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Injury to the Luschka ducts (LDs), also named "subvesicular" ducts, is an under-reported cause of biliary leak following laparoscopic cholecystectomy (LC). A systematic literature search according to PRISMA guidelines was conducted in PubMed, EMBASE and Cochrane Library including all publications that described a bile leak from an LD. A total of 136 articles were retrieved from the searched databases. After the removal of duplicates and non-eligible papers, 48 studies reporting 231 leaks were included: 20 (41.6%) case reports, 2 (4.3%) comparative studies, 7 (14.9%) meeting abstracts and 19 (40.4%) retrospective cohort articles. The rate of LD leak ranges from 0.05% to 1.9%, but injury to a duct of Luschka was the second most common cause of biliary leakage in all the cohort studies (5.5% to 41%). In 21 (43.7%) cases, the leak was successfully treated with a sphincterotomy through Endoscopic Retrograde Cholangiopancreatography (ERCP) plus or minus stenting, and in 12 (25%), re-laparoscopy was necessary. [ABSTRACT FROM AUTHOR]

Since the early 1990's, laparoscopic cholecystectomy has become the gold standard for the treatment of symptomatic gallbladder disease. Although the incidence of postoperative complications is generally lower with this approach, gallbladder perforation represents a serious risk that is among the most common complications of laparoscopic cholecystectomy. The sequalae that can follow iatrogenic perforation have not been well documented and only a few case reports exist in the current literature. In this paper we discuss two case reports of delayed perihepatic abscesses following prior laparoscopic cholecystectomy, ultimately resulting in fistulous tracts. The course of the disease is discussed along with the diagnostic workup and eventual successful management of the aforementioned complications. Treating enteric fistulae requires a systematic approach and is carried out in phases. Enteric fistula formation following laparoscopic cholecystectomy is a rare complication of retained gallstones that can present months to years following the index operation. Significant care should be taken to avoid perforation and all efforts should be made to retrieve stones if spillage occurs. [ABSTRACT FROM AUTHOR]

Introduction: Accurate disclosure of conflicts of interest (COI) is critical to interpretation of study results, especially when industry interests are involved. We reviewed published manuscripts comparing robot-assisted cholecystectomy (RAC) and laparoscopic cholecystectomy (LC) to evaluate the relationship between COI disclosures and conclusions drawn on the procedure benefits and safety profile. Methods: Searching Pubmed and Embase using key words "cholecystectomy", laparoscopic" and "robotic"/"robot-assisted" retrieved 345 publications. Manuscripts that compared benefits and safety of RAC over LC, had at least one US author and were published between 2014 and 2020 enabling verification of disclosures with reported industry payments in CMS's Open Payments database (OPD) (up to 1 calendar year prior to publication) were included in the analysis (n = 37). Results: Overall, 26 (70%) manuscripts concluded that RAC was equivalent or better than LC (RAC +) and 11 (30%) concluded that RAC was inferior to LC (RAC–). Six manuscripts (5 RAC + and 1 RAC–) did not have clearly stated COI disclosures. Among those that had disclosure statements, authors' disclosures matched OPD records among 17 (81%) of RAC + and 9 (90%) RAC– papers. All 11 RAC- and 17 RAC + (65%) manuscripts were based on retrospective cohort studies. The remaining RAC + papers were based on case studies/series (n = 4), literature review (n = 4) and clinical trial (n = 1). A higher proportion of RAC + (85% vs 45% RAC–) manuscripts used data from a single institution. Authors on RAC + papers received higher amounts of industry payments on average compared to RAC– papers. Conclusions: It is imperative for authors to understand and accurately disclose their COI while disseminating scientific output. Journals have the responsibility to use a publicly available resource like the OPD to verify authors' disclosures prior to publication to protect the process of scientific authorship which is the foundation of modern surgical care. [ABSTRACT FROM AUTHOR]

Current descriptions of the history of subtotal cholecystectomy require more details and accuracy. This study presented a narrative review of the articles on partial resections of the gallbladder published between 1898 and 2022. The Scale for the Assessment of Narrative Review Articles items guided the style and content of this paper. The systematic literature search yielded 165 publications. Of them, 27 were published between 1898 and 1984. The evolution of the partial resections of the gallbladder began in the last decade of the 19th century when Kehr and Mayo performed them. The technique of partial resection of the gallbladder leaving the hepatic wall in situ was well known in the 3rd and 4th decades of the 20th century. In 1931, Estes emphasised the term 'partial cholecystectomy'. In 1947, Morse and Barb introduced the term 'subtotal cholecystectomy'. Madding and Farrow popularised it in 1955–1959. Bornman and Terblanche revitalised it in 1985. This term became dominant in 2014. From a subtotal cholecystectomy technical execution perspective, it is either a single-stage (when it includes only the resectional component) or two-stage (when it also entails closure of the remnant of the gallbladder or cystic duct) operation. Recent papers on classifications of partial resections of the gallbladder indicate the extent of gallbladder resection. Subtotal cholecystectomy is an umbrella term for incomplete cholecystectomies. 'Subtotal open-tract cholecystectomy' and 'subtotal closed-tract cholecystectomy' are terms that characterise the type of completion of subtotal cholecystectomy. [ABSTRACT FROM AUTHOR]

Background: For acute cholecystitis in the latter 19th century and early 20th century, the diagnosis was difficult and the management not defined. Methods and Results: Bernhard Riedel of Jena in Germany documented his patients, analysed his results, and described his method of cholecystectomy. Conclusions: Riedel advocated early operation for acute cholecystitis when the conditions were favourable, as for acute appendicitis. He stressed the importance of good lighting, an experienced surgeon and trained assistants. He advocated conservative treatment for minor cholecystitis (biliary colic) until the diagnosis was certain, followed by elective cholecystectomy to reduce the risk of subsequent acute cholecystitis or bile duct stones. Caution was advised when analysing previous statistics, to ensure appropriate patient comparison. [ABSTRACT FROM AUTHOR]

Duodenal perforation consequent to prior surgery is a rare but severe complication carrying serious consequences if not promptly managed. This study aims to identify the best treatment pathway available to date. This is a systematic review registered to PROSPERO. The literature research was conducted on Ovid Medline, Embase, and Cochrane up to February 2022 to identify all papers reporting surgical-related duodenal perforations. Twelve articles were included. Most of these studies were case reports or case series. The most common cause of perforation was laparoscopic cholecystectomy (72.7%). The median time to symptom appearance was 2 days. Most of these perforations were severe injuries located in the first portion of the duodenum. Only one patient was treated with a non-interventional conservative management, which failed. Five patients were managed with interventional non-surgical treatments: 4 with endoscopy (50% failure) and one with a percutaneous occluder. Different surgical treatments were reported: direct suture (100% failure), direct suture and T-tube duodenostomy (75% failure), simple abdominal drainage, and suture with pyloric exclusion. Further extensive surgeries were also reported. The overall mortality rate was 13.6%, with a median hospital stay of 38.5 days. This review shows a wide spectrum of managements for patients with duodenal perforation related to prior surgery. The decision on which treatment to adopt must consider patient's clinical setting and duodenal defect characteristics (size, site, and time to diagnosis). A tentative treatment flowchart is provided, although larger sample size studies are needed to obtain a treatment pathway based on evidence. [ABSTRACT FROM AUTHOR]

Laparoscopic transcystic common bile duct exploration during laparoscopic cholecystectomy is the treatment of choice for patients with coexisting gallbladder and bile duct stones. Failure of this usually indicates laparoscopic choledocotomy, after which most patients are managed with primary duct closure and less frequently with T-tube placement or bilioenteric anastomosis. The objective of this paper is to describe the indications and complications of T-tube placement after laparoscopic choledocotomy in a consecutive series of single-stage management of 554 patients. Case series analysis of a prospectively collected historical database of all patients treated with T-tube drainage at Cosme Argerich Hospital from July 2008 and December 2020. Surgical indications and postoperative management will be discussed. Five hundred fifty-four patients underwent simultaneous scheduled laparoscopic cholecystectomy and common bile duct exploration during the analyzed period. One hundred thirteen (20.39%) required laparoscopic choledochotomy, after which 54 (48%) were treated with T-tube drainage, 23 for suspicion of incomplete bile duct clearance, 16 for impaired papillary drainage, 13 for inappropriate bile duct wall conditions, and 2 for lateral bile duct injuries. No significant morbidity was related to T-tube drainage. In our setting, and following a strict protocol, T-tube drainage after laparoscopic choledochotomy is a valid alternative to primary duct closure in selected patients. [ABSTRACT FROM AUTHOR]

The article presents abstracts on medical topics which include pancreatic neuroendocrine tumours, emergency cholecystectomy, and non-anatomical resection for colorectal liver metastasis.

