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Background Laparoscopic common bile duct exploration (LCBDE) during laparoscopic cholecystectomy (LC) is as effective as two-stage endo-laparoscopic treatment, but with shorter hospital stay, lower cost and recurrent stone rate. Aim of this paper was to report the authors’ experience with LCBDE during LC. Methods A retrospective analysis of patients who underwent LCBDE for ductal stones was performed. Recurrent stones were defined as CBD stones detected beyond 6 months from the procedure. Postoperative biliary stricture was defined as a symptomatic reduction of CBD diameter. Results Out of 3444 patients who underwent LC, 384 (11%) had CBD stones treated by trans-cystic duct exploration [214 (6%) patients, TCD-CBDE] or choledochotomy [170 (5%) patients, C-CBDE]. For TCD-CBDE and C-CBDE, mean operative time was 127 ± 69 and 191 ± 74 min, respectively. Major morbidity rate was 3% (n = 6) in TCD-CBDE and 6% (n = 11) in C-CBDE. The incidence of residual stones was 5% (n = 20) and complete ductal clearance rate was 95% (n = 364). After long-term follow-up (mean 189 ± 105 months) the recurrent stone rate was 2%. Discussion In expert centers, LCBDE during LC is safe and effective with low short and long term morbidity rates. [ABSTRACT FROM AUTHOR]

Background: Increasing the engagement of employees in the treatment process of patients may benefit a hospital and employee productivity and may result in better patient care and satisfaction with medical services. Given this, the first step in improving the quality of patient care is better availability of doctors for patients in a hospital ward. Methods: The research for this paper was conducted in six health care units in the Kuyavian-Pomeranian province in Poland. The research assessed how the elements relating to employees' behavior and things characteristic to medical service influence patients' willingness to recommend a hospital. Results: Patients' perception of services is linked with the behavior of medical employees and their engagement in the treatment process. Conclusion: Our research indicates that individual employee recognition and collective recognition of hospital employees as a whole were identified as the most important factors in employee engagement in the treatment process (employee productivity) and patients' satisfaction with medical service. [ABSTRACT FROM AUTHOR]

Background: Lactobacilli are non-spore forming, lactic acid producing, gram-positive rods. They are a part of the normal gastrointestinal and genitourinary microbiota and have rarely been reported to be the cause of infections. Lactobacilli species are considered non-pathogenic organisms and have been used as probiotics to prevent antibiotic associated diarrhea. There are sporadic reported cases of infections related to lactobacilli containing probiotics. Case presentation: In this paper we discuss a case of an 82 year old female with liver abscess and bacteremia from lactobacillus after using probiotics containing lactobacilli in the course of her treatment of Clostridium difficile colitis. The Lactobacillus strain identification was not performed and therefore, both commensal microbiota and the probiotic product should be considered as possible sources of the strain. Conclusion: Lactobacilli can lead to bacteremia and liver abscesses in some susceptible persons and greater awareness of this potential side effect is warranted with the increasing use of probiotics containing lactobacilli. [ABSTRACT FROM AUTHOR]

Much recent work on the economics of new technology adoption has investigated the roles of information and externalities. However, studies of technology adoption by physicians have not addressed these issues. This paper examines the adoption by general surgeons of laparoscopic cholecystectomy, a new surgical procedure which was introduced in 1989 The paper addresses the informational and cost externalities which may be generated when the first surgeon in a hospital adopts a new procedure. The findings suggest that access to information about laparoscopic cholecystectomy influenced surgeons' adoption behavior, and that externalities in hospitals may have hastened the diffusion of the procedure. [ABSTRACT FROM AUTHOR]

Background: Since the advent of laparoscopic cholecystectomy (LC) there has been continued debate regarding the management of acute cholecystitis with either early or delayed LC. Nearly all studies have demonstrated that early LC has a significantly shorter total length of hospital stay compared with delayed LC. Although previous randomized controlled trials and meta-analysis have shown clinical outcomes to favour early surgery, clinical practice continues to vary significantly worldwide. In addition, there is much confusion in the optimal timing for early LC with definitions of early varying from 72 h to 7 days. There have been numerous case-control studies investigating the timing of LC in acute cholecystitis. The aim of this paper is to pool the results from all case-control studies to investigate outcomes including mortality rates, complication rates, length of hospital stay and conversion rates to open procedures.Methods: A search of electronic databases was performed for case-control studies published between 1985-February 2015.Results: Results from 77 case-control studies showed statistically significant reductions in mortality, complications, bile duct leaks, bile duct injuries, wound infections, conversion rates, length of hospital stay and blood loss associated with early LC. Although LC within the 72-h window is optimal, patients operated after this window still benefit from early surgery compared to delayed surgery. The duration of symptoms in acute cholecystitis should not influence the surgeons' willingness to operate acutely.Conclusions: Early LC is clearly superior to delayed LC in acute cholecystitis. The most recent evidence-based practice strongly suggests that early LC should be standard of care in the management of acute cholecystitis. [ABSTRACT FROM AUTHOR]

Introduction and Study Aim: A virtual translumenal endoscopic surgical trainer (VTEST) is being developed to accelerate the development of natural orifice translumenal endoscopic surgery (NOTES) procedures and devices in a safe and risk-free environment. For a rapidly developing field such as NOTES, a needs analysis must be conducted regularly to discover emerging research trends and areas of potential high impact for a virtual simulator. This paper presents a survey-based study which follows a similar study conducted by this group in 2011 (Sankaranarayanan et al. in Surg Endosc 27:1607-1616, 2013).Methods: A 32-point questionnaire was distributed at the 2012 Natural Orifice Surgery Consortium for Assessment and Research annual meeting. These data were subsequently augmented by an identical online survey, targeted at the members of the American Society for Gastrointestinal Endoscopy and the Society of American Gastrointestinal and Endoscopic Surgeons, and analyzed.Results: Twenty-eight NOTES experts participated in the 2012 study. Cholecystectomy (CE) procedure remained the most commonly performed NOTES technique, with 18 positive responses (64%). In contrast to 2011, the popularity of the NOTES appendectomy (AE) was significantly lower, with only 2 (7%) instances (CE vs. AE, p < 0.001), while the number of peroral endoscopic myotomy (POEM, PE) cases had increased significantly, with 11 (39%) positive responses, respectively (PE vs. AE, p = 0.013). Strong preference toward hybrid rather than pure NOTES techniques (82 vs. 11%, p < 0.001) was also expressed. Other responses were similar to those in the 2011 study, with the VTEST™ utility in developing and testing new techniques and instruments ranked particularly high.Conclusion: Based on the results of this study, a decision was made to focus exclusively on the transvaginal hybrid NOTES cholecystectomy procedure, including both rigid and flexible scope techniques. The importance of developing a virtual NOTES simulator was reaffirmed, with POEM identified as a promising candidate for future simulator development. [ABSTRACT FROM AUTHOR]

The dissection of the cystic pedicle represents the "main" issue in performing the cholecystectomy, as well as the surgical moment when many accidents may happen. The paper analyzes the most frequent causes, which can generate iatrogenic injuries of the common bile duct (CBD) during the dissection of the cystic pedicle, such as the ductal and vascular anatomical variants, the local pathological transformation, human errors, etc. [ABSTRACT FROM AUTHOR]

Transvaginal access is the most popular natural orifice translumenal technique in the minimally invasive surgery. Reviews on non-gynecological transvaginal approach morbidities reveal that rates vary greatly. A systematic review of transvaginal approach in non-gynecological intraabdominal procedures was carried out to assess the risk of complications. A systematic search was conducted using MEDLINE, EMBASE, PubMed, and the Cochrane Library from the inception of these databases to March 2012. The following keywords were searched: 'transvaginal', 'NOTES', 'single incision', and 'single port'. From the total of 231 potentially eligible abstracts, 87 papers were retrieved and evaluated as fulfilling the eligibility criteria. The final analysis included 32 articles. The overall complications rate was 4.4 %, and complications related to the transvaginal port reached 2.4 %. Conversion rate to open surgery was 3.4 %. The incidence of postoperative urinary tract infection was 0.8 %. The mean operative time was 119 min. The mean hospital stay was 3.1 days (range 6 h-12 days). The technique of transvaginal access can offer several advantages for a patient and is associated with an acceptable rate of complications. [ABSTRACT FROM AUTHOR]

