultan Qaboos University Hospital, Muscat, Oman, in 2016 with massive hemoperitoneum two weeks after undergoing a LC procedure in another hospital. She was successfully managed using coil TAE. An extensive literature review revealed 101 cases of hepatic or cystic artery PSAs following a LC procedure. Haemobilia was the main presentation (85.1%) and the mean time of postoperative presentation was 36 days. The hepatic artery was involved in most cases (88.1%), followed by the cystic artery (7.9%) and a combination of both (4.0%). Most cases were managed with TAE (72.3%), with a 94.5% success rate. The overall mortality rate was 2.0%.

An Unusual Case of Primary Extranodal Lymphoma of the Gallbladder

Primary gallbladder lymphoma is an extremely rare disease. We report a case of a 63 year-old woman who has been admitted with gradual onset abdominal pain in the upper right quadrant and in the suprapubic region, nausea and malaise. According to the computed tomography scan of the abdomen, which was suggestive of chronic cholecystitis, she was treated conservatively. A laparoscopic cholecystectomy was performed 5 months later and the histological examination of the gallbladder showed a low grade small lymphocytic lymphoma. The patient has been taken over by the hematology team who kept her under surveillance as no further treatment was deemed as necessary. The purpose of this paper is to report a rare case of primary gallbladder lymphoma and to demonstrate that a laparoscopic cholecystectomy may be a valid treatment for this disease.

Difficulties in laparoscopic cholecystectomy: Conversion versus surgeon's failure

BACKGROUND

Laparoscopic cholecystectomy is considered to be gold standard treatment for symptomatic gall stones. Despite several benefits there are still disadvantages of laparoscopic cholecystectomy in difficult cases where anatomy is disturbed even in experienced hand. Aim of this study is to identify advantages of early conversion to open cholecystectomy in difficult cases and how it should not be associated with surgeon's failure.

METHODS

Observational study was conducted at tertiary care hospital of Karachi, Pakistan from January 2012 till June 2015. All patients who presented to general surgery department with symptomatic gall stones and planned for laparoscopic cholecystectomy was included in the study. Demographic data was collected. Preoperative workup includes baselines investigations with liver profile test and imaging study (ultrasound scan). All patient underwent laparoscopic cholecystectomy at first. Operative difficulties, incidence of conversion, reason for conversion and complication intra-operative or postoperative were recorded. Data was analyzed using SPSS 20.

RESULTS

Out of 1026 patients, 78.26% (803) were female. Mean age of patients were 41.30±8.43 years (range 26-68 years). Common presenting symptoms were pain at upper abdomen and dyspepsia. Most of the patients had multiple gall stones (93.85%). Nine hundred and ninety-two patients (96.68%) of patients underwent successful laparoscopic cholecystectomy. This includes patients in whom dissections were difficult because of disturbed anatomy of calots triangle. Only 3.13% of patients were converted to open cholecystectomy. There was a significant difference (<0.05) in complications observed between completed and converted cholecystectomies.

CONCLUSIONS

Conversion from laparoscopic to open procedure should be done in cases of technically difficult situations to avoid significant mortality and morbidity. Surgeons experience had a pivotal role in determining its need and justification.

Fluorescent cholangiography in laparoscopic cholecystectomy: the initial Canadian experience

BACKGROUND

Bile duct injury remains a worrisome complication of laparoscopic cholecystectomy. Indocyanine Green (ICG) fluorescent cholangiography (FC) is a new approach that facilitates real-time intraoperative identification of biliary anatomy. This technology is hoped to improve the safety of dissection within Calot's triangle.

METHOD

Demographics, intraoperative details, and subjective surgeon data were recorded for elective cholecystectomy cases involving ICG. Goals were to identify rates of bile duct identification, and assess the perceived benefit of the device.