Laparoscopic cholecystectomy (LC) has become the procedure of choice for the removal of gallbladder within the paediatric population. The aim of this study was to perform a systematic review and meta-analysis of the literature spanning the last 20 years to understand the indications for and safety of LCs in children. A comprehensive search of the published English language literature from January 2000 to June 2020 was done on PubMed, MEDLINE, and Google Scholar. In total, 76,524 LC cases were identified from 114 studies. 78.9% of the patients were female and average age was 12 years old. Associated haematological disorders were identified in 16% of cases. The commonest indication for LC was cholelithiasis (68.4% in 66 studies), followed by cholecystitis (59.2% in 53 studies). Median operating time was 77 min. Median hospital stay was 2 days. The overall postoperative complication rate was 3.4% Major complications included bile duct injury (0.4%) and intra- or post-operative bleeding (0.9%). The conversion rate to open procedure was 2%. When comparing post-operative outcomes between emergency and elective admissions, three papers lent themselves to meta-analysis demonstrating no significant difference (p = 0.42). There was no statistically significant difference in postoperative complication rate between "hot" and "cold" laparoscopic cholecystectomies (p = 0.6). This systematic review and meta-analysis is the largest collection of subjects on laparoscopic cholecystectomies in children. Laparoscopic cholecystectomy is a safe operation in children, with complication rates similar or comparable to the adult literature. Cholelithiasis, cholecystitis and biliary dyskinesia were the commonest indications for LC. • Cholelithiasis and cholecystitis are the commonest indications for LC. • Postoperative complication rate of laparoscopic cholecystectomy in children is 3.4%. • Laparoscopic cholecystectomy is a safe operation in children. • Serious postoperative complications include bile duct injury and bleeding. [ABSTRACT FROM AUTHOR]

We report the case of a 39-year-old male presenting with acute onset vomiting and diarrhoea. Initially treated empirically for gastroenteritis, imaging later confirmed a complicated episode of cholecystitis with fistular formation and intra-abdominal cyst. Following cholecystectomy, histology confirmed a case of xanthogranulomatous cholecystitis (XGC). This paper presents a detailed summary of the condition alongside a literature review of all available episodes of XGC since 2017 with the aim of highlighting diagnostic conclusions regarding the nature of the disease and its clinical manifestations. [ABSTRACT FROM AUTHOR]

BACKGROUND: Laparoscopic cholecystectomy with fluorescent cholangiography using indocyanine green dye (FC) identifies extrahepatic biliary structures, potentially augmenting the critical view of safety. We aim to describe trends for the largest single-center cohort of patients undergoing FC in laparoscopic cholecystectomy. STUDY DESIGN: A retrospective review of a prospectively maintained database identified patients undergoing laparoscopic cholecystectomy with FC at a single academic institution. Patient factors included age, sex, BMI, and American Society of Anesthesiologists score. Outcomes included operative time, conversion to open procedure, biliary injury, length of stay, and complications. RESULTS: A total of 828 patients underwent FC. Of these, 74.3% were female, the mean age was 50.4 years, and the average BMI 28.8 kg/m2 . Mean operating room time was 68.6 minutes. There were no mortalities or common bile duct injuries. Morbidities included 4 bile leaks and 1 retained stone. Six patients required conversion to an open approach. Operative time, length of stay, and open conversion significantly decreased after a standard indocyanine green protocol (p < 0.05). Compared with white light, FC demonstrated lower operative times (99 vs 68 minutes), length of stay (1.4 vs 0.4 days), open conversions (8% vs 0.7%), emergency department visits (13% vs 8%) and drain placements (12% vs 3%) (all p < 0.05). Patients with BMI greater than 30 saw elevated operative times and length of stay. CONCLUSIONS: In conclusion, this paper demonstrates improved operative outcomes with the use of FC through the consistent ability to delineate biliary anatomy, even in the setting of complex anatomy. No common bile duct injuries have occurred in our 7-year experience with FC. We recommend FC as the standard of care when performing laparoscopic cholecystectomies. [ABSTRACT FROM AUTHOR]

Background and aim:The problem of hemostasis in cholecystectomy is sometimes relevant to the present day. The main methods of hemostasis during this operation are: electrocoagulation, stitching of the gallbladder bed, application of a hemostatic sponge, etc. The aim of the present study is to conduct a comparative analysis of the use of various methods of hemostasis after cholecystectomy. Material and methods:The paper presents the results of a study of 200 patients with acute and chronic cholecystitis. Depending on the method of hemostasis, they were divided into 3 groups. Results:When analyzing the postoperative period of patients in clinical observation groups, significant differences were revealed in some parameters. The duration of hemostasis in the main group with bleeding from the bladder bed after laparoscopic cholecystectomy (LC) and open cholecystectomy (OC) was 2 times different from the time in the control group. As a result of repeated coagulation of the gallbladder bed, an additional zone of coagulation necrosis was formed, which in the postoperative period was a source of hyperthermia and a substrate for the pyoinflammatory process. Conclusion:Hemostatic sponge, is a fairly effective local hemostatic agent. The use of hemostatic sponge allows avoiding the specific dangers and complications of electrosurgical methods for stopping bleeding from the gallbladder bed, reducing postoperative complications by 1,5 times. [ABSTRACT FROM AUTHOR]

This systematic review was undertaken to define and summarize existing, proposed quality performance indicators (QPI) for hepato-pancreatico-biliary (HPB) procedures. A systematic literature review identified studies reporting on quality indicators for cholecystectomy, hepatectomy, pancreatectomy and complex biliary surgical procedures. The databases searched were MEDLINE, EMBASE, PubMed, and SCOPUS, with all literature available until the search date of 1 May 2020 included. The reference lists of all included papers, as well as related review articles, were manually searched to identify further relevant studies. Forty-five publications report quality indicators for pancreatectomy (n = 22), hepatectomy (n = 7), HPB resections in general (n = 12), and cholecystectomy (n = 6). No publications proposed QPI for complex biliary surgery. The 45 papers used national audit (n = 18), consensus methodology (n = 5), state-wide audit (n = 3), unit audit (n = 9), review methodology (n = 9), and survey methodology (n = 1). Sixty-one QPI were reported for pancreatectomy, 22 reported for hepatectomy, and 14 reported for HPB resections in general, in domains of infrastructure, provider, and documentation. Fourteen infrastructure and provider-based QPI were reported for cholecystectomy. There are few internationally agreed QPI for HPB procedures that allow global comparison of provider performance and that set aspirational goals for patient care and experience. [ABSTRACT FROM AUTHOR]

The article presents abstracts of medical research. They include "Is laparoscopic appendicectomy the gold standard in the smaller hospitals in Ireland?," Endo-laparoscopic approach vs conventional open surgery in the management of obstructing left-sided colonic carcinoma: a randomized trial," and "Randomized comparison of early versus late dissection of Calot's triangle in laparoscopic cholecystectomy."