Virtual simulation of laparoscopic surgery is getting attention for training novice surgeons and medical residents for practice. Virtual surgical simulation has many advantages because it can provide users with a safe environment without animal or patient subjects. Although several solutions are available in the market, there are no reported studies with detailed technical descriptions of the virtual simulation of laparoscopic cholecystectomy (gallbladder removal surgery), one of the major surgeries performed using laparoscopic surgical procedures. Here, we present a realistic laparoscopic cholecystectomy training simulator. The system was developed by applying state-of-the-art computer graphical technologies using an open source library and proposing a new method of deformable mesh carving. The deformable mesh carving is a volume-based method using potential fields and hexahedral finite element method. In this paper, we describe the detailed techniques used to realize the laparoscopic cholecystectomy simulation. The experimental and user study results prove that the presented system simulates the cholecystectomy procedures in real time with high degree of realism and fidelity. [ABSTRACT FROM AUTHOR]

Background: Single-incision laparoscopic surgery (SILS) is a technique in laparoscopic surgery, which is based on the idea that all the laparoscopic trocars are inserted through a single umbilical incision. This paper documents a single-centre experience, which performed the single-port surgery in children using an improvised trans-umbilical glove-port with conventional rigid instruments. Materials and Methods: We prospectively studied the outcomes of SILS procedures between January 2013 and June 2014. Materials required making our homemade trans-umbilical port consisted on: A flexible ring, a rigid larger ring, one powder-free surgical glove, a wire-to-skin and standard standards laparoscopic trocars. Results: A total of 90 consecutive procedures had been done in our institution: 15 girls and 75 boys (mean age: 7.5 years). We used SILS on 59 appendectomies with an average operative time of 48 minutes. We needed conversion to conventional surgery in three cases (two with perforated appendicitis and one for difficulty to mobilize the appendix). SIL cholecystectomy was performed for four patients with symptomatic cholelithiasis; mean operative time was 60 min. All patients were discharged on postoperative day 2. Eighteen boys with non-palpable testis were explored and treated. Other procedures included: Varicocelectomy (n = 2), intra-abdominal lymph node biopsies (n = 2), ovarian cystectomy (n = 1), ovarian transposition (n = 1), aspiration of renal hydatid cyst (n = 1), explorative laparoscopy in research to Meckel's diverticulum (n = 1) and intestinal intussusceptions (n = 1). No post-operative complications were seen in all cases. Conclusions: SILS in the paediatric population using conventional rigid instruments is feasible, safe and effective. It may be an alternative to the costly commercially available single-port systems especially in a developing country like Tunisia. [ABSTRACT FROM AUTHOR]

Iatrogenic bile duct injuries (BDI) are still a challenging diagnostic and therapeutic problem. With the introduction of the laparoscopic technique for the treatment of cholecystolithiasis, the incidence of iatrogenic BDI increased. The aim of the study was a retrospective analysis of 69 patients treated at the department due to iatrogenic BDI in the years 2004-2014. Material and methods. In this paper, we presented the results of a retrospective analysis of 69 patients treated at the Department due to iatrogenic BDI in the years 2004-2014. The data were analysed in terms of age, sex, type of biliary injury, clinical symptoms, the type of repair surgery, the time between the primary surgery and the BDI management, postoperative complications and duration of hospital stay. Results. 82.6% of BDI occurred during laparoscopic cholecystectomy, 8.7% occurred during open cholecystectomy, whereas 6 cases of BDI resulted from surgeries conducted for other indications. In order to assess the degree of BDI, Bismuth and Neuhaus classifications were used (for open and laparoscopic cholecystectomy respectively). 84.1% of patients with confirmed BDI, were transferred to the Department from other hospitals. The average time between the primary surgery and reoperation was 6.2 days (SD 4). The most common clinical symptom was biliary fistula observed in 78.3% of patients. In 28 patients, unsuccessful attempts to manage BDI were made prior to the admission to the Department in other centres. The repair procedure was mainly conducted by laparotomy (82.6%) and by the endoscopic approach (15.9%). Hepaticojejunostomy was the most common type of reconstruction following BDI (34.7%). Conclusions. The increase in the rate of iatrogenic bile duct injury remains a challenging surgical problem. The management of BDI should be multidisciplinary treatment. Referring patients with both suspected and confirmed iatrogenic BDI to tertiary centres allows more effective treatment to be implemented. [ABSTRACT FROM AUTHOR]

The number of breast reconstruction procedures has been increasing in recent years. One of the suggested treatment methods is breast reconstruction with a pedicled skin and muscle TRAM flap (transverse rectus abdominis muscle -TRAM). Surgical incisions performed during a cholecystectomy procedure may be located in the areas significant for flap survival. The aim of this paper is to present anatomical changes in abdominal walls secondary to pedicled skin and muscle (TRAM) flap breast reconstruction, which influence the planned access in cholecystectomy procedures. The authors present 2 cases of cholecystectomy performed due to cholelithiasis in female patients with a history of TRAM flap breast reconstruction procedures. The first patient underwent a traditional method of surgery 14 days after the reconstruction due to acute cholecystitis. The second patient underwent a laparoscopy due to cholelithiasis 7 years after the TRAM procedure. In both cases an abdominal ultrasound scan was performed prior to the operation, and surgical access was determined following consultation with a plastic surgeon. The patient who had undergone traditional cholecystectomy developed an infection of the postoperative wound. The wound was treated with antibiotics, vacuum therapy and skin grafting. After 7 weeks complete postoperative wound healing and correct healing of the TRAM flap were achieved. The patient who had undergone laparoscopy was discharged home on the second postoperative day without any complications.In order to plan a safe surgical access, it is necessary to know the changes in the anatomy of abdominal walls following a pedicled TRAM flap breast reconstruction procedure. [ABSTRACT FROM AUTHOR]

Gallbladder cancer is a relatively rare cancer of the gastrointestinal tract, most commonly detected (approximately 95% of cases) in the most advanced clinical stage IV and burdened with high mortality rate. This is mainly due to the nonspecific symptoms in the early stages of the disease. The remaining cases of gallbladder cancer are usually detected after surgery due to gallstone disease. Gallstones, their size and pancreatic juice reflux into the gallbladder are risk factors in the development of gallbladder cancer. In this paper the authors carried out a retrospective research based on an evaluation of a group of 38 patients treated surgically due to the gallbladder cancer in the years 2005-2012 in the Second Department of General and Gastroenterological Surgery in Białystok Medical University Hospital. In this group there were 29 women and 9 men, in age between 48-86 years. Although women suffered from gallbladder cancer more often than men, their survival rate was significantly better after the surgery. The research showed some benefits of extended surgical procedures even in patients with advanced stages of the disease, while the effectiveness of surgical treatment depends mainly on the possibility of radical resection of the primary lesion and, eventually, the resection of lymph nodes and other infiltrated tissues. [ABSTRACT FROM AUTHOR]