RESULTS

ICG was used in 12 biliary cases in Canada. Visualization rates of the cystic and common bile ducts were 100% and 83%, respectively. Also, 83% of surgeons felt that FC incorporated smoothly into the operation. No complications have been related to the technology.

CONCLUSIONS

FC allows noninvasive real-time visualization of the extrahepatic biliary tree. This novel technique has received positive feedback in its initial Canadian use and will likely be a durable adjunct for minimally invasive surgery.

'Single-Sitting' Laparoscopic Cholecystectomy and Endoscopic Removal of Common Bile Duct Stone for Cholelithiasis and Choledocholithiasis: a Feasibility Study

'Single-sitting' laparoscopic cholecystectomy followed by endoscopic common bile duct clearance is emerging as a viable option for management of cholelithiasis and concomitant choledocholithiasis. The only disadvantage of the procedure is logistical since it requires co-ordination between two teams-the surgeons and the endoscopists. This limitation can be overcome in centres where both the procedures are performed by one team. With a considerable experience in endoscopy, we conducted a prospective study in a select group of patients to assess the feasibility of this single-sitting approach. The study included 38 patients with a radiological diagnosis of choledocholithiasis or jaundice at presentation. After laparoscopic cholecystectomy, the patients were turned prone and subjected to endoscopic retrograde cholangiogram, sphincterotomy and extraction of the common bile duct stone. The procedure was successful in 33 (87 %) of patients. The mean procedure time and hospital stay were 2 h, 20 min and 2 days, respectively. None of the patients had any major complications. We conclude that in a select group of patients, single-sitting laparoscopic cholecystectomy followed by endoscopic clearance of the common bile duct stone is safe and effective.

Acute cholecystitis: risk factors for conversion to an open procedure

BACKGROUND

Laparoscopic cholecystectomy is one of the most common general surgical procedures performed. Conversion to an open procedure (CTO) is associated with increased morbidity and length of stay. Patients presenting with acute cholecystitis are at higher risk for CTO. Studies have attempted to examine risk factors for CTO in patients who undergo laparoscopic cholecystectomy for acute cholecystitis but are limited by small sample size. The aim of this study was to identify preoperative variables that predict higher risk for CTO in patients presenting with acute cholecystitis.

MATERIALS AND METHODS

Patients undergoing laparoscopic cholecystectomy for acute cholecystitis from 2005-2011 were identified from the American College of Surgeons' National Surgical Quality Improvement Program Participant Use File. Patients who underwent successful laparoscopic surgery were compared with those who required CTO. Demographics, comorbidities, and 30-d outcomes were analyzed. Multivariable logistic regression was used for variables with P value <0.1, with CTO used as the dependent variable.

RESULTS

A total of 7242 patients underwent laparoscopic cholecystectomy for acute cholecystitis. CTO was reported in 436 patients (6.0%). Those who required conversion were older (60.7 ± 16.2 versus 51.6 ± 18.0, P = 0.0001) and mean body mass index was greater (30.8 ± 7.6 versus 30.0 ± 7.3, P = 0.033) compared with those whose procedure was completed laparoscopically. Vascular, cardiac, renal, pulmonary, neurologic, hepatic disease, diabetes, and bleeding disorders were more prevalent in CTO patients. Mortality (2.3% versus 0.7%, P < 0.0001), overall morbidity (21.8% versus 6.0%, P < 0.0001), serious morbidity (14.9% versus 3.8%, P < 0.0001), reoperation (3.4% versus 1.4%, P = 0.001), and surgical site infection (9.2% versus 1.8%, P < 0.0001) rates, as well as length of stay (8.6 ± 13.0 versus 3.4 ± 6.7, P < 0.0001) were greater in those requiring CTO. The following factors were independently associated with CTO: age (odds ratio [OR], 1.01, P = 0.015), male gender (OR, 1.77, P = 0.005), body mass index (OR, 1.04, P < 0.0001), preoperative alkaline phosphatase (OR, 1.01, P = 0.0005), white blood cell count (OR, 1.06, P = 0.0001), and albumin (OR, 0.52, P = 0.0001).