Introduction: Patients undergoing elective laparoscopic cholecystectomy (ELLC) represent a heterogeneous group making it challenging to stratify risk. The aim of this paper is to identify pre-operative factors associated with adverse peri- and post-operative outcomes in patients undergoing ELLC. This knowledge will help stratify risk, guide surgical decision making and better inform the consent process.Methods: All patients who underwent ELLC between January 2015 and December 2019 were included in the study. Pre-operative data and both peri- and post-operative outcomes were collected retrospectively from multiple databases using a deterministic records-linkage methodology. Patients were divided into groups based on clinical indication (i.e. biliary colic versus cholecystitis) and adverse outcomes were compared. Multivariate regression models were generated for each adverse outcome using pre-operative independent variables.Results: Two-thousand one hundred and sixty-six ELLC were identified. Rates of peri- and post-operative adverse outcomes were significantly higher in the cholecystitis versus biliary colic group and increased with number of admissions of cholecystitis (p < 0.05). Rates of subtotal (29.5%), intra-operative complication (9.8%), post-operative complications (19.6%), prolonged post-operative stay (45.9%) and re-admission (16.4%) were significant in the group of patients with ≥ 2 admissions with cholecystitis.Conclusion: Our data demonstrate that patients with repeated biliary admission (particularly cholecystitis) ultimately face an increased risk of a difficult ELLC with associated complications, prolonged post-operative stay and readmissions. These data provide robust evidence that individualised risk assessment and consent are necessary before ELLC. Strategies to minimise recurrent biliary admissions prior to LC should be implemented. [ABSTRACT FROM AUTHOR]

Background: Despite the call to enhance accuracy and value of operation records few international recommended minimal standards for operative notes documentation have been described. This study undertook a systematic review of existing operative reporting systems for laparoscopic cholecystectomy (LC) to fashion a comprehensive, synoptic operative reporting template for the future. Methods: A search for all relevant articles was conducted using PubMed version of Medline, Scopus and Web of Science databases in June 2021, for publications from January 1st 2011 to October 25th 2021, using the keywords: laparoscopic cholecystectomy AND operation notes OR operative notes OR proforma OR documentation OR report OR narrative OR audio-visual OR synoptic OR digital. Two reviewers (NOC, GMC) independently assessed each published study using a MINORS score of ≥ 16 for comparative and ≥ 10 for non-comparative for inclusion. This systematic review followed PRISMA guidelines and was registered with PROSPERO. Synoptic operative templates from published data were assimilated into one "ideal" laparoscopic operative report template following international input from the World Society of Emergency Surgery board. Results: A total of 3567 articles were reviewed. Following MINORS grading 25 studies were selected spanning 14 countries and 4 continents. Twenty-two studies were prospective. A holistic overview of the operative procedure documentation was reported in 6/25 studies and a further 19 papers dealt with selective surgical aspects of LC. A unique synoptic LC operative reporting template was developed and translated into Chinese/Mandarin, French and Arabic. Conclusion: This systematic review identified a paucity of publications dealing with operative reporting of LC. The proposed new template may be integrated digitally with hospitals' medical systems and include additional narrative text and audio-visual data. The template may help define new OR (operating room) recording standards and impact on care for patients undergoing LC. [ABSTRACT FROM AUTHOR]

Background: We have limited information about neuroendocrine carcinoma (NEC) of the gallbladder. The purpose of this paper is to compare clinical and pathological features between different age groups and prognostic factors for gallbladder NEC and how it differs from adenocarcinoma (ADC) of the gallbladder. Patients and methods: This study included 28 gallbladder NEC patients and 137 ADC patients whose clinical characteristics and pathological findings were retrospectively collected. Propensity score matching and Cox regression analysis were used for the analysis of prognostic factors. Results: We divided NEC patients into two groups based on the age more than or less than 60 years. Most of the NEC patients less than 60 years old complained of abdominal pain or discomfort (p = 0.038), and more younger patients accepted adjuvant therapy (p = 0.020) than older patients did. CD56 was positive in all patients more than 60 years old, which is significantly higher than that of younger patients (p = 0.039). The mean age was similar between NEC and ADC patients. After eliminating confounding factors between NEC and ADC patients, the overall survival rates were still lower in NEC patients. Univariate analysis extracted six possible risk factors. Multivariate analysis indicated that surgery type, tumor size, and existence of gallstones were independent prognostic factors. Conclusion: The overall survival of gallbladder NEC is not associated with age. In this study, surgical method and tumor size were found to be independent risk factors for NECs. In addition, NEC patients have a worse prognosis than ADC patients with similar clinical and pathological features. [ABSTRACT FROM AUTHOR]

Accurate surgery duration estimation is necessary for optimal OR planning, which plays an important role in patient comfort and safety as well as resource optimization. It is, however, challenging to preoperatively predict surgery duration since it varies significantly depending on the patient condition, surgeon skills, and intraoperative situation. In this paper, we propose a deep learning pipeline, referred to as RSDNet, which automatically estimates the remaining surgery duration (RSD) intraoperatively by using only visual information from laparoscopic videos. The previous state-of-the-art approaches for RSD prediction are dependent on manual annotation, whose generation requires expensive expert knowledge and is time-consuming, especially considering the numerous types of surgeries performed in a hospital and the large number of laparoscopic videos available. A crucial feature of RSDNet is that it does not depend on any manual annotation during training, making it easily scalable to many kinds of surgeries. The generalizability of our approach is demonstrated by testing the pipeline on two large datasets containing different types of surgeries: 120 cholecystectomy and 170 gastric bypass videos. The experimental results also show that the proposed network significantly outperforms a traditional method of estimating RSD without utilizing manual annotation. Further, this paper provides a deeper insight into the deep learning network through visualization and interpretation of the features that are automatically learned. [ABSTRACT FROM AUTHOR]

Background: Recently, we reported the feasibility of indocyanine green (ICG) near-infrared fluorescence (NIRF) imaging to identify extrahepatic biliary anatomy during laparoscopic cholecystectomy (LC) in pediatric patients. This paper aimed to describe the use of a new technology, RUBINA™, to perform intra-operative ICG fluorescent cholangiography (FC) in pediatric LC.Methods: During the last year, ICG-FC was performed during LC using the new technology RUBINA™ in two pediatric surgery units. The ICG dosage was 0.35 mg/Kg and the median timing of administration was 15.6 h prior to surgery. Patient baseline, intra-operative details, rate of biliary anatomy identification, utilization ease, and surgical outcomes were assessed.Results: Thirteen patients (11 girls), with median age at surgery of 12.9 years, underwent LC using the new RUBINA™ technology. Six patients (46.1%) had associated comorbidities and five (38.5%) were practicing drug therapy. Pre-operative workup included ultrasound (n = 13) and cholangio-MRI (n = 5), excluding biliary and/or vascular anatomical anomalies. One patient needed conversion to open surgery and was excluded from the study. The median operative time was 96.9 min (range 55-180). Technical failure of intra-operative ICG-NIRF visualization occurred in 2/12 patients (16.7%). In the other cases, ICG-NIRF allowed to identify biliary/vascular anatomic anomalies in 4/12 (33.3%), including Moynihan's hump of the right hepatic artery (n = 1), supravescicular bile duct (n = 1), and short cystic duct (n = 2). No allergic or adverse reactions to ICG, post-operative complications, or reoperations were reported.Conclusion: Our preliminary experience suggested that the new RUBINA™ technology was very effective to perform ICG-FC during LC in pediatric patients. The advantages of this technology include the possibility to overlay the ICG-NIRF data onto the standard white light image and provide surgeons a constant fluorescence imaging of the target anatomy to assess position of critical biliary structures or presence of anatomical anomalies and safely perform the operation. [ABSTRACT FROM AUTHOR]

The article focuses on the 20th anniversary of the first laparoscopic cholecystectomy, a procedure that was initially viewed with skepticism. The Society of American Gastrointestinal Endoscopy and the Society of American Gastrointestinal and Endoscopic Surgeons has convened a group to deal with the barriers to the development and safe introduction of natural orifice transluminal endoscopic surgery. The group has established the Natural Orifice Surgery Consortium for Assessment and Research.