Background: This study examined the association of cholelithiasis post-cholecystectomy with subsequent cancers and evaluated the risk of cancer in patients with both cholelithiasis and cholecystectomy. Methods: The Taiwanese National Health Insurance Research Database was used to identify 15545 newly diagnosed cholelithiasis patients from 2000 to 2010, and 62180 frequency-matched non-cholelithiasis patients. A total of 5850 (37.6 %) with cholelithiasis patients received a cholecystectomy. The risk of developing cancer after cholecystectomy was measured using the Cox proportional-hazards model. Results: The incidence of developing cancer in the cholelithiasis cohort was 1.52-fold higher than that in the comparison cohort ( p < 0.001). Compared with patients aged 20-34 years, patients in older age groups had a higher risk of developing cancer. The hazard ratio (HR) for developing gallbladder, extrahepatic bile duct, pancreatic, liver, stomach, and colorectal cancer was 59.3, 10.7, 3.12, 1.90, 1.71, and 1.36-fold higher for patients with cholelithiasis, respectively. After a cholecystectomy, the HR for developing stomach and colorectal cancer was 1.81-fold and 1.56-fold, respectively. The incidence rate ratio was higher for the first 5 years and over 5 years (5.05 and 4.46, respectively) (95 % confidence interval 4.73-5.39 and 4.11-4.84, respectively) in proximal colon and stomach cancer patients with cholecystectomies. Conclusions: Cholelithiasis patients have a higher risk of gastrointestinal cancer, particularly of gallbladder and extrahepatic bile duct cancer. Post-cholecystectomy patients have a risk of colorectal and stomach cancer within the first 5 years and persisting after 5 years, respectively. This paper proposes strategies for preventing gastrointestinal cancer. [ABSTRACT FROM AUTHOR]

Background: Systemic mast cell activation disease (MCAD) is characterized by an increased and unregulated release of mast cell mediators which can evoke a multifaceted clinical picture often resembling irritable bowel syndrome or fibromyalgia. Because of the considerable prevalence (~ 17 %) of MCAD surgeons are frequently unwittingly confronted with MCAD patients in whom unexpected intraoperative and postoperative complications may occur. Therefore, knowledge of the particular requirements is of relevance for surgical treatment of MCAD patients. Objective: The present paper outlines a concept of surgical treatment of MCAD patients based on the literature which is illustrated by a case report on emergency laparoscopic cholecystectomy. Conclusions: Due to the high prevalence of MCAD in the general population it can be assumed that the frequency in the surgical patient population is similar. If a patient has MCAD, specific characteristics should be taken into account in the surgical procedure to avoid increased operative and complication risks resulting from MCAD. [ABSTRACT FROM AUTHOR]

Aim: The aim of this paper is to study the outcome of day case laparoscopic cholecystectomy (DCLC) in children. Materials and Methods: A clinical pathway for day care laparoscopic cholecystectomy was followed with emphasis on the analgesia, post-operative nausea and vomiting (PONV), feeding, mobilization, pain scoring and patient satisfaction. Demographic and clinical data were recorded prospectively from March 2013 to November 2013. The setup allowed easy access to an overnight stay if needed. Hospital stay, complications, the need for medical advice after discharge, convalescence and patients satisfaction were analyzed. Results: We admitted 11 children with symptomatic cholelithiasis for day case laparoscopic surgery. There were no intra- or post-operative complications. The incidence of PONV was 0/11. There was no readmission. 4/11 patients complained of shoulder tip pain on follow-up next day. There was no overnight stay. Conclusions: Adoption of a DCLC pathway is feasible and safe for children. Emphasis on adequate pain management and avoidance of PONV results in a high rate of day case surgery equivalent to that achieved in adult practice. [ABSTRACT FROM AUTHOR]

Starting from November issue 2008, articles would be chosen as CME papers from each issue of the Surgical Practice. One CME point (active) has been accredited per CME article in Surgical Practice. Fellows of The College of Surgeons of Hong Kong could obtain CME points by returning the completed answer sheet by mail or fax to the College office. [Extracted from the article]

Patients with a history of cholecystectomy have been thought to be the high - risk population in early colorectal cancer screening in China. However, there are relatively few studies on the association between cholecystectomy and colorectal adenoma (precancerous lesions of colorectal cancer) around the world. The aim of this paper is to comprehensively evaluate the studies on the relationship between cholecystectomy and colorectal adenoma published both at home and abroad by meta - analysis. Methods Thirteen studies which met the inclusion criteria were divided into cohort study group (n = 6) and case - control study group (n = 7) according to research methods. A meta - analysis was performed using Review manager 5. 2 software to calculate the relative risk (RR) of the cohort study group and the odds ratio (OR) of the case - control study group, as well as their 95% confidence intervals (CI). Results A total of 5940 cases and 158 995 cases were included in the cohort study group and case - control group, respectively. The meta - analysis revealed a positive association between cholecystectomy and colorectal adenoma (RR = 1. 32, 95% CI: 1. 07 - 1. 61 ; OR = 1. 17, 95% CL: 1. 08 - 1. 26). Conclusion Cholecystectomy leads to an increase in the risk of colorectal adenoma. [ABSTRACT FROM AUTHOR]

Background: In the literature there are a number of studies that suggest a possible correlation between cholelithiasis/cholecystectomy and colorectal cancer. The exposure of the colon mucosa to the action of bile acids that potentially have a carcinogenic effect due to the change in anatomy after cholecystectomy, seems to be the explanation of this association. The purpose of this paper was to search for such a correlation in our study group. Methods: We performed a retrospective cross-sectional study, analyzing the patients admitted to the First Surgical Clinic of the County Emergency Clinical Hospital Tîrgu Mureș, between January 1st, 2005-December 31st, 2010. Analyzing the medical records, operation protocols and histopathological results, we paid attention to demographics, location of neoplasia, the time elapsed since the cholecystectomy to the discovery of neoplasia, histological types, trying to perform correlations between these parameters and the lithiasic factor. Results: Out of the 534 patients admitted and operated with the diagnosis of colorectal cancer, 15.6% (n = 83) showed a history of gallbladder stone affection. Most patients came from urban areas, the average age was 67.2 (range 39-88 years), females were more affected. The most common locations were: the sigmoid colon (26.5%), rectum (36.3%) and the most common histological form was moderately differentiated adenocarcinoma. Conclusions: Similar to other studies, our work suggests a slight increase in the incidence of colorectal cancer in patients that underwent a cholecystectomy, without drawing a firm conclusion. We deem it necessary to see if diet changes of the Romanian population affect this relationship. [ABSTRACT FROM AUTHOR]

Background: In this study, we evaluated the association between these polymorphisms and gallstone disease using meta-analysis and compared the hepatic ABCG5/G8 mRNA expression and biliary lipids composition in patients with different genotypes of T400K and Y54C. Methods: Data were analyzed using the Stata/SE 11.0 software and a random- effects model was applied irrespective of between-study heterogeneity. Hepatic mRNA expression of ABCG5/G8 genes in 182 patients with gallstone disease and 35 gallstone-free patients who underwent cholecystectomy were determined using real-time PCR. Genotypes of Y54C and T400K in the ABCG8 gene were determined by allelic discrimination using either genomic DNA or hepatic cDNA as template by Taqman assays. Biliary compostion in gallbladder bile was assayed in these patients as well. Results: Ten papers including 13 cohorts were included for the final analysis. In the genotype model, the overall association between genotype with gallstone was significant for D19H (OR = 2.43, 95%CI: 2.23–2.64, P<0.001), and for Y54C (OR = 1.36, 95%CI: 1.01–1.83, P = 0.044), or T400K (OR = 1.17, 95%CI: 0.96–1.43. P = 0.110). In allele model, minor alleles of D19H polymorphism (allele D: OR = 2.25, 95%CI: 2.10–2.42, P<0.001) and of T400K polymorphism (allele K: OR = 1.18, 95%CI: 1.06–1.31, P<0.001) were related with an increased risk of gallstone disease. However, minor allele of Y54C polymorphism (allele Y, OR = 1.08, 95%CI: 0.96–1.21, P = 0.146) was not related with gallstone disease. I2 statistics indicated no significant between-study heterogeneity for all genetic models for any of the three polymorphisms. Funnel plot and Egger’s test suggested the absence of publication bias as well. However, no association of T400K and Y54C polymorphism with hepatic ABCG8/G5 mRNA expression or biliary lipids composition was found. Conclusions: Our study showed strong association of D19H polymorphism with gallstone disease. T400K and Y54C polymorphism, though to a less extent, may also relate with gallstone disease. [ABSTRACT FROM AUTHOR]