CONCLUSIONS

CTO for acute cholecystitis remains low but not clinically negligible. The identified risk factors can potentially guide management and patient selection for delayed intervention for acute cholecystitis.

The effect of single-dose administration of dexamethasone on postoperative pain in patients undergoing laparoscopic cholecystectomy

Background:

Postoperative pain is considered as a reason of patient’s delay in discharge and disability aggravation. Therefore, multimodal approaches have been suggested in order to mitigate pain and decrease postoperative side effects.

Objectives:

The aim of this study was to evaluate analgesic effect of a single dose injection of dexamethasone on reducing postoperative pain in laparoscopic cholecystectomy.

Patients and Methods:

In this double-blind, prospective study, 122 patients aged 18-60 years old, whom were selected for laparoscopic cholecystectomy, were classified into two case and control groups, and 61 patients were included in each group. The case (D) group underwent general anesthesia and a single- dose intravenous injection of dexamethasone. The Control (C) group received general anesthesia and intravenous injection of normal saline. Total dose of consumed meperidine and pain intensity during first 24 hours were evaluated in both groups.

Results:

No significant difference existed between two groups regarding age, sex, weight and operation time. Pain intensity in group D was significantly less than group C (P < 0.01) after two, six and 12 hoursof surgery. No significant difference existed in pain intensity between two groups at the beginning of and 24 hours after the surgery (P > 0.05). Meperidine consumption in group D was significantly less than group C (P < 0.05).

Conclusions:

Findings of present study showed that single dose of intravenous dexamethasone, led to less pain intensity and amounts of meperidine consumption, in comparison with placebo.

Does concentration of surgical expertise improve outcomes for laparoscopic cholecystectomy? 9 year audit cycle

BACKGROUND

Evidence from surgery shows that high volume is often associated with better outcomes. The aim of this study was to investigate this principle related to elective laparoscopic cholecystectomy practice.

METHODS

A retrospective analysis of all conversions and complications for patients undergoing elective laparoscopic cholecystectomy was performed. Data was collected and then repeated after restrictions were implemented to concentrate practice. Hospital databases and patient notes were used to collect data.

RESULTS

Between January 1999 and March 2004, 1605 laparoscopic cholecystectomies were performed by 8 surgeons. Case load varied from an average of <1 to 104 procedures per annum. Only 1 surgeon was an upper gastrointestinal specialist. Overall rates for conversion to open surgery were 4.9%, common bile duct injury was 0.31%, bile leak 0.75%, bowel injury 0.25%, haemorrhage 0.44% and death 0.06%, which met guidelines. Significant correlation between conversion and procedure number was identified (p=0.033) Between April 2006 and March 2010, 1820 laparoscopic cholecystectomies were performed by 4 surgeons. Case load varied from 23 to 268 procedures per annum, 2 surgeons were upper gastrointestinal specialists. Overall rates for conversion to open surgery were 3.5%, common bile duct injury 0.1%, bile leak 0.9%, bowel injury 0.21%, haemorrhage 0.16% and death 0.1%. Conversion rates were significantly lower in re-audit data (p=0.027), but remained lowest for the highest volume sub-specialist surgeons (p=0.016).

CONCLUSIONS

Concentrating expertise to those surgeons with interest and commitment to laparoscopic cholecystectomy service led to standardisation and reduction in conversion rates. There is correlation between volume of surgery and outcomes.

Biliary complications during a decade of increased cholecystectomy rate

BACKGROUND

Bile duct injury is a rare complication of cholecystectomy. The aims of this study were to analyse the mechanism and outcome of biliary complications and determine the Northern Ireland incidence of bile duct injury over the last decade.