Introduction: Endoscopic and open surgical interventions are widely implemented as the standard practice in common bile duct exploration. However, the laparoscopic approach has been also reported to have comparative/superior outcomes in this concept. This has created an ongoing debate about the ideal approach to adopt in practice.Methods: A systematic review of the published evidence over the last decade that has looked into the outcomes of laparoscopic exploration of the common bile duct through transductal and transcystic approaches.Results: Our systematic review included 36 relevant papers. The majority were based on nonrandomized protocols conducted in single centers with high expertise. The data analysis showed that laparoscopic common bile duct exploration through both approaches was successful in more than 84% of the patients, with an average length of hospital stay of 5.6 days. Conversion to open surgery was reported in 5%-8% of the patients, and the bile leak rates from the more recent studies was 0%-12%, with mortality figures of 0%-1.3%. The outcomes were statistically in favor of the transcystic route when compared to the transductal route from the viewpoints of bile leak rates, mean operative time, duration of hospital stay and morbidity.Conclusion: In experienced hands, both laparoscopic approaches in common bile duct exploration are safe in patients who are clinically fit to have this intervention. It is associated with a statistically significant lower overall morbidity and shorter duration of hospital stay when compared to open surgery. Relevant up-to-date high-quality randomized trials are unavailable. [ABSTRACT FROM AUTHOR]

Bile duct lesions with leakage and stenosis can occur after open or laparoscopic cholecystectomy. Multiple factors are involved either related to the patient or external due to technical equipment or surgeon. Bismuth classification is generally accepted. The aim is to restore the bile duct and to prevent short-term and long-term complications such as biliary fistula, intra-abdominal abscess, biliary stricture, recurrent cholangitis, and secondary biliary cirrhosis. Endoscopic therapy with biliary sphincterotomy alone or with the additional placement of a biliary/nasobiliary stent drainage is recommended. Stenting should be avoided if complete strictures exist or a circumferential resection of the duct. Endotherapy can be considered a sensible option and should be the main-stay treatment in these patients but one must keep in mind it is costly and is usually practiced by experienced teams in tertiary centers. The purpose of our paper is to exemplify this complication which is inherently rare, to highlight the diagnostic and treatment tools with minimal long-term sequelae. [ABSTRACT FROM AUTHOR]

Background: Endoscope is the eye of surgeon in minimally invasive surgery (MIS). Prevailing handheld endoscopes are manually steered, which can cause endoscope-instrument fencing. Robotic endoscopes can reduce the fatigue but could not reduce collisions. Handheld endoscopes with a flexible bending tip can reduce the shaft pivoting and collisions. However, its steering is challenging. In this paper, we present a robotic flexible endoscope with auto-tracking function and compare it with the conventional rigid endoscopes.Methods: A robotic flexible endoscope (RFE) with shared autonomy is developed. The RFE could either track the instruments automatically or be controlled by a foot pedal. A mockup cholecystectomy was designed to evaluate the performance. Five surgeons were invited to perform the mockup cholecystectomy in an abdominal cavity phantom with a manual rigid endoscope (MRE), a robotic rigid endoscope (RRE), and the RFE. Space occupation, time consumption, and questionnaires based on the NASA task load index were adopted to evaluate the performances and compare the three endoscope systems. An ex vivo experiment was conducted to demonstrate the feasibility of using the RFE in a biological tissue environment.Results: All surgeons completed the mockup cholecystectomy with the RFE independently. Failure occurred in the cases involving the RRE and the MRE. Inside the body cavity, the space occupied when using the RFE is 17.28% and 23.95% (p < 0.05) of that when using the MRE and the RRE, respectively. Outside the body cavity, the space occupied when using the RFE is 14.60% and 15.53% (p < 0.05) of that by using MRE and RRE. Time consumed in the operations with MRE, RRE, and RFE are 28.3 s, 93.2 s and 34.8 s, respectively. Questionnaires reveal that the performance of the RFE is the best among the three endoscope systems.Conclusions: The RFE provides a wider field of view (FOV) and occupies less space than rigid endoscopes. [ABSTRACT FROM AUTHOR]

Background: Although laparoscopic inguinal hernia repair was described about 30 years ago and advantages of the technique have been demonstrated, the utilization of this approach has not been what we would expect. Some reasons may be the need for surgeons to understand the posterior anatomy of the groin from a new vantage point, as well as to acquire advanced laparoscopic skills. Recently, however, the introduction of a robotic approach has dramatically increased the adoption of minimally invasive techniques for inguinal hernia repair.Methods: Important recent contributions to this evolution have been the establishment of a new concept known as the critical view of the Myopectineal Orifice (MPO) and the description of a new way of understanding the posterior view of the antomy of the groin (inverted Y and the five triangles). In this paper, we describe 10 rules for a safe MIS inguinal hernia repair (TAPP, TEP, ETEP, RTAPP) that combines these two new concepts in a unique way.Conclusions: As the critical view of safety has made laparoscopic cholecystectomy safer, we feel that following our ten rules based on understanding the anatomy of the posterior groin as defined by zones and essential triangles and the technical steps to achieve the critical view of the MPO will foster the goal of safe MIS hernia repair, no matter which minimally invasive technique is employed. [ABSTRACT FROM AUTHOR]

Laparoscopic cholecystectomy commonly performed under general anesthesia with controlled mechanical ventilation to overcome the path physiological changes of carbon dioxide insufflations, increase intra-abdominal pressure and manipulations of patient positioning during surgery. Recently, laparoscopic surgery is targeted to manage the elderly who they have limited cardiac reserve and those with high risk under general anesthesia, in these patients, regional anesthesia offering several advantages. The present paper aims to find out the applicability of epidural anesthesia in laparoscopic cholecystectomy (LC) in patients with compromised cardiopulmonary status who they are at risk to have their operation under general anesthesia or who they are unwilling to do their surgery under regional anesthesia. This study was approved that all patients have had stable vital sign (mean Blood pressure & heart rate) Mild to moderate shoulder pain which occurs in 42.8% of patients were treated by small dose of opioid. Epidural anesthesia is a good choice and reasonable type of anesthesia can be used for laparoscopic cholecystectomy in patient with compromised cardiovascular system & for those patients who they are unwilling to do their surgery under general anesthesia and provide good postoperative outcome. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to elucidate the effects of cholecystectomy on the risk of colorectal cancer (CRC) by conducting a meta-analysis of 10 cohort studies. Methods: The eligible cohort studies were selected by searching the PubMed and EMBASE databases from their origination to June 30, 2016, as well as by consulting the reference lists of the selected articles. Two authors individually collected the data from the 10 papers. When the data showed marked heterogeneity, we used a random-effects model to estimate the overall pooled risk; otherwise, a fixed effects model was employed. Results: The final analysis included ten cohort studies. According to the Newcastle-Ottawa Scale (NOS), nine papers were considered high quality. After the data of these 9 studies were combined, an increased risk of CRC was found among the individuals who had undergone cholecystectomy (risk ratio (RR) 1.22; 95% confidence interval (CI) 1.08–1.38). In addition, we also found a promising increased risk for colon cancer (CC) (RR 1.30, 95% CI 1.07–1.58), but no relationship between cholecystectomy and rectum cancer (RC) (RR 1.09; 95% CI 0.89–1.34) was observed. Additionally, in the sub-group analysis of the tumor location in the colon, a positive risk for ascending colon cancer (ACC) was found (RR 1.18, 95% CI 1.11–1.26). After combining the ACC, transverse colon cancer (TCC), sigmoid colon cancer (SCC) and descending colon cancer (DCC) patients, we found a positive relationship with cholecystectomy (RR 1.18, 95% CI 1.11–1.26). Furthermore, after combining the ACC and DCC patients, we also found a positive relationship with cholecystectomy (RR 1.28; 95% CI 1.11–1.26) in the sub-group analysis. In an additional sub-group analysis of patients from Western countries, there was a positive relationship between cholecystectomy and the risk of CRC (RR 1.20; 95% CI 1.05–1.36). Furthermore, a positive relationship between female gender and CRC was also found (RR 1.17; 95% CI 1.03–1.34). However, there was no relationship between gender and CC or RC. Furthermore, no publication bias was observed, and the sensitivity analysis indicated stable results. Conclusions: This meta-analysis of 10 cohort studies revealed that cholecystectomy is associated with an increased risk for CRC, CC and ACC, particularly in Western countries. No relationship between cholecystectomy and RC was observed. There was no relationship between gender and either CC or RC, but a positive relationship between female gender and CRC was observed. [ABSTRACT FROM AUTHOR]