Background: Early laparoscopic cholecystectomy imposes itself as an option of choice for treatment of acute cholecystitis, while the rate of conversions to open procedure represents a key parameter for evaluating the outcome. Aim: The aim of this paper was to evaluate the results of the laparoscopic cholecystectomy in acute versus chronic cholecystitis through determining the conversion rate in open method, as well as to analye some predictive factors that may impact the decision to convert to open. Material and methods: An analytical case control study was conducted at the University Clinic for Digestive Surgery in Skopje within a period of 27 months. The first group included 62 patients with acute cholecystitis on whom the laparoscopic cholecystectomy was performed in the period from zero to the seventh day from the onset of symptoms. The second group included 62 patients with chronic cholecystitis who underwent laparoscopic cholecystectomy. Gender, age, history of cholecystitis, the time passed from the first symptoms till laparoscopic cholecystectomy and the duration of the intervention were analysed as factors that can possibly act on conversion. Results: There were no significant differences (p > 0.05) between the group of patients with acute and the one with chronic cholecystitis due to conversion rate. In both groups, there was a significant difference in conversion due to the duration of the laparoscopic cholecystectomy (p < 0.05), and in the group with acute cholecystitis also due to the time passed from the first symptoms till the laparoscopic intervention (p < 0.01). Conclusion: The rate of conversions can be reduced with a prompt approach to predictive factors. [ABSTRACT FROM AUTHOR]

Background: The laparoscopic technique has many advantages compared with open surgery for symptomatic cholecystolithiasis. Despite these advantages, many patients complain about shoulder pain (SP) after laparoscopic cholecystectomy. The purpose of this review was to evaluate intraperitoneal instillation (IPI) of saline and local anesthesia (LA) to minimize SP. Methods: A search of the literature was conducted using PubMed and Excerpta Medica Database (EMBASE). Eligibility criteria were: randomized clinical trials (RCT) evaluating IPI of saline and/or LA to minimize incidence or severity of SP after laparoscopic cholecystectomy. Only papers published in English were included. Data extracted were year of publication, number of participants and allocation, timing of IPI, and nonsignificant or significant effect on incidence or severity of SP. Results: A total of 24 RCTs were included in the review. Four RCTs reported results on IPI saline as intervention versus nothing as control. Seven RCTs reported results on IPI LA as intervention versus nothing as control. Sixteen RCTs reported results on IPI LA as intervention versus saline as control. IPI saline resulted in a significant reduction in SP severity compared with nothing. IPI LA was associated with an overall significant reduction of SP severity compared with nothing. Results regarding the effect IPI LA versus saline showed contradictory results in regards to both SP incidence and severity. Conclusions: Both IPI of saline and LA can be used to reduce SP severity after laparoscopic cholecystectomy. It is not possible to conclude whether the incidence of SP can be reduced with saline or LA, due to contradictive results. [ABSTRACT FROM AUTHOR]

Laparoscopic surgery has been widely adopted and new technical innovation, procedures and evidence based knowledge are persistently emerging. This review documents recent major advancements in laparoscopic surgery. A Pub Med search was made in order to identify recent advances in this field. We reviewed the recent data on randomized trials in this field as well as papers of systematic review. Laparoscopic cholecystectomy is the most frequently performed procedure, followed by laparoscopic bariatric surgery. Although bile duct injuries are relatively uncommon (0.15%-0.6%), intraoperative cholangiography still plays a role in reducing the cost of litigation. Laparoscopic bariatric surgery is the most commonly performed laparoscopic gastrointestinal surgery in the USA, and laparoscopic Nissen fundoplication is the treatment of choice for intractable gastroesophageal reflux disease. Recent randomized trials have demonstrated that laparoscopic gastric and colorectal cancer resection are safe and oncologically correct procedures. Laparoscopic surgery has also been widely developed in hepatic, pancreatic, gynecological and urological surgery. Recently, SILS and robotic surgery have penetrated all specialties of abdominal surgery. However, evidence-based medicine has failed to show major advantages in SILS, and the disadvantage of robotic surgery is the high costs related to purchase and maintenance of technology. Laparoscopic surgery has become well developed in recent decades and is the choice of treatment in abdominal surgery. Recently developed SILS techniques and robotic surgery are promising but their benefits remain to be determined. [ABSTRACT FROM AUTHOR]

Background: Open cholecystectomy (OC) is often preferred over laparoscopic cholecystectomy (LC) in patients with liver cirrhosis and portal hypertension, but evidence is lacking to support this practice. This meta-analysis aimed to clarify which surgical technique is preferable for symptomatic cholecystolithiasis in patients with liver cirrhosis. Methods: A meta-analysis was conducted according to the PRISMA guidelines. Articles published between January 1990 and October 2011 were identified from MEDLINE, Embase and the Cochrane Library. Randomized clinical trials (RCTs) comparing outcomes of OC versus LC for cholecystolithiasis in patients with liver cirrhosis were included. The quality of the RCTs was assessed using the Jadad criteria. Results: Following review of 1422 papers by title and abstract, a meta-analysis was conducted of four RCTs comprising 234 surgical patients. They provided evidence of at least level 2b on the Oxford Level of Evidence Scale, but scored poorly according to the Jadad criteria. Some 97·0 per cent of the patients had Child-Turcotte-Pugh (CTP) grade A or B liver cirrhosis. In all, 96·6 per cent underwent elective surgery. No postoperative deaths were reported. LC was associated with fewer postoperative complications (risk ratio 0·52, 95 per cent confidence interval (c.i.) 0·29 to 0·92; P = 0·03), a shorter hospital stay (mean difference − 3·05 (95 per cent c.i. − 4·09 to − 2·01) days; P < 0·001) and quicker resumption of a normal diet (mean difference − 27·48 (−30·96 to − 23·99) h; P < 0·001). Conclusion: Patients with CTP grade A or B liver cirrhosis who undergo LC for symptomatic cholecystolithiasis have fewer overall postoperative complications, a shorter hospital stay and resume a normal diet more quickly than those who undergo OC. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Abstract: A challenge in virtual reality based laparoscopic cholecystectomy simulation is to construct a fast and accurate deformable gallbladder model. This paper proposed a multi-layered mass-spring model which can adapt well to the built-in accelerating algorithms in PhysX-Engine of Graphics Processing Unit (GPU). The gallbladder was first segmented from clinical Computed Tomography (CT) images. From the segmentation result, a surface mesh of a gallbladder was constructed. The inner layers of a mass-spring model were generated from the surface mesh based on the anatomical structure of gallbladder. We configured the parameters of the springs based on the biomechanical properties of gallbladder to ensure the reality of the deformation results. Preliminary experiments demonstrated that our model was able to achieve satisfactory results in terms of both visual perception and time performance. [Copyright &y& Elsevier]

Background and study aims: Natural orifice transluminal endoscopic surgery (NOTES) is a technique still in experimental development whose safety and effectiveness call for assessment through clinical trials. In this paper we present a three-arm, noninferiority, prospective randomized clinical trial of 1 year duration comparing the vaginal and transumbilical approaches for transluminal endoscopic surgery with the conventional laparoscopic approach for elective cholecystectomy. Patients and methods: Sixty female patients between the ages of 18 and 65 years who were eligible for elective cholecystectomy were randomized in a ratio of 1:1:1 to receive hybrid transvaginal NOTES (TV group), hybrid transumbilical NOTES (TU group) or conventional laparoscopy (CL group). The main study variable was parietal complications (wound infection, bleeding, and eventration). The analysis was by intention to treat, and losses were not replaced. Results: Cholecystectomy was successfully performed on 94 % of the patients. One patient in the TU group was reconverted to CL owing to difficulty in maneuvering the endoscope. After a minimum follow-up period of 1 year, no differences were noted in the rate of parietal complications. Postoperative pain, length of hospital stay, and time off from work were similar in the three groups. No patient developed dyspareunia. Surgical time was longer among cases in which a flexible endoscope was used (CL, 47.04 min; TV, 64.85 min; TU, 59.80 min). Conclusions: NOTES approaches using the flexible endoscope are not inferior in safety or effectiveness to conventional laparoscopy. The transumbilical approach with flexible endoscope is as effective and safe as the transvaginal approach and is a promising, single-incision approach. [ABSTRACT FROM AUTHOR]