METHODS

Annual numbers of cholecystectomies were obtained from the Northern Ireland Hospital Inpatient System database. Bile duct injury referrals to a hepatobililary unit over an 11-year period from 2000 were reviewed. Mechanism and recognition of injury, referral interval, management and outcome were analysed.

RESULTS

The annual incidence of laparoscopic cholecystectomy in Northern Ireland increased from 0.038% in 1995 to 0.101% in 2009. Thirty-five patients with biliary complications from cholecystectomy were referred from 2000. The incidence of bile duct injury associated with laparoscopic cholecystectomy during this period was 0.2%. Only 26% of injuries were recognised intra-operatively, only 40% were referred immediately and 91% required operative intervention.

CONCLUSION

The incidence of laparoscopic cholecystectomy has increased in Northern Ireland. The incidence of bile duct injuries over the last 11 years was 0.2%. Recognition and referral were delayed in most cases. The majority of injuries required operative management and long-term follow-up.

Hem-o-lok clip found in common bile duct after laparoscopic cholecystectomy and common bile duct exploration: a clinical analysis of 8 cases

Currently laparoscopic cholecystectomy (LC) and common bile duct exploration (LCBDE) has become the standard surgical procedure for cholecystolithiasis and choledocholithiasis. During the operation cystic duct and vessels are usually controlled by Hem-o-lok clips. However, recently we found clips dropping into CBD in 8 patients during fiberoptic choledochoscope 2-3 months after operation. Therefore, there is risk that clip can migrate during postoperative period, which probably lead to hemorrhage and bile leakage after LC if this occurs within postoperative few days, or even cause recurrent stone in CBD. So, using of Hem-o-lok clips may be not a safe method to control vessels and cystic duct during LC. To our knowledge, this condition has not previously been reported. In our view, other more effective and safe method ligating cystic duct and gallbladder vessels, such as effective and convenient thread knotting method, should be investigated.

Is laparoscopic cholecystectomy safe for acute cholecystitis in the presence of ventriculo-peritoneal shunt?

INTRODUCTION

In patients with ventriculo-peritoneal shunts, laparoscopic procedures were previously contraindicated for the potential risks of elevating intra-cranial pressure resulting from increased intra-abdominal pressure and shunt malfunction/infection.

PRESENTATION OF CASE

Here we present a case of a patient with ventriculo-peritoneal shunt who successfully and uneventfully underwent laparoscopic cholecystectomy for acute cholecystitis without any shunt manipulation or intra-cranial pressure monitoring.

DISCUSSION

Several methods have been suggested to decrease the risks of increased intra-cranial pressure during laparoscopic cholecystectomy in patients with ventriculo-peritoneal shunts, but have not been routinely used.

CONCLUSION

Standard technique laparoscopic cholecystectomy can be safely used to manage patients with VP shunts presenting with acute gall bladder disease.

Single-incision laparoscopic cholecystectomy: Single institution experience and literature review

Single-incision laparoscopic surgery is a rapidly evolving field as a bridge between traditional laparoscopic surgery and natural orifice transluminal endoscopic surgery. We report one of the initial clinical experiences in Japan with this new technique. Four cases of gallbladder diseases were selected for this new technique. A single curved intra-umbilical 25-mm incision was made by pulling out the umbilicus. A 12-mm trocar was placed through an open approach, and the abdominal cavity was explored with a 10-mm semi-flexible laparoscope. Two 5-mm ports were inserted laterally from the laparoscope port. A 2-mm mini-loop retractor was inserted to retract the fundus of the gallbladder. Dissection was performed using an electric cautery hook and an Endograsper roticulator. There were two women and two men with a mean age of 50.5 years (range: 40-61 years). All procedures were completed successfully without any perioperative complications. In all cases, there was no need to extend the skin incision. Average operative time was 88.8 min. Postoperative follow-up didnot reveal any umbilical wound complication. Single-incision laparoscopic cholecystectomy is feasible and a promising alternative method as scarless abdominal surgery for the treatment of some patients with gallbladder disease.