Background: Early laparoscopic cholecystectomy has been adopted as the treatment of choice for acute cholecystitis due to a shorter hospital length of stay and no increased morbidity when compared to delayed cholecystectomy. However, randomised studies and meta-analysis report a wide array of timings of early cholecystectomy, most of them set at 72 h following admission. Setting early cholecystectomy at 72 h or even later may influence analysis due to a shift towards a more balanced comparison. At this time, the rate of resolving acute cholecystitis and the rate of ongoing acute process because of failed conservative treatment could be not so different when compared to those operated with a delayed timing of 6–12 weeks. As a result, randomised comparison with such timing for early cholecystectomy and meta-analysis including such studies may have missed a possible advantage of an early cholecystectomy performed within 24 h of the admission, when conservative treatment failure has less potential effects on morbidity. This review will explore pooled data focused on randomised studies with a set timing of early cholecystectomy as a maximum of 24 h following admission, with the aim of verifying the hypothesis that cholecystectomy within 24 h may report a lower post-operative complication rate compared to a delayed intervention. Methods: A systematic review of the literature will identify randomised clinical studies that compared early and delayed cholecystectomy. Pooled data from studies that settled the early intervention within 24 h from admission will be explored and compared in a sub-group analysis with pooled data of studies that settled early intervention as more than 24 h. Discussion: This paper will not provide evidence strong enough to change the clinical practice, but in case the hypothesis is verified, it will invite to re-consider the timing of early cholecystectomy and might promote future clinical research focusing on an accurate definition of timing for early cholecystectomy for acute cholecystitis. [ABSTRACT FROM AUTHOR]

Hybrid surgical simulators based on augmented reality (AR) solutions benefit from the advantages of both the box trainers and the virtual reality simulators. This paper reports on the results of a long development stage of a hybrid simulator for laparoscopic cholecystectomy that integrates real and the virtual components. We first outline the specifications of the AR simulator and then we explain the strategy adopted for implementing it based on a careful selection of its simulated anatomical components, and characterized by a real-time tracking of both a target anatomy and of the laparoscope. The former is tracked by means of an electromagnetic field generator, while the latter requires an additional camera for video tracking. The new system was evaluated in terms of AR visualization accuracy, realism, and hardware robustness. Obtained results show that the accuracy of AR visualization is adequate for training purposes. The qualitative evaluation confirms the robustness and the realism of the simulator. In conclusion, the proposed AR simulator satisfies all the initial specifications in terms of anatomical appearance, modularity, reusability, minimization of spare parts cost, and ability to record surgical errors and to track in real-time the Calot's triangle and the laparoscope. Thus, the proposed system could be an effective training tool for learning the task of identification and isolation of Calot's triangle in laparoscopic cholecystectomy. Moreover, the presented strategy could be applied to simulate other surgical procedures involving the task of identification and isolation of generic tubular structures, such as blood vessels, biliary tree, and nerves, which are not directly visible. [ABSTRACT FROM AUTHOR]

Aim: The optimal treatment for advanced gallbladder cancer, in particular T2 stage cancer, is unclear. The use of "radical cholecystectomy" or more extended procedures with extra-hepatic bile duct resection are matter of debate. Due to the lack of consensus regarding the oncological significance of routine extra-hepatic bile duct (EBD) resection for gallbladder carcinoma, we decided to perform a systematic review investigating the real benefit of this procedure focusing on the primary outcomes of overall survival and disease-free survival.Methods: A systematic literature search was performed using PubMed, EMBASE, Scopus and the Cochrane Library Central according to the PRISMA statement guidelines for conducting and reporting systematic reviews. Multiple primary and secondary outcomes were analyzed.Results: The selected articles included 424 patients who underwent routine EBD resection without bile duct infiltration. Only two papers discussed the number of dissected lymph nodes during EBD resection for gallbladder carcinoma. Four of the seven included papers reported on tumor involvement in lymph nodes at rates ranging between 39% and 83%. All of the studies included in this systematic review reported on results of overall survival. In general, 5-years OS rate of the EBD-resected patients was not significantly different than that of the EBD-preservation group, while the mobility was significantly higher in the EBD resection group.Conclusions: Routine EBD resection in gallbladder cancer patients without bile duct infiltration is not associated with improved overall survival, improved lymph-node harvesting or with minor recurrence rate, but it is associated with higher morbidity rates. [ABSTRACT FROM AUTHOR]

Background: Clinical pathways aim to standardize perioperative and postoperative care of surgical procedures and are shown to result in a significant optimization associated with cost reduction. The aim of this study was to establish the impact of two different implementations forms of clinical pathways on the pathway compliance and resulting costs. Methods: Data of patients undergoing elective cholecystectomy for symptomatic cholecystolithiasis were collected over two different periods: using a clinical pathway in the form of a paper-based checklist, or a clinical pathway integrated into the paper-based medical treatment and nursing documentation. Outcome measures were compliance of the clinical pathway and total costs per case. Results: The compliance was significantly higher using integrated pathways compared to paper-based checklists ( n = 117 of 123, 95 % vs 54 of 118, 46 %; p < 0.001). Mean total costs (€2206 vs €2458, p = 0.027) and length of hospital stay (2.13 vs 2.77 days, p < 0.001) were significantly reduced by the integrated clinical pathway compared to checklists. Further, the variation of costs per case and variation of length of hospital stay were significantly smaller with integrated clinical pathway (±€440 vs ±€538, p = 0.039 and ±0.53 vs ±0.68 days, p < 0.001, respectively). No difference regarding postoperative complication was observed ( n = 3 vs. 4 events; p = 0.67). Conclusion: Integrated clinical pathways display a significant higher compliance compared to checklists resulting in reduced total costs, shorter hospital stay and a smaller variation of cost, making it a useful tool in process controlling and planning. [ABSTRACT FROM AUTHOR]

Purpose - This paper aims to develop a novel miniature 3-axis force sensor which can detect the interaction forces during tissue palpation in MIS (minimally invasive surgery). MIS offers many significant merits compared with traditional open surgery, the wound to the patients and the postoperative pains are alleviated and reduced dramatically. However, the inherent drawback due to lack of force feedback still exists while conducting some operation procedures. For example, tissue palpation performed easily during open surgery could not be realized in an MIS manner. Design/methodology/approach - The force sensor is based on the resistive-based sensing method that utilizes strain gauges to measure the strain when the external loads are acting on the tip of the sensor. A novel flexible tripod structure with bending and compression deformations is designed to discriminate the magnitudes and directions of the three orthogonal force components. A linear characteristic matrix is derived to disclose the relationship between the sensitivity and the geometric parameters of the structure, and a straightforward geometric parameterized optimization method considering the sensitivity isotropy is proposed to provide the sensor structure with high sensitivity and adequate stiffness. Findings - The sensor prototype can perform force measurement with sensing ranges of ± 3.0 N in axial direction and ± 1.5 N in radial direction, and the resolutions are 5 per cent and 1 per cent, respectively. It is concluded that this force sensor is compatible with MIS instruments and the ex-vivo experiment shows that the sensor can be used to perform tissue palpation during MIS procedures. Originality/value - This paper is intended to address the significant role of force sensing and force feedback during MIS operations, and presents a new application of the resistive-based sensing method in MIS. A tripod structure is designed and a straightforward optimization method considering the sensitivity isotropy of the sensor is proposed to determine geometric parameters suited for the given external loads. [ABSTRACT FROM AUTHOR]