Background: Large bowel obstruction is rarely caused by adhesions. To our knowledge, the few cases reported in literature are secondary to previous abdomino-pelvic surgery, and are in female patients. Case Reports: We report two cases of large bowel obstruction due to adhesions in males with no previous abdominal surgery. The first case was a 73 years old male previously well, who presented with a one week history of abdominal colicky pain with nausea. Initially this patient was thought to have symptomatic gallstones as a result of an ultrasound scan report. Consequently, a decision to take the patient for laparoscopic cholecystectomy was reached. Due to difficulties in achieving penumoperitoneum, a laparotomy was done; the patient was found to have a fibrous band across transverse colon causing obstruction. The second case was a 61 years old male, known diabetic and hypertensive, who presented with epigastric pain, nausea, vomiting and constipation. Abdominal X-rays demonstrated large bowel obstruction. At laparotomy, this patient was found to have adhesions causing sigmoid colon obstruction. Conclusion: In this paper, we demonstrate the rarity of large bowel obstruction secondary to adhesions especially in a virgin abdomen, emphasize the importance of good radiological expertise, and highlight the need to consider adhesions as a very rare but possible cause of large bowel obstruction. [ABSTRACT FROM AUTHOR]

Introduction: The recent introduction of a Surgical Safety Checklist has significantly reduced the morbidity and mortality of surgery. Such a simple measure that can impact so highly on surgical outcomes causes all surgeons to pause for thought. This paper documents the introduction of a 10-step intraoperative surgical checklist (ISC) to standardize performance, decision-making, and training during laparoscopic cholecystectomy (LC). The checklist's impact on conversion rates to open cholecystectomy (OC) is presented. Methods: In 2004, a 10-step ISC was introduced by a single consultant surgeon for the performance of LCs. Data were collected comparing LCs between 1999-2003 (period 1) and 2004-2008 (period 2). Data on sex, age, American Society of Anesthesiology grade, previous abdominal surgery, severity of gallbladder pathology, and conversion to OC were recorded. The chi-squared test with Yates correction was used to compare groups. Results: In total, 637 LCs were performed, 277 during period 1 and 360 during period 2. Risk factors for conversion (gender, age, previous abdominal surgery, and severity of gallbladder pathology) were not significantly different in the two periods studied. The overall conversion rate to OC fell significantly in period 2 ( p = 0.001). Subgroup analysis also showed a significant reduction in conversion rates in female patients ( p = 0.002) and patients with grades III and IV gallbladder disease ( p = 0.001). Conclusions: The introduction of a 10-step ISC was temporally related to reduced conversion rates to OC. The standardization of a frequently performed operation such as a LC that could potentially lead to an impact as great the one we observed warrants further attention in prospective, appropriately designed studies. [ABSTRACT FROM AUTHOR]

Background: Natural orifice transluminal endoscopic surgery (NOTES) and single-incision surgery (SIS) are less invasive alternatives to traditional laparoscopic techniques. Concerns exist over the safety of these new approaches, and randomized controlled trials have yet to confirm a net benefit. If NOTES and SIS techniques are to become standard practice, then they should be shown to be safe and hold clear benefits to patients. We aim at comparing the available results by using these techniques in a standard laparoscopic operation (cholecystectomy). Methods: A systematic review using available databases (MEDLINE, EMBASE, and the Cochrane Controlled Trials Register) and the published English language medical literature was performed. All the archived articles were cross-referenced. Outcome data obtained from a Cochrane review of laparoscopic cholecystectomy were used as the control group. All the operations performed via a single incision were grouped under SIS, and operations in which a natural orifice (alone or as a hybrid technique) was analyzed, under NOTES group. Mortality and complications were the primary outcome measures. Results: One hundred thirty-five papers including 4703 patients (714 NOTES, 3989 SIS) were selected for analysis. Overall complication rate was 4.2% in the NOTES group versus 4.3% in the SIS group, with a distinct complication profile. No mortality was reported in either group. NOTES procedures had a longer mean operative time than SIS techniques (107 versus 79 minutes). The conversion rate between NOTES and SILS was similar (3.4% versus 3.3%, respectively). Discussion: No difference in the incidence of complications was observed with the newer techniques. Adequately powered randomized control trials are needed to clarify whether SIS/NOTES cholecystectomy has a similar length of hospital stay to traditional laparoscopic cholecystectomy. The increased occurrence of specific types of complications and their use in acute pathology needs further investigation to warrant further use in routine surgical practice. [ABSTRACT FROM AUTHOR]

Introduction. Single-incision laparoscopic surgery (SILS) is a virtually "scarless" technique. A retrospective analysis is performed to evaluate an initial experience of this surgical approach. Materials and Methods. From January 2010 to October 2011, SILS was considered as a minimally invasive approach to abdominal disease. The access was made by a standard wound protector and a size 6 glove. A series of little accesses were made on the tips of the glove-fingers to induce pneumoperitoneum and to create a working channel for the laparoscopic instruments. An analysis of costs of this technique was made too. Results. SILS was successfully completed with low cost in 34 patients: 20 appendectomy, 12 cholecystectomy, and 2 right colectomy were performed with a median operative time of 35, 45, and 67.5 minutes, respectively. In no patient any conversion to standard laparoscopy or to open surgery was needed. The postoperative course was uneventful in all patients. In right hemicolectomy, the oncological parameters were respected. Conclusions. In this paper the glove-port technique showed multiple advantages. The SILS is a feasible approach for some pathologies in selected patients. The glove-port is a simple, low-cost, reproducible, and sure method to perform SILS in a high-experienced laparoscopic surgical centre. [ABSTRACT FROM AUTHOR]

safety and feasibility. In human trials, safety and feasibility remain at the forefront; however, additional logistic, practical, and regulatory requirements must be addressed. The purpose of this paper is to evaluate and summarize published studies to date of NOTES in humans. The literature review was performed using PUBMED and MEDLINE databases. Articles published in human populations between 2007 and 2011 were evaluated. A review of this time period resulted in 48 studies describing procedures in 916 patients. Transcolonic and transvesicular procedures were excluded. The most common procedure was cholecystectomy (682, 75%). The most common approach was transvaginal (721, 79%). 424 procedures (46%) were pure NOTES and 491 (54%) were hybrid NOTES cases. 127 (14%) were performed in the United States of America and 789 (86%) were performed internationally. Since 2007, there has been major development in NOTES in human populations. A preponderance of published NOTES procedures were performed internationally. With further development, NOTES may make less invasive surgery available to a larger human population. [ABSTRACT FROM AUTHOR]

Introduction: Single-incision laparoscopic surgery (SILS) is a "new" method to perform "old" operations. Though SILS has been referred to by many names, for the sake of this paper, any procedure done laparoscopically through one incision (regardless of the number of ports or working channels) will be considered a SILS procedure. This brief review will discuss the history of SILS, current applications, and potential pitfalls. Methods: To explore the outcomes of SILS cholestectomy in a community setting, we conducted a historical control study comparing, through retrospective review, 50 laparoscopic cholecystectomies to 50 SILS cholecystectomies, all performed by one of the authors (DT). Results: Of the 50 patients selected, 12 patients had cholangiograms performed at the same time. The mean operative time for all cases was 50.4 minutes (range 31 minutes to 108 minutes). For the noncholangiogram group, the mean operative time was 48 minutes whereas it was 57.7 minutes for patients requiring a cholangiogram. Mean estimated blood loss was 28 mL. There was a 20% "conversion" rate (n = 10): 4 with an additional trocar, 5 with a 4-port technique, 1 with an open procedure. Discussion: We conclude that, although SILS is a relatively new procedure for general surgery, we feel it is here to stay. Although the only documented benefit is cosmetic, SILS is equivalent to conventional laparoscopy in all other respects. [ABSTRACT FROM AUTHOR]