Introduction: Variation in outcomes from surgery is a major challenge and defining surgical findings may help set benchmarks, which currently do not exist in laparoscopic cholecystectomy. This study outlines a new surgical scoring system incorporating key operative findings. Methods: English language studies (from January 1965 to July 2014) pertaining to severity scoring and predictors of difficult laparoscopic cholecystectomy were searched for in PubMed, Embase and Cochrane databases using the search terms 'Laparoscopic cholecystectomy or Lap chole' and/or 'Scoring Index or Grading system or Prediction of difficulty or Conversion to open' in various combinations. Cross-referencing from papers retrieved in the original search identified additional articles. Results: Sixteen published papers report a gallbladder (GB) scoring system, but all relate to pre-operative clinical and imaging findings, rather than operative findings. The current scoring system, using operative findings incorporates the appearance of the GB, presence of GB distension, ease of access, potential biliary complications and time taken to identify cystic duct and artery. A score of <2 would imply mild difficulty, 2-4 moderate, 5-7 severe and 8-10 extreme. Conclusion: This paper reports one of the first operative classifications of findings at laparoscopic cholecystectomy. It has the potential to allow benchmarks for international collaboration of operative and patient outcomes in patients undergoing laparoscopic cholecystectomy. [ABSTRACT FROM AUTHOR]

This paper presents a case of critical anatomic variation in laparoscopic cholecystectomy, as an anterior segmental branch of segment V from the left hepatic artery passing anterior to the fundus of the gallbladder and coursing to the anterior hepatic segment. A 46-year-old man was admitted to our hospital complaining of hypochondralgia attributed to gallbladder stones. An aberrant artery crossed the ventral side of the neck of the gallbladder and ran into the right liver Glissonean sheath of segment V. During laparoscopic cholecystectomy, this artery was taped and exposed from proximal to distal ends, revealing an origin from the left hepatic artery with the vessel acting as the anterior branch of segment V to the liver. The cystic artery branching from the aberrant artery was found on the left side of the gallbladder. Laparoscopic cholecystectomy was performed with no injury to the hepatic arteries and the patient was discharged 3 days postoperatively. In general laparoscopic cholecystectomy, we expose only the area inside Calot's triangle. With such an approach, this type of aberrant hepatic artery may be injured intraoperatively without consequences. Detailed preoperative evaluation using modalities such as 3-dimensional reconstruction of CT and knowledge of variations in the hepatic artery will help avoid vessel injury. [ABSTRACT FROM AUTHOR]

Background: Cholecystectomy and inguinal hernioplasty are the most frequent surgeries in Chile and the world. Laparoscopic inguinal hernioplasty, being a clean surgery, reports mesh infection rates of less than 2% and adding a simultaneous laparoscopic cholecystectomy is controversial due to an increase in the risk of mesh infection. The aim of this paper is to report the results of simultaneous TAPP hernioplasty with laparoscopic cholecystectomy.Method: Retrospective analysis of the digestive surgery database. We identified cases in which laparoscopic inguinal TAPP repair and simultaneous laparoscopic cholecystectomy were performed. Demographic, clinical information, hernia type and size, data from the surgery and its complications were also retrieved and analyzed.Results: We identified 21 patients, 86% male and with an average age of 61 years range 46-84. 72% of the hernias were unilateral, predominating indirect 50%, direct 28% and the remaining were femoral and mixed. The average hernia size was 2.2 cm. The meshes used were 56% polypropylene, 37% polyester and 5% PVDF. We report one gallblader perforation. At a median time of 40 months of follow-up (range 4-89 months), one hernia recurrence was found (3.7%), there were no reoperations at the time of the interview and there were no cases of mesh infection. Complications of surgery includes one ipsilateral testicular atrophy 4.8% and 1 ipsilateral inguinal seroma 4.8%.Conclusions: In this series of cases, adding clean contaminated surgery to the inguinal TAPP hernioplasty was not associated with an increase in the infection of the mesh. [ABSTRACT FROM AUTHOR]

Abstract: Performed on either an elective or urgent basis, cholecystectomy currently represents the most common abdominal operation due to the widespread use of laparoscopy and the progressively expanded indications. Compared to traditional open surgery, laparoscopic cholecystectomy minimised the duration of hospitalisation and perioperative mortality. Albeit generally considered safe, cholecystectomy may result in adverse outcomes with non-negligible morbidity. Furthermore, the incidence of worrisome haemorrhages and biliary complications has not been influenced by the technique shift. Due to the growing medico-legal concerns and the vast number of cholecystectomies, radiologists are increasingly requested to investigate recently operated patients. Aiming to increase familiarity with post-cholecystectomy cross-sectional imaging, this paper provides a brief overview of indications and surgical techniques and illustrates the expected early postoperative imaging findings. Afterwards, most iatrogenic complications following open, converted, laparoscopic and laparo-endoscopic rendezvous cholecystectomy are reviewed with examples, including infections, haematoma and active bleeding, residual choledocholithiasis, pancreatitis, biliary obstruction and leakage. Multidetector computed tomography (CT) represents the "workhorse" modality to rapidly investigate the postoperative abdomen in order to provide a reliable basis for an appropriate choice between conservative, interventional or surgical treatment. Emphasis is placed on the role of early magnetic resonance cholangiopancreatography (MRCP) and additional gadoxetic acid-enhanced MRCP to provide a non-invasive anatomic and functional assessment of the operated biliary tract.Teaching Points: • Having minimised perioperative mortality and hospital stay, laparoscopy has now become the first-line approach to performing cholecystectomy, even in patients with acute cholecystitis.• Laparoscopic, laparo-endoscopic rendezvous, converted and open cholecystectomy remain associated with non-negligible morbidity, including surgical site infections, haemorrhage, residual lithiasis, pancreatitis, biliary obstruction and leakage.• Contrast-enhanced multidetector computed tomography (CT) is increasingly requested early after cholecystectomy and represents the "workhorse" modality that rapidly provides a comprehensive assessment of the operated biliary tract and abdomen.• Magnetic resonance cholangiopancreatography (MRCP) is the best modality to provide anatomic visualisation of the operated biliary tract and is indicated when biliary complications are suspected.• Additional gadoxetic acid (Gd-EOB-DTPA)-enhanced MRCP non-invasively provides functional biliary assessment, in order to confirm and visualise bile leakage. [ABSTRACT FROM AUTHOR]

Purpose: During laparoscopic common bile duct exploration (LCBDE) where Calot’s triangle cannot be safely dissected due to a ‘frozen’ hepatic hilum secondary to severe inflammation or fibrosis, the preferred transcystic approach to the common bile duct (CBD) is precluded. The aim of this paper is to describe a safe method of accessing the CBD via a trans-infundibular approach (TIA) in complex cases where conventional access to the cystic duct or CBD is denied.Methods: A retrospective review of 154 consecutive patients who underwent LCBDE at a single centre between 2014 and 2018 was performed. Outcomes of this study were successful access to the CBD to achieve choledochoscopy, successful stone clearance (when required), conversion to open surgery, total or subtotal cholecystectomy, post-operative complications, and length of hospital stay.Results: Nine (5.8%) patients underwent access to the CBD via TIA choledochoscopy. TIA-LCBDE resulted in a stone extraction rate of 86% with one patient requiring choledochotomy. There were zero conversions to open surgery, and total/near total cholecystectomy was achieved in all patients. One patient suffered a post-operative complication for bilateral atelectasis and lower respiratory tract infection. Median length of hospital stay was 3 days.Conclusions: The use of a trans-infundibular approach to the CBD is indicated when the hepatic hilum is ‘frozen’ with severe inflammation and/or fibrosis precluding safe dissection of the critical structures within Calot’s triangle. This strategy enables exploration of the CBD via the transcystic route without the need for critical view dissection or choledochotomy. [ABSTRACT FROM AUTHOR]