Aim This paper presents our initial experience of single incision laparoscopic total colectomy and proctocolectomy. Method Four female patients (mean age 35.5 years; mean body mass index 24.7 kg/m2) underwent total colectomy with end ileostomy ( n = 2) and proctocolectomy with stapled ileum pouch-anal ( n = 1) and rectal ( n = 1) anastomosis with loop ileostomy, for benign disease, using a single-incision laparoscopic approach. The single port was placed at the umbilicus or the ileostomy site. Specimen extraction was through the port site. Results Operative procedures were performed with a mean operative time of 212 min, mean blood loss of 30 ml and no intraoperative complication. No additional abdominal ports were required. A postoperative ileus ( n = 1) on day three resolved spontaneously and the. mean hospital stay was 4.5 days. Conclusion Single-incision laparoscopic total colectomy or proctocolectomy is feasible for benign disease in selected patients. [ABSTRACT FROM AUTHOR]

Background: General surgery trainees' perceptions regarding their own laparoscopic training remain poorly defined. The objective of this survey was to identify and evaluate learner experiences with laparoscopic procedures in general surgery programs on a national level. Methods: Two hundred eighty-four residents were identified and contacted at English-speaking general surgery programs across Canada. Each was asked to complete a web- or paper-based survey regarding their demographics, experiences with basic and advanced minimally invasive surgery (MIS) procedures, and perceived barriers to training. Results: Two hundred fifty-two of 284 (89%) surveyed residents responded. Eighty-seven percent of the residents had access to a skills lab that taught MIS techniques; however, standardized MIS curricula were implemented 53% of the time. Eighty percent of residents felt that skills lab training translated to improved performance in the OR. Although 90% of residents felt that they would be comfortable performing basic laparoscopic procedures, only 8% stated they would be comfortable performing advanced procedures at the end of their training. Moreover, 90% of general surgery residents felt that it was the academic surgical department's responsibility to teach both basic and advanced procedures, and 35% of respondents felt their surgical program was meeting this requirement. Half of the residents felt they had limited opportunity to be a primary surgeon because an MIS fellow was present. Conclusions: There exists a wide disparity between the expectations of residents and their actual experience. The majority of residents are concerned that they will not acquire sufficient laparoscopic skills during their training to perform advanced cases in practice. Additionally, the balance between resident and fellow-level cases needs to be more clearly defined as the majority of respondents identified the presence of a MIS fellow as a negative learning influence. Finally, although most centers had a surgical skills lab, 47% of respondents felt that the curriculum was not standardized and this also needs to be addressed. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Different reasons may cause difficult intraoperative surgical situations. This study aims to predict intraoperative complexity by classifying and evaluating preoperative patient data. The basic prediction problem addressed in this paper involves the classification of preoperative data into two classes: easy (Class 0) and complex (Class 1) surgeries. Methods and material: preoperative patient data were collected from 337 patients admitted to the Klinikum rechts der Isar hospital in Munich, Germany for laparoscopic cholecystectomy (LAPCHOL) in the period of 2005–2008. The data include the patient''s body mass index (BMI), sex, inflammation, wall thickening, age and history of previous surgery, as well as the name and level of experience of the operating surgeon. The operating surgeon was asked to label the intraoperative complexity after the surgery: ‘0’ if the surgery was easy and ‘1’ if it was complex. For the classification task a set of classifiers was evaluated, including linear discriminant classifier (LDC), quadratic discriminant classifier (QDC), Parzen and support vector machine (SVM). Moreover, feature-selection was applied to derive the optimal preoperative patient parameters for predicting intraoperative complexity. Results: Classification results indicate a preference for the LDC in terms of classification error, although the SVM classifier is preferred in terms of results concerning the area under the curve. The trained LDC or SVM classifier can therefore be used in preoperative settings to predict complexity from preoperative patient data with classification error rates below 17%. Moreover, feature-selection results identify bias in the process of labelling surgical complexity, although this bias is irrelevant for patients with inflammation, wall thickening, male sex and high BMI. These patients tend to be at high risk for complex LAPCHOL surgeries, regardless of labelling bias. Conclusions: Intraoperative complexity can be predicted before surgery according to preoperative data with accuracy up to 83% using an LDC or SVM classifier. The set of features that are relevant for predicting complexity includes inflammation, wall thickening, sex and BMI score. [Copyright &y& Elsevier]

Background: While laparoscopy is now the standard for cholecystectomy, recent papers have focused on single-incision approaches. Intraoperative cholangiography remains an integral part of laparoscopic cholecystectomy but has not yet been well described within the single-access literature. We discuss our method of single-incision laparoscopic cholecystectomy with routine intraoperative cholangiograms. Methods: A retrospective review of our surgical database was completed. One hundred twenty-three patients undergoing laparoscopic cholecystectomy were identified (83 standard laparoscopy, 40 single-incision laparoscopy). Patient demographics including age and body mass index (BMI), and indications for surgery, operative time, intra- and postoperative complications, and ability to complete cholangiography were analyzed. Results: All patients with standard laparoscopy had successful cholangiograms. Two patients did not undergo cholangiography based on a preoperative decision (pregnancy). In the 40 patients who underwent single-incision cholecystectomy, 38 cholangiograms were completed (95%). One patient with acute cholecystitis had a small cystic duct which could not be cannulated. The second had a cystic duct through which the cholangiocatheter could not be advanced. Comparative analysis of patient demographics showed a significant difference in patient age between the two groups, as well as a significantly greater number of patients undergoing single-incision cholecystectomy for symptomatic cholelithiasis as opposed to acute cholecystitis. Discussion: Completion of intraoperative cholangiography is an important aspect of cholecystectomy in order to identify choledocholithiasis and verify anatomy. With the advent of single-access laparoscopy, standard operative principles should not be compromised. Cholangiography may provide a safer approach to cholecystectomy when adopting a new technique. We present our technique of single-incision cholecystectomy and routine cholangiography with a 95% success rate. The ability to perform single-incision intraoperative cholangiograms will allow a safe, more minimally invasive approach to cholecystectomy with suspected choledocholithiasis and obviate the need to convert to standard multiport laparoscopy for the sole reason of completing cholangiograms. [ABSTRACT FROM AUTHOR]

Introduction: The rate of cholecystectomy in northwestern Ontario is double the provincial rate. This paper explores the demographics of cholecystectomy and the role for rural endoscopic retrograde cholangiopancreatography (ERCP) services in the central part of this region. Methods: We conducted a literature review of ERCP services and cholecystectomy rates, as well as a hospital chart review of patients who underwent laparoscopic cholecystectomies in Sioux Lookout, Ont. We contacted surgeons and gastroenterologists from referral centres in Winnipeg, Man., and Thunder Bay, Ont., for the charts of patients from our catchment area who underwent ERCP. Results: Patients in our region who require urgent and emergent surgery are flown by fixed-wing aircraft to referral centres in Winnipeg and Thunder Bay for assessment and surgery. The rate of ERCP in our population is 150 in 100 000, which is threefold that of other populations, and our cholecystectomy rate is the highest in Ontario. Conclusion: Substantial savings in transportation expenses would offset the development costs of an ERCP program and provide more integrated patient care. The volume of patients would support maintenance of competency. This rural area with a high rate of gallbladder disease would benefit from the development of a rural ERCP program. [ABSTRACT FROM AUTHOR]

Objectives: Biliary injuries are frequently accompanied by vascular injuries, which may worsen the bile duct injury and cause liver ischemia. We performed an analytical review with the aim of defining vasculobiliary injury and setting out the important issues in this area. Methods: A literature search of relevant terms was peformed using OvidSP. Bibliographies of papers were also searched to obtain older literature. Results: Vasculobiliary injury was defined as: an injury to both a bile duct and a hepatic artery and/or portal vein; the bile duct injury may be caused by operative trauma, be ischaemic in origin or both, and may or may not be accompanied by various degrees of hepatic ischaemia. Right hepatic artery (RHA) vasculobiliary injury (VBI) is the most common variant. Injury to the RHA likely extends the biliary injury to a higher level than the gross observed mechanical injury. VBI results in slow hepatic infarction in about 10% of patients. Repair of the artery is rarely possible and the overall benefit unclear. Injuries involving the portal vein or common or proper hepatic arteries are much less common, but have more serious effects including rapid infarction of the liver. Conclusions: Routine arteriography is recommended in patients with a biliary injury if early repair is contemplated. Consideration should be given to delaying repair of a biliary injury in patients with occlusion of the RHA. Patients with injuries to the portal vein or proper or common hepatic should be emergently referred to tertiary care centers. [ABSTRACT FROM AUTHOR]