Background: Significant research papers have been published to assess the relation between rapid weight loss and the development of cholelithiasis, and the risk factors behind it. Assessment of cholelithiasis development after rapid weight loss as a result in most of bariatric surgery will help in reducing the admission rate to hospitals because of colic pain, and the complication related to stones formation. Objective: This study aimed at measuring the association of rapid weight loss with the development of gallbladder stones and identifying the role of prophylactic cholecystectomy. Methods: PubMed database was used for articles selection. All relevant articles to our review with the following topics: Bariatric Surgery, Gallbladder stones, bariatric surgery complication were included. We excluded other articles which are not related to this field. The data were extracted according to specific form in which it is going to be reviewed by group members to assess the relation between bariatric surgery and the development of stones, and weight loss as well as the benefits of prophylactic cholecystectomy against gallbladder stones. Conclusion: Bariatric surgery can lead to gallstone formation because of the rapid excess weight loss. Small percentage may become symptomatic and rarely cholecystectomy becomes needed during the first year of the bariatric surgery. So, it is not evidently recommended to be done as prophylaxis. However, Prophylactic medicinal therapy (Ursodeoxycholic acid) in the first 6 months can be used instead. [ABSTRACT FROM AUTHOR]

This paper investigates the automatic monitoring of tool usage during a surgery, with potential applications in report generation, surgical training and real-time decision support. Two surgeries are considered: cataract surgery, the most common surgical procedure, and cholecystectomy, one of the most common digestive surgeries. Tool usage is monitored in videos recorded either through a microscope (cataract surgery) or an endoscope (cholecystectomy). Following state-of-the-art video analysis solutions, each frame of the video is analyzed by convolutional neural networks (CNNs) whose outputs are fed to recurrent neural networks (RNNs) in order to take temporal relationships between events into account. Novelty lies in the way those CNNs and RNNs are trained. Computational complexity prevents the end-to-end training of “CNN+RNN” systems. Therefore, CNNs are usually trained first, independently from the RNNs. This approach is clearly suboptimal for surgical tool analysis: many tools are very similar to one another, but they can generally be differentiated based on past events. CNNs should be trained to extract the most useful visual features in combination with the temporal context. A novel boosting strategy is proposed to achieve this goal: the CNN and RNN parts of the system are simultaneously enriched by progressively adding weak classifiers (either CNNs or RNNs) trained to improve the overall classification accuracy. Experiments were performed in a dataset of 50 cataract surgery videos, where the usage of 21 surgical tools was manually annotated, and a dataset of 80 cholecystectomy videos, where the usage of 7 tools was manually annotated. Very good classification performance are achieved in both datasets: tool usage could be labeled with an average area under the ROC curve of A z = 0.9961 and A z = 0.9939 , respectively, in offline mode (using past, present and future information), and A z = 0.9957 and A z = 0.9936 , respectively, in online mode (using past and present information only). [ABSTRACT FROM AUTHOR]

Diseases of the biliary tract are the most common feline hepatic disorders. Cholangitis is the term used to describe inflammation of the biliary tract in felines and can be associated with parasites. Affected animals must undergo clinical or surgical treatment, or a combination of both. In this paper we presented a 10-year-old male, mongrel feline with an obstruction of the biliary tract caused by a rare infection of Platynosomum fastosum. [ABSTRACT FROM AUTHOR]

Introduction: The evolution of Natural Orifice Translumenal Endoscopic Surgery® (NOTES®) represents a case study in surgical procedural evolution. Beginning in 2004 with preclinical feasibility studies, and followed by the creation of the NOSCAR® collaboration between The Society of American Gastrointestinal and Endoscopic Surgeons and the American Society for Gastrointestinal Endoscopy, procedural development followed a stepwise incremental pathway. The work of this consortium has included white paper analyses, obtaining outside independent funding for basic science and procedural development, and, ultimately, the initiation of a prospective randomized clinical trial comparing NOTES® cholecystectomy as an alternative procedure to laparoscopic cholecystectomy.Methods: Ninety patients were randomized into a randomized clinical trial with the primary objective of demonstrating non-inferiority of the transvaginal and transgastric arms to the laparoscopic arm. In the original trial design, there were both transgastric and transvaginal groups to be compared to the laparoscopic control group. However, after enrollment and randomization of 6 laparoscopic controls and 4 transgastric cases into the transgastric group, this arm was ultimately deemed not practical due to lagging enrollment, and the arm was closed. Three transgastric via the transgastric approach were performed in total with 9 laparoscopic control cases enrolled through the TG arm. Overall a total of 41 transvaginal and their 39 laparoscopic cholecystectomy controls were randomized into the study with 37 transvaginal and 33 laparoscopic cholecystectomies being ultimately performed. Overall total operating time was statistically longer in the NOTES® group: 96.9 (64.97) minutes versus 52.1 (19.91) minutes.Results: There were no major adverse events such as common bile duct injury or return to the operating room for hemorrhage. Intraoperative blood loss, length of stay, and total medication given in the PACU were not statistically different. There were no conversions in the NOTES® group to a laparoscopic or open procedure, nor were there any injuries, bile leaks, hemorrhagic complications, wound infections, or wound dehiscence in either group. There were no readmissions. Visual Analogue Scale (VAS) pain scores were 3.4 (CI 2.82) in the laparoscopic group and 2.9 (CI 1.96) in the transvaginal group (p = 0.41). The clinical assessment on cosmesis scores was not statistically different when recorded by clinical observers for most characteristics measured when the transvaginal group was compared to the laparoscopic group. Taken as a whole, the results slightly favor the transvaginal group. SF-12 scores were not statistically different at all postoperative time points except for the SF-12 mental component which was superior in the transvaginal group at all time points (p < 0.05).Conclusion: The safety profile for transvaginal cholecystectomy demonstrates that this approach is safe and produces at least non-inferior clinical results with superior cosmesis, with a transient reduction in discomfort. The transvaginal approach to cholecystectomy should no longer be considered experimental. As a model for intersociety collaboration, the study demonstrated the ultimate feasibility and success of partnership as a model for basic research, procedural development, fundraising, and clinical trial execution for novel interventional concepts, regardless of physician board certification. [ABSTRACT FROM AUTHOR]

Acute calculous cholecystitis is a common disease in cirrhotic patients. Laparoscopic cholecystectomy can resolve this problem but is performed based on the premise that the local inflammation must been controlled. An Initial ultrasound guided percutaneous transhepatic cholecystostomy may reduce the local inflammation and provide advantages in subsequent surgery. In this paper, we detailed our experience of treating acute severe calculous cholecystitis in patients with advanced cirrhosis by delayed laparoscopic cholecystectomy plus initiated ultrasound guided percutaneous transhepatic cholecystostomy and provided the analysis of the treatment effect. We hope this paper can provided a kind of standard procedure for this special disease; however, further prospective comparative randomized trials are needed to assess this treatment in cirrhotic patients with acute cholecystitis. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic cholecystectomy (LC) is the treatment of choice for symptomatic cholecystolithiasis. Despite the many advantages over open surgery, many patients complain about referred pain to the shoulder during the postoperative course. The purpose of this review was to evaluate different intraoperative surgical methods to minimize shoulder pain (SP). Methods: A search of the literature was conducted using PubMed, Excerpta Medica Database (EMBASE), and Cochrane database of systematic reviews. Eligibility criteria were: randomized clinical trials or meta-analysis evaluating intraoperative surgical methods applied to minimize incidence or severity of SP after LC. Only papers published in English were included. Data extracted were year of publication, number of participants and allocation, nonsignificant or significant effect on incidence or severity of SP. Results: A total of 31 papers where included in the review. Seven, 8, and 12 papers investigated the effect of drains, abdominal wall lift (AWL), and low-pressure pneumoperitoneum respectively. Four papers investigated drain suction, active gas aspiration, low insufflation flow or NO insufflation respectively. The interventions that overall showed a significant reduction on either the incidence or severity of SP were low-pressure pneumoperitoneum, low insufflation rate, and active gas aspiration. Conclusions: Drainage and AWL are not recommended to reduce SP after LC. Low-pressure pneumoperitoneum with carbon dioxide is the best documented intraoperative surgical method to minimize both the incidence and severity of SP after LC. [ABSTRACT FROM AUTHOR]

Background Index cholecystectomy ( IC) refers to an operation during a patient's first hospital admission with symptomatic gallstone ( GS) disease. There are proven reductions in cost, hospital bed days and GS-related complications while awaiting elective surgery. IC has not been universally adopted, particularly in smaller centres where logistics can present a barrier. The aim of this paper is to describe the introduction of routine IC at Hastings Hospital and the effects in terms of waiting time until surgery; GS-related re-presentations and complications while awaiting surgery; operative complications and overall hospital stay. Methods Data were collected for all patients who underwent cholecystectomy in the year following the introduction of IC (2015/2016). The results were compared with data from the year 2009/2010. Results A total of 259 cholecystectomies were performed over the 2015/2016 study period compared with 186 in the 2009/2010 study period. The IC rate increased from 9.89% in 2009 to 75.4% in 2015 ( P < 0.001). The incidence of GS pancreatitis whilst waiting for surgery reduced from six in 2009 compared with one in 2015 ( P = 0.046). The operative complications were similar in both groups. Total hospital stay was also similar. Conclusion The study shows that it is possible to perform IC in a rural setting reducing complications of waiting and in particular, rates of GS-related pancreatitis were significantly reduced. It can be done safely with an accommodating acute on-call system. [ABSTRACT FROM AUTHOR]

Different approaches are available for the treatment of combined cholecystocholedocholithiasis including totally laparoscopic (TL) treatment, simultaneous laparoendoscopic treatment, and sequential treatments (ST) combining endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) with cholecystectomy. This review aimed to clarify the issue of the simultaneous laparoendoscopic rendezvous (RV). A careful analysis of papers was performed to determine the results, technical differences, limits, disadvantages, and advantages of RV compared with other options. Data were collected from 27 papers concerning 795 patients. The overall effectiveness of RV was 92.3%. The morbidity rate was 5.1%, and the mortality rate was 0.37%. Almost all the authors were satisfied with the procedure. The authors’ comparison to ST and TL showed that the advantages outweigh the disadvantages mostly related to logistical problems. There is confusion concerning the definitions and techniques of RV due to differences in combining surgical and endoscopic steps of the procedure. The results are at least comparable with those of the other available approaches. The effectiveness of RV is greater with reciprocal implementation of surgical and endoscopic procedures. The morbidity and the risk of iatrogenic damage seem lower than with ERCP-ES and the risk of residual stones lower than with TL treatment. The RV procedure is safe and can sometimes be the preferable option, but collaboration between surgeon and endoscopist is mandatory. [ABSTRACT FROM AUTHOR]

Natural orifice translumenal endoscopic surgery (NOTES) has moved quickly from preclinical investigation to clinical implementation. However, several major technical problems limit clinical NOTES including safe access, retraction and dissection of the gallbladder, and clipping of key structures. This study aimed to identify challenges and develop solutions for NOTES during the initial clinical experience. Under an Institutional Review Board (IRB)-approved protocol, patients consented to a natural orifice operation for removal of either the gallbladder or the appendix via either the vagina or the stomach using a single umbilical trocar for safety and assistance. Nine transvaginal cholecystectomies, one transgastric appendectomy, and one transvaginal appendectomy have been completed to date. All but one patient were discharged on postoperative day 1 as per protocol. No complications occurred. The limited initial evidence from this study demonstrates that NOTES is feasible and safe. The addition of an umbilical trocar is a bridge allowing safe performance of NOTES procedures until better instruments become available. The addition of a flexible long grasper through the vagina and a flexible operating platform through the stomach has enabled the performance of NOTES in a safe and easily reproducible manner. The use of a uterine manipulator has facilitated visualization of the cul de sac in women with a uterus to allow for safe transvaginal access. [ABSTRACT FROM AUTHOR]

Background: In this paper, we report on a modified technique of laparoscopic cholecystectomy (LC), using three-trocars in cases of difficult anatomy at the Calot's triangle without the insertion of more additional trocars, in order to validate its feasibility, efficacy, and safety. Patients and Methods: We retrospectively analyzed 67 consecutive cases of body-first LCs performed for gallbladder disease from January to December 2007. The surgical technique was compared with respect to operative times, conversion to open cholecystectomy, postoperative complications, and length of postoperative stay. Results: The body-first LC was successful in 64 patients (95.6%). The median operating time was 32 minutes (range, 27–90) for chronic cholecystitis, 53 minutes (range, 41–145) for acute cholecystitis, and 62 minutes (range, 35–170) for interval cholecystectomy. The difference in duration of the surgical procedure between the chronic cholecystitis group and the other two groups was significant ( P < 0.05). We did not find any significant difference in the average operating time between the acute cholecystitis group and the interval cholecystectomy. The average postoperative hospital stay was 1 day (range, 1–3). No common bile duct injuries and no complications occurred in the series reported in this paper. Conclusions: The body-first three-trocar LC is a safe option when dealing with patients with difficult anatomy at the Calot's triangle. It yields a low conversion rate and avoids the insertion of any additional trocars. Further studies are required on the long-term efficiency and reliability of this technique in order to fully evaluate its value. [ABSTRACT FROM AUTHOR]

Grasping a tense, inflamed gall bladder during laparoscopic cholecystectomy for acute cholecystitis is often a problem. Although many surgeons have developed techniques to deal with this, the published work lacks information about how to manage this problem. To collate experience about how to deal with this we interviewed 20 experienced Australian surgeons and compiled a repertoire of tactics that might help deal with this clinical situation. Most surgeons indicated that they deflated the gall bladder using a needle and suction as a preliminary step. Most respondents also described the use of a specific type of forceps for the task. Various manoeuvres, such as displacement of the gall bladder with forceps, dislodging an impacted stone to make it easier to grasp, the use of a retraction suture through the gall bladder were described. The various tactics are summarized in the paper. A range of strategies applied by experienced surgeons for the task of gripping a difficult gall bladder has been documented in this paper. The variety of approaches suggests that surgeons should be prepared to flexibly apply different approaches to this task. [ABSTRACT FROM AUTHOR]

An amendment to this paper has been published and can be accessed via a link at the top of the paper. [ABSTRACT FROM AUTHOR]

This article focuses on Mirizzi Syndrome (MS) that occurs in about I % of patients coming to cholecystectomy. The importance of MS derives from the risk of bile duct injury during surgery. While that was recognized prior to the era of laparoscopic cholecystectomy it is blamed for many of the injuries now encountered and for the change toward a pattern of excisional injury as opposed to transection or ligation injuries, which were more common with open surgery. This article shows that it is the unsuspected case of MS that poses the greatest hazard.

Surgical workflow recognition has numerous potential medical applications, such as the automatic indexing of surgical video databases and the optimization of real-time operating room scheduling, among others. As a result, surgical phase recognition has been studied in the context of several kinds of surgeries, such as cataract, neurological, and laparoscopic surgeries. In the literature, two types of features are typically used to perform this task: visual features and tool usage signals. However, the used visual features are mostly handcrafted. Furthermore, the tool usage signals are usually collected via a manual annotation process or by using additional equipment. In this paper, we propose a novel method for phase recognition that uses a convolutional neural network (CNN) to automatically learn features from cholecystectomy videos and that relies uniquely on visual information. In previous studies, it has been shown that the tool usage signals can provide valuable information in performing the phase recognition task. Thus, we present a novel CNN architecture, called EndoNet, that is designed to carry out the phase recognition and tool presence detection tasks in a multi-task manner. To the best of our knowledge, this is the first work proposing to use a CNN for multiple recognition tasks on laparoscopic videos. Experimental comparisons to other methods show that EndoNet yields state-of-the-art results for both tasks. [ABSTRACT FROM PUBLISHER]