Introduction. Recurrent residual choledocholithiasis refers to the presence of concretions in the bile ducts found in patients who have undergone cholecystectomy. The incidence of recurrent cholithiasis is estimated to be 2-10%, whereas the incidence of recurrent cholithiasis after endoscopic retrograde cholangiopancreatography (ERCP) amounts to 4-24%. Aim. The aim of this paper was to analyze the case of a patient with recurrent choledocholithiasis after laparoscopic cholecystectomy, who underwent endoscopic exploration of the bile ducts performed 6 times, including endoscopic sphincterotomy (ES) and biliary prostheses. Case study. A 49-year old patient was admitted to the Teaching Hospital showing symptoms of extrahepatic cholestasis. On admittance, she reported nausea lasting for a few days, meteorism and strong pain typical of biliary colic, located in her right epigastric region and irradiating to her spine. Additionally, she complained of a bitter taste in her mouth and bitter belching. The patient had been operated on 9 years before for acute cholecystitis. Results and discussion. This presented case poses a question for a clinician concerning the risk factors for recurrent choledocholithiasis. In the majority of cases, i.e., as many as 80%, recurrent cholithiasis is detected within 3 years following ERCP with sphincterotomy. The risk of choledocholithiasis recurrence after endoscopic evacuation of the stones is within the range of 4-24%. The identification of factors causing this disease will contribute to its prevention, early diagnosis and treatment of any further recurrences and complications from choledocholithiasis. Data from published literature prove that damage to the sphincter causes chronic cholangitis, which then contributes to the formation of concretions. Other risk factors include dilated bile ducts and performed cholecystectomy. All these factors occurred and were observe in the analyzed patient. Conclusions. The basic treatment for this recurrent disease is ES performed during an ERCP procedure. This case emphasizes those problems associated with the prevention and treatment of recurrent choledocholithiasis. [ABSTRACT FROM AUTHOR]

Thoracobiliary fistula is a rare complication of hydatid cyst disease of the liver especially in calcified form. Given the rarity and high mortality of such fistula, it is not surprising that there is no consensus about surgical treatment of this condition. In the present paper we report two cases of thoracobiliary fistula of complicated calcified hydatid cyst of the liver. A 64- year-old man with cough and biliary sputum and a 66-year-old man with cough and right biliary pleural effusion (pleurobiliary fistula). The patients underwent left hepatectomy with cholecystectomy and T-tube choledochal drainage in one patient and successful decortication of the lung, and cystectomy with excision of calcified pericystectomy of the liver in another patient. Pathologic examinations revealed calcified hydatid cysts of the liver. Because of poor prognosis of thoracobiliary fistula, radical surgical intervention is recommended. [ABSTRACT FROM AUTHOR]

The transgastric approach to the abdominal cavity has been under experimental investigation in recent years as a method of natural orifice transluminal endoscopic surgery (NOTES). In this study our team, consisting of surgeons and gastroenterologists, focused on training techniques with currently available instruments to perform transgastric procedures. The purpose of this paper is to evaluate the learning process during the establishment of a training program for NOTES. Therefore several procedures were tested in terms of training issues such as the applicability of instruments and techniques for both gastroenterologists and surgeons. After initial testing of the basic steps, a defined training program was initialized in an animal facility of a medical company. Permission for animal training was applied for and granted by the local government. Ten training sessions were performed on a porcine model using animals with a median weight of 65 kg (40–85 kg). General anesthesia was performed in all cases. Transgastric tube resection (TTR), cholecystectomy (TCE), cardiomyotomy (TMY), and small bowel segmental resection (TSBR) were performed. The learning process was evaluated, including handling issues for flexible instruments, access, closure problems, and special technical issues. Procedure duration, as a marker of the learning curve effect, was evaluated. Intra-esophageal friction, lack of platform stability, lack of precision in tissue retraction, and lack of independence of endoscopic vision were the most difficult technical problems encountered. The operative time range was 25–85 min for TTR, 75–185 min for TCE, 95–220 min for TMY, and 100–260 min for TSBR. A learning curve was demonstrated for each investigated technique. These results are promising in terms of the ability of surgeons and gastroenterologists to develop these procedures into a clinical applicable version. Technical limitations were more important than differences in medical education, providing that there is a certain level of experience in both flexible endoscopy and laparoscopy, as well as a team approach. [ABSTRACT FROM AUTHOR]

Background: Bile duct injury following cholecystectomy is an iatrogenic catastrophe which is associated with significant perioperative morbidity and mortality, reduced long-term survival and quality of life, and high rates of subsequent litigation. The aim of this article was to review the management of bile duct injury after cholecystectomy. Methods: Medline and PubMed database search was undertaken to identify articles in English from 1970 to 2008 using the key words ‘bile duct injury’, ‘cholecystectomy’ and ‘classification’. Additional papers were identified by a manual search of the references from the key articles. Case report was excluded. Results: Early recognition of bile duct injury is of paramount importance. Only 25%–32.4% of injuries are recognized during operation. The majority of patients present initially with non-specific symptoms. Management depends on the timing of recognition, the type, extent and level of the injury. Immediate recognition and repair are associated with improved outcome, and the minimum standard of care after recognition of bile duct injury is immediate referral to a surgeon experienced in bile duct injury repair. There is a growing body of literature supporting the importance of early referral to a tertiary care hospital which can provide a multidisciplinary approach to treat bile duct injury. Inadequate management may lead to severe complications. Conclusions: None of the classification system is universally accepted as each has its own limitation. The optimal management depends on the timing of recognition of injury, the extent of bile duct injury, the patient's condition and the availability of experienced hepatobiliary surgeons. [ABSTRACT FROM AUTHOR]

This case describes an intraoperative incidental finding and surgical removal of ectopic liver tissue attached to the gallbladder during a standard laparoscopic cholecystectomy for acute cholecystitis. These anomalies are rare, with interesting associations and possible clinically relevant complications. The details of the case, along with a brief literature review of embryology, common ectopic sites, and associations/complications, are presented in this paper. Since laparoscopic cholecystectomy is a very common procedure, it is important to increase vigilance of ectopic liver tissues during surgeries to minimize complications and provide optimal management. [ABSTRACT FROM AUTHOR]

Pseudoaneurysm of a cystic artery is a rare entity that commonly occurs secondary to biliary procedures. Most of the cases in literature are consisted of ruptured aneurysms and to our knowledge, except our case, there were only 3 cases with unruptured aneurysms, which incidentally were detected by radiological methods. When cystic artery pseudoaneurysm is present with acute cholecystitis, most of the reports in literature suggested open cholecystectomy with the ligation of the cystic artery as a main treatment option. In this paper we present a case of acute cholecystitis with unruptured cystic artery pseudoaneurysm that incidentally was detected by computed tomography (CT). Cystic artery pseudoaneurysm was handled laparoscopically with simultaneous cholecystectomy. Due to high risk of rupture, surgeons have evaded laparoscopic approach to acute cholecystitis, which accompanied cystic artery pseudoaneurysm. However herein, we proved that laparoscopic management of cystic artery pseudoaneurysm with simultaneous cholecystectomy is feasible and reliable method. [ABSTRACT FROM AUTHOR]

Introduction and aim of the study: The aim of this retrospective study was an analysis of the success rate of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in a group of patients with pancreatobiliary malignancies and other pancreatobiliary diseases. These patients had undergone Billroth II gastrectomy, which posed a specific and very difficult technical problem for ERCP due to the significantly altered anatomical relationships. Material and methods: This study took thirteen years (November 1994 - December 2007). The paper retrospectively assesses 112 patients with Billroth II gastrectomy who underwent ERCP. Results: The indications for performing ERCP were cholestasis in 92, acute biliary pancreatitis in 12, acute cholangitis in 6, and suspicion of bile leak after laparoscopic cholecystectomy (LCE) in 2 patients. A cannulation success rate of 90.2% (101 of 112 patients) was achieved in performing ERCP in patients with Billroth II gastrectomy. Normal ERCP results were present in 4 patients. ERCP results in the remaining 97 patients were pathological (78 patients were diagnosed with choledocholithiasis, 14 with malignant biliary stenosis, 3 with benign biliary stenosis, and 2 with bile leak after LCE). Endoscopic treatment was undertaken in all of these 97 patients immediately after diagnostic ERCP. Endoscopic papillotomy was always performed as an initial step with the use of special papillotomes. Overall, therapeutic ERCP was absolutely successful in 83 of the 97 patients (85.6%) who were originally treated with endoscopy. Conclusions: ERCP in patients with Billroth II gastrectomy is much more demanding than the standard procedure due to the different postoperative anatomy. ERCP success is determined by the abundance of variable instrumentation and, of course, the personal experience and skill of the endoscopist. ERCP properly performed in patients with Billroth II gastrectomy is a highly effective and safe method of endoscopic diagnostics and treatment of pancreatobiliary malignancies and other pancreatobiliary diseases, The achieved success rate can be almost the same as under normal anatomical conditions. [ABSTRACT FROM AUTHOR]

Laparoscopic cholecystectomy (LC), the procedure of choice for elective cholelithiasis, is now also used in the management of acute cholecystitis. Empyema of the gallbladder is unexpectedly encountered in a proportion of these patients. This paper describes our experience with LC in the treatment of patients with empyema of the gallbladder. From May 1992 to July 2007, 315 patients with a clinical diagnosis of acute cholecystitis underwent LC. Operative and histopathology reports were used to identify patients with empyema of the gallbladder, to which retrospective chart reviews were applied. Factors associated with conversion and complications were assessed to determine their predictive power. Being male and having high levels of aspartate transaminase (AST), alanine transaminase (ALT), and white blood cells significantly influenced the prediction of empyema. The conversion rate was significantly higher for empyema and acute cholecystitis, but the complication rate did not differ significantly between these conditions. Previous abdominal surgery was an independent risk factor for conversion and complications. Also, temperature >37.5°C, AST >60 IU/l, and ALT >60 IU/l were associated with higher conversion rates. The hospital stay was longer in patients with empyema, while the operation time did not differ between the two groups. Empyema of the gallbladder can be encountered in patients with presumed acute cholecystitis. Preoperatively differentiating between simple acute cholecystitis and empyema is difficult, if not impossible. The conversion rate is expected to be higher when empyema is approached laparoscopically than for simple acute cholecystitis or symptomatic cholelithiasis. [ABSTRACT FROM AUTHOR]

In this paper we describe work we have done in developing an insertable surgical imaging device with multiple degrees of freedom for minimally invasive surgery. The device is fully insertable into the abdomen using standard 12 mm trocars. It consists of a modular camera and lens system which has pan and tilt capability provided by two small DC servo motors. It also has its own integrated lighting system that is part of the camera assembly. Once the camera is inserted into the abdomen, the insertion port is available for additional tooling, motivating the idea of single-port surgery. A third zoom axis has been designed for the camera as well, allowing close-up and faraway imaging of surgical sites with a single camera unit. In animal tests with the device we have performed surgical procedures including cholecystectomy, appendectomy, running (measuring) the bowel, suturing, and nephrectomy. Preliminary tests suggest that the new device may have advantages over a standard laparoscope including the following. ∙Low-cost and simple design. ∙Easier and more intuitive to use than a standard laparoscope. ∙Joystick operation requires no specialized operator training. Pan/tilt functions provide a large imaging volume not restricted by the fulcrum point of standard laparoscope. ∙Time to perform procedures was better than or equivalent to a standard laparoscope. We believe these insertable platforms will be an integral part of future surgical systems. The platforms can be used with tooling as well as imaging devices, allowing many surgical procedures to be performed using such a system. [ABSTRACT FROM AUTHOR]

Objectives: Spinal anesthesia (SA) for laparoscopic cholecystectomy (LC) is only contemplated in patients where general anesthesia (GA) is contraindicated. In this paper, we present our experience of over 12 years of performing laparoscopic cholecystectomy, primarily under spinal anesthesia. Methods: Over the last 12 years, LC was done under SA in 3492 patients. There was no modifications in technique, as compared to the same procedure done under GA. The intra-abdominal pressure was kept at 8–10 mm Hg. Sedation was given, if required, and conversion to GA was done in patients not responding to sedation or with failure of SA. Results were compared with those of 538 patients undergoing LC under GA. Results: Eighteen (0.52%) patients required a conversion to GA. Hypotension requiring support was recorded in 700 (20.05%) patients, and 429 (12.29%) patients experienced neck and/or shoulder pain. Overall, 2.29% (80) patients had vomiting in the postoperative period, as compared to 30.30% (163 patients) in patients administered GA. In total, 34.36% (1200) patients required injectable diclofenac for their abdominal pain within 2 hours postoperatively after SA, and oral analgesic was required in 2150 (61.57%) patients within the first 24 hours. On the other hand, 91.45% patients operated on under GA required injectable analgesics in the immediate postoperative period. Postural headache persisting for an average of 2.6 days was seen in 206 (5.9%) patients in the postoperative period after SA. There was no difference in operative parameters between the two groups, with 88.95% patients requiring only three ports under SA, as compared to 89.41% in the GA group. Operative time, too, was not much different. Postoperatively, biliary leak was seen in 0.60% patients, as compared to 0.93% in the GA group. Average time to discharge was almost similar in both the groups. Kernofsky's performance status showed a 98.6% satisfaction level in patients. Conclusions: LC done under spinal anesthesia does not require any change in technique and, at the same time, has a number of advantages, as compared to general anesthesia, and should be the anesthesia of choice. [ABSTRACT FROM AUTHOR]

Abstract: Laparoscopic cholocystectomy has been practiced for close to 20 years. The rate of common duct injury remains somewhere between 0.4 to 0.7 percent and is approximately the same around the world. Recent papers have stressed ways in which laparoscopic common duct injury can be avoided, but none of the methods mentioned is foolproof. In addition, this complication can occur to even the most experienced laparoscopic surgeon. The author believes that injury to the common duct during laparoscopic cholocystectomy is not a result of the practice below the standard, but an inherent risk of the operation. This injury needs to be emphasized by the surgical community as an inherent risk of the operation, and patients should be fully informed of this potential complication. [Copyright &y& Elsevier]

Natural orifice transluminal endoscopic surgery (NOTES) makes it possible to perform intraperitoneal surgical procedures with a minimal number of access points in the abdominal wall. It is not yet possible to perform these interventions without the help of abdominal wall entryways, so these procedures are hybrids, a fusion of minilaparoscopy and transluminal endoscopic surgery. In this paper we present a prospective clinical series of 15 patients who underwent transvaginal hybrid cholecystectomy for cholelithiasis. This was a prospective clinical series of 15 consecutive female patients, nonrandomly chosen and without a control group, who underwent a fusion transvaginal NOTES and minilaparoscopy procedure with two entryways for cholelithiasis. One was umbilical and measured 5 mm in diameter, and the other was in the right upper quadrant and measured 3 mm in diameter. The scheduled surgical intervention was performed on the 15 patients in whom it had been indicated. There were no intraoperative complications. One patient had mild hematuria that resolved in less than 12 h; there were no other complications after average follow-up of 124 days. Nine patients were discharged in 24 h, and two were discharged less than 12 h after the procedure. Hybrid transvaginal cholecystectomy is a good surgical model for minimally invasive surgery, a combination of NOTES and minilaparoscopy. It can be performed in surgical settings where laparoscopy is practised regularly, using the instruments normally used for endoscopy and laparoscopic surgery. Owing to the reproducibility of the intervention and the ease of vaginal closure, hybrid transvaginal cholecystectomy will permit further development of NOTES in the future. [ABSTRACT FROM AUTHOR]